Complete the following information about the claim on Form SSA 2960 USA/UY 3:
a. Name of worker
Enter the first and last name(s) of the worker.
b. Name of worker at birth
Enter the name of the worker at his or her birth.
c. Worker’s sex
Check the appropriate sex of the worker.
d. Uruguayan birth registration number
Enter the Uruguayan birth registration number if it appears on the application or
on the Uruguayan liaison form. If the applicant did not provide the Uruguayan birth
registration number, indicate UNKNOWN in the Remarks field and provide the following
information about the claimant.
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 name at birth
Enter the name of the worker at his or her birth.
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 Uruguayan
benefits, or both, in the appropriate columns.
k. Date Claim Filed
Enter the filing date certified to the Uruguayan liaison agency on all initial claims
packages or in response to the Uruguayan liaison 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 Uruguayan benefits in response to the Uruguayan liaison agency’s request for specific
information. If the requested information is not available, indicate “unknown.” If
our records include the requested information but it is not verified in our records,
, 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) 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 has a proof
code for the date of death.
o. 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 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 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 has a proof code for the worker’s
citizenship.