Basic (09-26)
The International Benefits and Processing (IBP) and the Naples , Italy Federal Benefits Unit (FBU) complete the Form SSA e2960 USA/ RO 3 via the Totalization Data Collection Program (TDCP). Use the Form SSA e2960 USA/ RO 3 to:
Transmit claims and related material to the Romani an liaison agency National House of Public Pensions ;
Request information from the liaison agency; and
Respond to requests from the Romanian liaison agency.
Use the following information to complete eForm SSA e2960 USA/RO 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.
Complete the following information about the claim on the Form SSA e2960 USA/RO 3:
Name of worker
Enter the first and last name(s) of the worker.
Name of worker at birth
Enter the worker's name at birth if it has changed.
Worker’s sex
Check the appropriate sex of the worker.
Romanian birth registration number
Enter the Romanian birth registration number, if the number appears on the application or on the Romanian liaison form. If the claimant did not provide the Romanian birth registration number, indicate UNKNOWN in the Remarks field and provide the following information about the claimant.
First name,
Surname,
Date of birth, and
Place of birth
Worker’s U.S. Social Security Number (SSN)
Enter the worker’s U.S. SSN
Claimant’s name
Enter claimant’s name.
Claimant’s name at birth
Enter the claimant's name at birth if it has changed.
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.
Claimant’s address and telephone number
Enter the complete address and telephone number of the claimant.
Type of benefits claimed
On initial claims packages, indicate the type of claim for U.S. benefits and Roma nian benefits, both, in the appropriate columns.
Date Claim Filed
Enter the filing date certified to the Roma nian liaison agency on all initial claims packages or in response to 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 Roma nian 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.
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.
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.
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.
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.
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.
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.
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.
Certificate of Insurance Periods
Check this block when including a U.S. earnings record.
Romanian Applications
Check the block when including Romanian applications.
Medical Evidence
Check this block when including medical evidence that the claimant submitted or from SSA records.
Date of information requested
Indicate the date of the liaison agency’s request if responding to a request.
Other
If attaching material not covered by any block shown, briefly explain the attachment on the space provided for “Remarks”.
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:
Romanian certificate of insurance periods
Check this block to request the Romanian certificate of insurance periods.
Medical evidence
Check this block to request medical evidence from the liaison agency
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.
If requesting information not covered by items in GN 01775.220B.3.a. through GN 01775.220B.3.c in this subsection, briefly explain the request in the space provided for “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.