Effective Dates: 08/28/2013 - Present Previous | Next

Basic (10-05)

GN 01746.220 Completing Form SSA-2960-J

A. When to use

The SSA-2960-J is completed in the modules in OIO or by VARO in Manila. It is used to:

  • •

    Transmit claims and related material to the appropriate Japanese agency

  • •

    Request information from those agencies, and

  • •

    Respond to requests from those agencies.

B. Description of form

This is an electronic form and can be located, completed and printed by accessing the Totalization Data Collection Program (TDCP).

C. Procedure

Follow these instructions to complete the items on the form. Be sure to check the appropriate address information in the “FROM” block.

1. Information about the claim

Complete the items in Part 1 as follows:

a. Item A

Always enter the first and last names of the worker.

b. Item B

Always enter the maiden name if the worker is a married woman. Enter the name at birth for a man, if it is different.

c. Item C

Check the appropriate sex of the worker.

d. Item D

Always enter the Japanese Basic Pension Number if the number is shown on the application or on the Japanese liaison form.

e. Item E

Always enter the worker's U.S. SSN.

f. Items F, G, and H

Always enter the complete name, maiden name, and U.S. SSN of the claimant if the claimant is not the worker entered in Item A.

g. Item I

Always enter the complete address and telephone number of the claimant.

h. Item J

On initial claims packages, indicate the type of claim for U.S. benefits and/or Japanese benefits in the appropriate columns.

i. Item K

Enter the filing date being certified to the Japanese agency on all initial claims packages or in response to the agency's request for the filing date.

2. Certification of data

Complete the Certification of Data part of the form only when transmitting a claim for Japanese benefits in response to the Japanese agency’s request for specific information. If the requested information is not available, indicate “unknown.” If the requested information is known but is not verified in SSA records, enter the information but do not check the “Verified” block.

a. Item A – name and date of birth

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    Enter the names of all claimants and in survivor cases, the name of the deceased worker. Enter the first and last names and, if applicable, the maiden name.

  • •

    Enter the date of birth for all claimants and, if applicable, for the deceased worker.

  • •

    Check the “Verified” block if the date of birth has been used to award U.S. benefits, or the date is shown on the MBR as proven.

b. Item B – worker/contributor's date of death

Enter the deceased worker's date of death in survivor claims. Check “Verified” if the date has been used to award U.S. benefits or the date is shown on the MBR as proven.

c. Item C – date of marriage

Enter the date of marriage if a spouse or widow(er) is claiming benefits. Check “Verified” if the data has been used to award U.S. benefits or the date is shown on the MBR as proven.

d. Item D – date of divorce

Enter the date of divorce if a divorced spouse or widow(er) is claiming benefits. Check “Verified” if the data has been used to award U.S. benefits or the date is shown on the MBR as proven.

e. Item E – country of birth

Enter the country of birth for the worker. Check “Verified” if the data has been used to award U.S. benefits or the date is shown on the MBR as proven.

f. Item F – citizenship

Enter the country of citizenship of the worker. Check “Verified” if the data has been used to award U.S. benefits or the date is shown on the MBR as proven.

3. Information provided

If you are sending an initial claims package or responding to an assistance request, check all appropriate blocks to indicate the type of material being sent to the Japanese agency. Check item:

a. Item A

If attaching the U.S. coverage record.

b. Item B

If attaching Japanese applications J/USA 1 and/or J/USA 2, check the appropriate block.

c. Item C

If attaching medical evidence submitted by the claimant or from SSA files.

d. Item D

If responding to a request from the Japanese agency. Indicate the date of the agency’s request.

e. Item E

If attaching material not covered by any block shown, briefly explain the attachment in the space provided for “Remarks.”

4. Information needed

If you are requesting information under the Agreement, check “Yes.” If you answer “No,” attach a consent statement. Check:

a. Item A

If requesting a Japanese coverage record. Form J/USA 4 must be attached when making this request.

b. Item B

If requesting a copy of medical evidence from the Japanese agency’s files.

c. Item C

If following up on an earlier request to the Japanese agency. Show the date of the original request.

d. Item D

If requesting information not covered by items A-C shown above, briefly explain the request in the space provided for “Remarks.”

5. Remarks

Keep remarks to a minimum and make them clear and concise. Do not use technical jargon or abbreviations. Be sure to enter your name in the signature block.

To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0201746220
GN 01746.220 - Completing Form SSA-2960-J - 08/28/2013
Batch run: 10/17/2016
Rev:08/28/2013