TN 1 (04-13)
GN 01748.220 Completing the SSA-2960 USA/DN3 (USA/Denmark Agreement on Social Security Transmittal/Request/Certification Form)
A. Process for the SSA-2960 USA/DN3
The Division of International Operations and the Oslo Norway Federal Benefits Unit (FBU) completes the SSA-2960 USA/DN3 via the Totalization Data collection Program (TDCP). Use the SSA-2960 USA/DN3 to:
Transmit claims and related material to the Danish agency.
Request information from the Danish agency.
Respond to requests from the Danish agency.
B. Procedure for completing the SSA 2960 USA/DN3 eform
Use the following procedure to complete the items on the SSA-2960 USA/DN3 eform:
Date of Original field
Date(s) of Follow-ups field
Date automatically propagates
Follow-up date(s) automatically propagates.
Select the appropriate foreign agency
Office / Office Code and Fax numbers (if provided) automatically propagate based on user’s profile.
1. Information about the Claim
Complete the following information about the claim on the SSA-2960 US/DN3:
a. Name of Worker
Enter the first and last name(s) of the worker.
b. Name of Worker at Birth
Enter the maiden name if the worker is a married woman.
Enter the name at birth for a man, if it is different.
c. Worker’s Sex
Check the appropriate sex of the worker.
d. Danish Central Personal Registration Number (CPR) or Date of Birth
Enter the Danish CPR number, if the number appears on the application or on the Danish liaison form. (A Danish “CPR” number is the Danish central personal registration number.) If CPR number is not provided, indicate UNKNOWN.
e. Worker’s U.S. Social Security Number (SSN)
Enter the worker’s U.S. SSN.
f. Claimant’s Name
Enter claimant’s name.
g. Claimant’s Name at Birth
Enter claimant’s maiden name if applicable.
h. Claimant’s U.S. SSN
Enter claimant’s U.S. SSN when he or she is not the worker entered in item A.
i. Claimant’s Address and Telephone Number
Enter the complete address and telephone number of the claimant.
j. Type of Benefits Claimed
On initial claims packages, indicate the type of claim for U.S. benefits or Danish benefits in the appropriate columns.
k. Date Claim Filed
Enter the filing date certified to the Danish 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 Danish benefits in response to the Danish agency’s request for specific information.
If the requested information is not available, indicate “unknown.” If our records do not verify the known requested information, enter the information but do not check the “Verified” block.
a. Name and Date of Birth
Enter the names of all claimants and in survivor cases, the name of the deceased worker.
Enter the date of birth for all claimants and if applicable, for the deceased worker.
Check the “Verified” block if we used the date of birth to award U.S. benefits, or the master beneficiary record (MBR) has a proof code for the date of birth.
b. Worker/Contributor’s Date of Death
Enter the deceased worker’s date of death in survivor claims.
Check the “Verified” block if SSA used the date of death to award U.S. benefits, or the MBR has a proof code for the date of death.
c. Date of Marriage
Enter the date of marriage if a spouse or widow(er) is claiming benefits. Check Verified” if we used the date of marriage to award U.S. benefits or the MBR has a proof code for the date of marriage.
d. Date of Divorce
Enter the date of divorce if a divorced spouse or widow(er) is claiming benefits. Check “Verified” if we used the date of divorce to award U.S. benefits or the MBR has a proof code for the date of the divorce.
e. Country of Birth
Enter the country of birth for the worker. Check “Verified” if we used the data to award U.S. benefits or the MBR has a proof code for the country of birth.
f. Worker’s Citizenship
Enter the country of citizenship of the worker. Check “Verified” if we used the data to award U.S. benefits or the MBR has a proof code for the worker’s citizenship.
3. Providing Information to the Danish Agency
If you send an initial claims package or respond to an assistance request, check all appropriate blocks to indicate the type of material being sent to the Danish Agency.
a. Coverage Record
Check this block when including a U.S. earnings record.
b. Danish Applications
Check this block when including Danish applications.
c. Medical Evidence
Check this block when including medical evidence the claimant submitted or from SSA files.
d. Date Information Requested
Indicate the date of the Danish agency’s request if responding to a request from them.
If attaching material not covered by any block shown, briefly explain the attachment in the space provided for “Remarks.”
4. Information SSA needs from the Danish Agency
If you are requesting information under the Agreement, check “Yes.”
If you answer “No,” attach a consent statement.
Check at least one block to indicate the type of material we are requesting from the Danish agency.
a. Danish Coverage record
Check this block to request the Danish coverage record.
b. Medical Evidence
Check this block to request medical evidence from the Danish agency.
c. Status of Request Date
Check this block to follow up on an earlier request to the Danish agency. Show the date of the original request in the space provided.
If requesting information not covered by items in GN 01748.220B.4.a. through GN 01748.220B.4.c. (in this section), briefly explain the request in the space provided for “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.