TN 1 (04-13)
GN 01752.220 Completing the SSA-2960 USA/PO3 (U.S.A. – Poland Agreement on Social Security Transmittal/Request/Certification Form)
A. Process for the SSA-2960 USA/PO3
The Office of International Operations (OIO), and the Warsaw, Poland Federal Benefits Unit (FBU) completes the SSA-2960 USA/PO3 via the Totalization Data Collection Program (TDCP). Use the SSA-2960 USA/PO3 to:
Transmit claims and related material to ZUS or KRUS;
Request information from ZUS or KRUS; and
Respond to requests from ZUS or KRUS.
Poland provides a wide range of benefits including retirement, survivors and disability benefits; one-time indemnity payments and benefits awarded as a result of work accidents and occupational diseases, and funeral grants through two major Social Security systems.
The Social Insurance Institution (Zaklad Ubezpieczen Spolecznych-ZUS) is a two-tier system that administers the social security provisions under the old and new laws in Poland for non-agricultural workers, and
The Agricultural Social Insurance Fund (Kasa Rolniczego Ubezpieczenia Spolecznego-KRUS) administers the social security provisions under the laws governing farmers in Poland.
B. Procedure for completing the SSA-2960 USA/PO3 eform
Use the procedure in the following chart to complete the items on the SSA-2960 USA/PO3 eform.
Date of Original field
Date(s) of Follow-ups field
Date is automatically entered
Follow-up date(s) will automatically propagate.
Select the appropriate foreign agency
Office/Office Code and Fax numbers (if provided) automatically propagate based on user’s profile.
1. Completing Information about the claim on the SSA-2960 USA/PO3
Complete the following information about the claim on the SSA-2960 USA/PO3:
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.
c. Worker’s Sex
Enter the sex of the worker.
d. Worker’s Polish I.D. Number
If the number is on the application or on the ZUS/KRUS liaison form, enter the Polish I.D. Number.
e. U.S. Social Security Number
Enter the worker’s U.S. Social Security Number (SSN).
f. Claimant’s Name
Enter the claimant’s name at birth or maiden name, if the claimant is not the worker entered in item GN 01752.220B.1.a in this section.
NOTE: For “f1 Claimant’s Sex” enter the sex of the claimant.
g. Claimant’s Name at Birth
Enter the claimant’s name at birth.
h. Claimant’s Polish ID Number
Enter the Polish I.D. number, if available.
i. Claimant’s Reference Number
Enter the Polish Reference number.
j. Claimant’s U.S. SSN
Enter the claimant’s U.S. SSN.
k. Claimant’s Address and Telephone Number
Enter the claimant’s address and telephone number.
l. Type of Benefits
Enter the type of benefits claimed (U.S. or Poland) in the block provided for:
Retirement or Old Age
m. Date Claims Filed
Enter the Date Claim Filed (Month/Day/Year).
2. Certification of Data
Complete the Certification of Data part of the SSA-2960 USA/PO3 only when transmitting a claim for Polish benefits, for specific information in response to ZUS or KRUS.
If the requested information is not available, indicate “unknown.” If you know the requested information, but our records cannot verify the information, enter the information, and 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 relationship for all claimants and, if applicable, for the deceased worker.
Enter the date the claimant provided the information (month/day/year).
If we use the date of birth to award U.S. benefits, or the date indicated on the master beneficiary record (MBR) as proof, check the “Verified” block.
b. Worker/Contributor’s Insured Date of Death
Enter the deceased worker’s date of death in survivor claims. Check the “Verified” block if we 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) claims benefits. Check the “Verified” block 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) claims benefits. Check the “Verified” block 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 the “Verified” block if we used the data to award U.S. benefits or the MBR has a proof code for the country of birth.
Enter the country of citizenship of the worker. Check the “Verified” block 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 Polish agencies
If you send an initial claims package or respond to an assistance request, check all appropriate blocks to indicate the type of material sent to ZUS or KRUS.
Check this block when including a U.S. coverage record.
Republic of Poland Applications
Check this block when including a Republic of Poland application.
Check this block when including medical evidence submitted by the claimant or from SSA files.
Date Information Requested
Indicate the date of ZUS or KRUS request if responding to a request from them.
If you attach material not covered by any block shown, briefly explain the attachment in the space provided for “Remarks.”
4. Information SSA needs from the Polish agencies
If you request 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 SSA is requesting from the Polish Agencies.
a. Polish Coverage Record
Check this block to request the Polish coverage record.
b. Medical Evidence
Check this block to request a copy of medical evidence from the ZUS or KRUS files.
c. Status of Request Dated
Check this block to follow up on an earlier request to ZUS or KRUS. Show the date of the original request in the space provided.
Check this block to request information not covered in GN 01752.220B.4 in this section. Briefly explain your request in the Remarks box.
5. Remarks portion of the SSA-2960 USA/PO3
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.