Effective Dates: 10/22/2024 - Present Previous | Next

TN 1 (10-24)

GN 01771.220 Completing the Form SSA e2960 USA/SI 3 (U.S. – Slovenia Agreement on Social Security Transmittal/Request/Certification)

A. Using eForm SSA e2960 USA/SI 3

The Division of International Operations (DIO) and the Rome, Italy Federal Benefits Unit (FBU) complete the Form SSA e2960 USA/SI 3 via the Totalization Data Collection Program (TDCP). Use the Form SSA e2960 USA/SI 3 to:

  • •

    Transmit claims and related material to the Slovenian liaison agency Pension and Disability Insurance Institute of Slovenia;

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    Request information from the liaison agency; and

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    Respond to requests from the Slovenian liaison agency.

B. Completing the eForm SSA e2960 USA/SI 3

Use the following information to complete eForm SSA e2960 USA/SI 3:

Item

Explanation

Date of Original field

Date automatically propagates

Date(s) of Follow-ups field

Follow-up date(s) automatically propagates.

To field

Select the appropriate foreign agency.

From field

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 Form SSA e2960 USA/SI 3:

a. Name of worker

Enter the first and last name(s) of the worker.

b. Name of worker at birth

Enter the worker's name at birth if it has changed.

c. Worker’s sex

Check the appropriate sex of the worker.

d. Slovenian birth registration number

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

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    First name,

  • •

    Surname,

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    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 claimant's name at birth if it has changed.

h. Claimant’s U.S. SSN

Enter claimant’s U.S. SSN if 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 Slovenian benefits, both, in the appropriate columns.

k. Date Claim Filed

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

l. Certification of data

Complete the certification of data part of the form only when transmitting a claim for Slovenian benefits in response to the liaison agency 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.

m. 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 if the master beneficiary record (MBR) or Numident (NUMI) has a proof code for the DOB.

n. 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 if the MBR or NUMI has a proof code for the date of death.

o. Date of Marriage

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

p. 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 if the MBR has a proof code for the date of the divorce.

q. 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 if the MBR or NUMI has a proof code for the country of birth.

r. 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 if the MBR or NUMI has a proof code for the worker’s citizenship.

2. Providing information to the Slovenian liaison agency

When sending an initial claims package or responding to an assistance request, check all appropriate blocks to indicate the type of material being sent to the liaison agency.

a. Coverage record

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

b. Slovenian Applications

Check the block when including Slovenian applications.

c. Medical Evidence

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

d. Date of information requested

Indicate the date of the liaison agency’s request if responding to a request.

e. Other

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

3. Information SSA needs from the liaison agency

When requesting information under the Agreement, check “Yes.” If “No” is checked, attach a consent statement. Check at least one block to indicate the type of material SSA is requesting from the liaison agency:

a. Slovenian coverage record

Check this block to request the Slovenian certified coverage record.

b. Medical evidence

Check this block to request medical evidence from the liaison agency

c. Status of request date

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

d. Other

If requesting information not covered by items in GN 01771.220B.3.a. through GN 01771.220B.3.c in this subsection, briefly explain the request in the space provided for “Remarks”.

4. Remarks

For “Remarks”, follow these guidelines:

Add only necessary remarks and ensure they are clear and concise. Do not use technical jargon or abbreviations. Technicians must enter their name in the signature block.

To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0201771220
GN 01771.220 - Completing the Form SSA e2960 USA/SI 3 (U.S. – Slovenia Agreement on Social Security Transmittal/Request/Certification) - 10/22/2024
Batch run: 10/22/2024
Rev:10/22/2024