TN 6 (10-03)

A. Introduction

Forms SSA-2960-CA and SSA-2960-QC are used only by the designated border offices and the Office of International Operations (OIO). Both forms are available through the Totalization Benefits Resource Kit on the Intranet at http://eis.ba.ssa.gov/eis/misc/resource-kits/resourcekits.htm and are in a bilingual English and French format. SSA-2960-CA is further identified by the designation USA/CAN 3 (É-U/CAN 3) in the upper right hand corner and is addressed to the Income Security Programs Branch in Ottawa. SSA-2960-QC is further identified by the designation USA/QUÉ 3 (É-U/QUÉ 3) in the upper right hand corner and is addressed to the Régie des rentes du Québec in Québec City. Complete these forms via the Totalization Data Collection Program (TDCP).

B. Policy - Transmittal form SSA-2960

Designated border offices must complete the appropriate transmittal form SSA-2960:

• to route applications for Canadian benefits (the CDN-USA 1 or QUE/USA-1) and associated material to the Canadian agencies in Ottawa or Quebec; or

• if an applicant has filed for U.S. Totalization benefits and it is necessary to request a Canadian coverage record from Ottawa or Quebec because the worker has at least 6 U.S. credits but not enough to be insured.

C. Procedure - Completing transmittal form SSA-2960

Use the following information to complete those items on the transmittal form that are not self-explanatory. Complete forms via the Totalization Data Collection Program (TDCP). When entering dates, write out the name of the month rather than showing the date entirely in numbers, e.g. March 2, 2003 rather than 3/2/2003.

1. From section

Check the first block and include the 3-digit code of the designated border office when completing the OIO form and include the office's mailing address or use the border office's customized form which includes the border office's full mailing address.

2. Information about the claim

a. Name of Number Holder (NH)

Enter the name of the person on whose record the claim is based. Do not enter the name of the applicant unless the applicant is also the NH. If the NH is deceased, enter “Deceased” after the name.

b. Canadian Social Insurance (SIN) or Old-Age Security (OAS) Number

Enter the 9-digit Canadian SIN number (all numeric) separated into 3 groups of 3 numbers each. If unknown, enter “Unknown” in the appropriate space and enter the NH's father's name and mother's maiden name in the appropriate spaces.

Enter the 11-digit Canadian OAS number (all numeric). The last 9 digits are the same as the Canadian Social Insurance number. If unknown, enter “Unknown” in the appropriate space.

c. Address of Claimant

If the NH is deceased, enter the NAME of the claimant as well as the address of the claimant.

d. Telephone Number

Always enter the claimant's telephone number, if known.

e. Type of Benefits Claimed

Check the appropriate block(s) to indicate from whom benefits are being claimed as well as the type(s) of benefit being claimed.

f. Date Claim Filed

Enter the date the claim was filed using month, day, and year format. When entering the date, write out the name of the month rather than showing the date in numbers, e.g. March 2, 2003 rather than 3/2/2003.

3. Certification of Data

When entering dates, write out the name of the month rather than showing the date in numbers, e.g. March 2, 2003 rather than 3/2/2003.

4. Information Provided

If the SSA-2960 is being used to transmit material to Ottawa and/or Quebec, check the appropriate block(s) to identify the material.

NOTE: When the claimant has submitted a document that must be sent to both Ottawa and Quebec, prepare a certified photocopy for both agencies.

5. Information Required

Designated border offices should check only blocks a) “Evidence of Coverage Periods” or e) “No Information Required.” No other block should be checked.

6. Remarks

Keep remarks to a minimum. When needed, remarks should be clear and concise. Don't use technical jargon or abbreviations.

NOTE: Canada may need to develop a worker's lag earnings under the Canadian system. Therefore, list any Canadian work alleged by the worker during the current or preceding calendar year in the Remarks section.

7. Signature

A Claims Representative (CR) or higher should sign the form in the space provided and also print the name and title of the individual completing this form. The date and SSA seal will be automatically inserted on the form.

D. Procedure - Disposition of transmittal form SSA-2960

If a U.S. claim (regular or Totalization) is filed, print two copies of the completed Form SSA-2960. Send one copy of the completed form to Ottawa and/or Quebec and keep the other copy of the completed form with the U.S. claim.

E. References

• Application for Canadian benefits, GN 01715.220

• Designated border offices, GN 01715.320

• Forms SSA-2960-CA and SSA-2960-QC “Request/Transmittal/Certification Form,” GN 01716.220