TN 1 (05-13)
GN 01750.220 Completing the SSA–e2960–U3–CZ (Transmittal/Request/Certification Form, USA/CZ3)
A. Process for the SSA-e2960–U3–CZ
The Division of International Operations, and the Warsaw, Poland Federal Benefits Unit (FBU) completes the SSA-e2960–U3-CZ via the Totalization Data Collection Program (TDCP). Use the SSA-e2960–U3–CZ to:
Transmit claims and related material to Ceske Spravy Socialnlho Zabezpeceni (CSSZ).
Request information from CSSZ.
Respond to requests from CSSZ.
B. Procedure for completing the eform SSA-e2960–U3–CZ
Follow the procedure in this subsection to complete the items on the SSA-e2960–U3–CZ:
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-e2960–U3–CZ:
a. Name of Worker
Enter the first and last names of the worker.
b. Worker’s Full Name 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.
NOTE: b1. section is for Czech-use only.
c. Worker’s Sex
Enter the sex of the worker.
d. Worker’s Czech Birth Number
Enter the Czech Birth Number if the number is on the application or on the Czech liaison form.
e. Worker’s U.S. Social Security Number (SSN)
Enter the worker’s U.S. SSN.
f. Claimant’s Name
Enter the claimant’s name.
g. Claimant’s Birth Name
Enter the claimant’s name at birth.
NOTE: g1. section is for Czech-use only.
h. Claimant’s U.S. SSN
Enter the claimant’s U.S. SSN.
i. Claimant’s Czech Birth Number
Enter the claimant’s Czech Birth Number.
j. Claimant’s Address and Telephone Number
Enter the complete address and telephone number of the claimant.
k. Type of Benefits Claimed
On the initial claims package, indicate the type of claim for U.S. benefits or Czech benefits in the appropriate columns.
l. Date Claim Filed
Enter the filing date certified to CSSZ on initial claims package or in response to CSSZ’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 Czech benefits in response to CSSZ for specific information.
If the requested information is not available, indicate “unknown.” If the requested information is available, but not verified in SSA records, enter the information but do not check the “Verified” block.
a. Date of Birth/Name
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.
Enter the place of birth for all claimants and, if applicable, for the deceased worker.
Enter the relationship for all claimants.
Enter the date the information is provided.
Check the “Verified” block if SSA used the date of birth to pay U.S. benefits, or the 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 pay U.S. benefits, or the MBR has a proof code for the date of death.
c. Date of marriage
Enter the marriage if a spouse or widow(er) is claiming benefits. Check “Verified” if SSA used the date of marriage to pay 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 SSA used the date of divorce to pay U.S. benefits or the MBR has a proof code for the date of the divorce.
e. Worker’s citizenship
Enter the country of citizenship for the worker. Check “Verified” if SSA used the data to pay U.S. benefits or the MBR has a proof code for the worker’s citizenship.
f. Certification of orphan child in school age 16-26
Enter the name(s) of the orphan child in school age 16-26.
Enter the name of the school for the orphan child school age 16-26.
Enter the presumed date of graduation for the orphan child school age 16-26.
Check the “Verified” block if SSA used the data to pay U.S. benefits, or the MBR has a proof code for the data.
3. Providing Information to the Czech Republic 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 CSSZ.
NOTE: If the claim is not under the agreement, a consent statement must be attached for requested information.
a. Coverage Record
Check this block when including a U.S. coverage record.
b. Czech Republic Application
Check this block when including a Czech Republic application.
c. Medical Evidence
Check this block when including medical evidence the claimant submitted or from the claimant’s SSA files.
d. Date Information Requested
Indicate the date of CSSZ’s request if responding to a request from it.
If attaching material not covered by any block shown, briefly explain the attachment in the space provided for “Remarks.”
4. Requesting Information from the Czech Republic Agency
a. Czech Republic Coverage record
Check this block to request the Czech Republic coverage record.
b. Medical Evidence
Check this block to request medical evidence from the claimant’s CSSZ files.
c. Status of Request Date
Check this block to follow up on an earlier request to CSSZ. Show the date of the original request in the space provided.
Check this block to request information not covered by items in GN 01750.220B.4.a. through GN 01750.220B.4.c. (in this section). Briefly explain the request in the space provided for “Remarks.”