Date automatically propagates

Follow-up date(s) automatically propagates

Select the appropriate foreign agency

Office/Office Code and Fax numbers automatically generate based on User’s profile.

Enter the following information in Part 1, a. through g., of the SSA-2960-LX as follows:

1. a. 

   Name of Worker

   Enter the first and last name of the worker.

   Enter the first and last name at birth.

   NOTE: Luxembourg must have this information to locate the worker's records.

2. b. 

   U.S. Social Security Number

   Enter the worker's U.S. SSN.

3. c. 

   Luxembourg Registration Number

   Enter the worker's Luxembourg Registration Number if it is on the application or on the Luxembourg liaison form.

   If unknown, enter “unknown.”

4. d. 

   Name of Claimant

   Enter the claimant’s first and last name.

   Enter the claimant’s first and last name at birth.

   Show the claimant's maiden name.

   NOTE: Luxembourg needs this information to assign a registration number.

5. e. 

   Address of Claimant

   Enter the claimant’s address and telephone number in the appropriate boxes.

6. f. 

   Type of Benefits Claimed

   Select the column with the type of benefits claimed. In initial claims packages, indicate the type of claim for Luxembourg or U.S. benefits.

7. g. 

   Date Claim Filed (M/D/Y)

   Enter the certified filing date to the Luxembourg agency on all initial claims packages and in response to a Luxembourg agency's request for the filing date.

Enter the following information in Part 2 of the SSA-2960-LX in all cases:

1. a. 

   Date of Birth

   • •

     Name

     Enter the first and last names of all claimants.

   • •

     Date (M/D/Y)

     Enter the date of birth for all claimants.

   • •

     Verified

     Check the appropriate block if OIO used the date of birth to award U.S. benefits; or SSA proved the data shown on the Master Beneficiary Record (MBR).

   Enter the following information in Part 2 if SSA is transmitting a claim for Luxembourg benefits, or if a Luxembourg agency requested the information.

   • •

     Monthly Benefit

     Enter the amount of the monthly benefit creditable (MBC) for the first month in which a full benefit was paid or November 1, 1993, whichever is later.

     For retirement and disability claims, enter the MBC for the worker. For survivor claims, enter the MBC for the widow and children.

   • •

     Effective Date (M/Y)

     Enter the first month and year that SSA paid a full benefit, or November 1, 1993, whichever is later.

     If the claim is for survivor benefits, enter the effective date of the survivor benefits.

2. b. 

   Worker’s Date of Death

   Enter the date of death if applicable.

3. c. 

   Date of Marriage

   Enter the date of marriage if applicable.

4. d. 

   Date of Divorce

   Enter the date of divorce if applicable.

   Verified Column

   Check the appropriate blocks if OIO used the data to award U.S. benefits, or SSA proved the data shown on the MBR.

5. e. 

   Prior Periods of Disability

   Enter the following dates only if Luxembourg specifically requests this information.

   If the worker was entitled to U.S. DIB benefits enter the beginning and ending date of entitlement. If the worker was not entitled to U.S. DIB benefits, enter “NONE”.

   Verified Column

   Check this block to certify DIB information.

Check the appropriate block(s) in a. through e. to indicate the type of material OIO sends to the Luxembourg agency.

1. a. 

   Coverage Record

   if attaching a U.S. coverage record

2. b. 

   Medical Evidence

   if attaching medical evidence submitted by the claimant or from OIO files

3. c. 

   Information Requested On (M/D/Y)

   if responding to a request from a Luxembourg agency and enter the date of the request

4. d. 

   No Information Provided

   if there are no attachments

5. e. 

   Other – See Remarks

   if attaching material not covered by any block shown above

   NOTE: Briefly explain the attachment in “REMARKS.”

Check the appropriate block(s) in a. through e. to indicate the type of material OIO requests from the Luxembourg agency.

1. a. 

   Coverage Record

   if requesting a Luxembourg coverage record

2. b. 

   Medical Evidence

   if requesting a copy of medical evidence from the Luxembourg agency's files

3. c. 

   Status of Earlier Request (M/D/Y)

   if following up on an earlier request to the Luxembourg agency and show the date of the original request

4. d. 

   No Information Provided

   if you are not requesting any information

5. e. 

   Other – See Remarks

   if you are requesting information not covered by a block shown above

   NOTE: Briefly explain your request in “Remarks.”