Complete the following information about the claim on the Form SSA 2960 USA/BR 3:

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; and enter the name at birth for a man, if it is different.

c. Worker's sex

Check the appropriate sex of the worker.

d. Brazilian birth registration number

Enter the Brazilian birth registration number, if the number appears on the application or on the Brazilian liaison form. If the claimant did not provide the Brazilian birth registration number, indicate UNKNOWN in the Remarks field and provide the following information about the claimant.

• •

  Forename,

• •

  Surname,

• •

  Date of birth, and

• •

  Place of birth

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 the maiden name if the claimant is a married woman; and enter the name at birth for a man, if it is different.

h. Claimant's U.S. SSN

Enter claimant’s U.S. SSN when he or she is not the worker entered in item A on the form.

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 and Brazilian benefits, both, in the appropriate columns.

k. Date claim filed

Enter the filing date certified to the Brazilian liaison agency on all initial claims packages or in response of the agency’s request for the filing date.

Certification of data

Complete the certification of data part of the form only when transmitting a claim for Brazilian benefits in response to INSS’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.

l. 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 (DOB) for all claimants and for the deceased worker. Check the “Verified” block if SSA used the DOB to award U.S. benefits, or the master beneficiary record (MBR) has a proof code for the DOB.

m. 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.

n. Date of marriage

Enter the date of marriage if a spouse or widow(er) is claiming benefits. Check the “Verified” block if SSA used the date of marriage to award U.S. benefits or the MBR has a proof code for the date of the marriage.

o. Date of divorce

Enter the date of divorce if a divorced spouse or widow(er) is claiming benefits. Check the “Verified” block if SSA used the date of marriage to award U.S. benefits or the MBR has a proof code for the date of the divorce.

p. Country of birth

Enter the country of birth for the worker. Check the “Verified” block if SSA used the data to award U.S. benefits or the MBR has a proof code for the country of birth.

q. Worker's citizenship

Enter the country of citizenship of the worker. Check the “Verified” block if SSA used the data to award U.S. benefits or the MBR has a proof code for the worker’s citizenship.

If you send an initial claims package or respond to an assistance request, check all appropriate blocks to indicate the type of material you sent to INSS.

a. Coverage record

Check this block when including a U.S. earnings record.

b. Brazilian applications

Check the block when including Brazilian applications.

c. Medical evidence

Check this block when including medical evidence that the claimant submitted or from SSA files.

d. Date of information requested

Indicate the date of INSS request if responding to a request from them.

e. Other

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

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 INSS:

a. Brazilian coverage record

Check this block to request the Brazilian certified coverage record.

b. Medical evidence

Check this block to request medical evidence from INSS

c. Status of request date

Check this block to follow up on an earlier request to INSS. Show the date of the original request in the space provided.

d. Other

If requesting information not covered by items in GN 01758.220B.4.a. through GN 01758.220B.4.c in this subsection, briefly explain the request in the space provided for “Remarks”.

For “Remarks”, follow these guidelines:

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