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

To field

From 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.

Check item:

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.

e. Other

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.

d. Other

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.”


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0201750220
GN 01750.220 - Completing the SSA-e2960-U3-CZ (Transmittal/Request/Certification Form, USA/CZ3) - 04/28/2017
Batch run: 04/28/2017
Rev:04/28/2017