Date of Original

(M/D/Y)

Current date automatically propagates.

Date(s) of Follow-Up(s)

(M/D/Y)

Follow-Up dates automatically propagate.

From:

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

To:

Check the appropriate block.

1. Information About The Claim

a. Name of Number Holder (NH)

Enter number holder’s name.

If the NH is deceased, enter “Deceased” after the name.

b. Name at Birth

Enter name at birth.

c. Canadian Social Insurance Number or Old Age Security Number

Enter the Canadian number or Old Age Security Number.

d. U.S. Social Security Number (SSN)

Enter the U.S. SSN.

e. Father’s Name

Enter the father’s first name and last name.

f. Mother’s Maiden Name

Enter the mother’s first name, married last name, and in the third box, enter the maiden name.

g. Address of Number Holder/Claimant

Enter number holder’s or claimant’s address.

If the NH is deceased, change the block label to “Address of Claimant” and enter the name and address of the claimant here.

h. Telephone Number

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

i. Type of Benefits Claimed

Check the appropriate benefits under the appropriate country.

Do not complete when responding to assistance requests.

j. Date Claim Filed

Protective Filing Date for the claim.

2. Certification of Data

Enter the date of birth in the appropriate fields if applicable.

Enter the first and last name in the appropriate fields if applicable.

Check the verified column for all information verified.

a. Date of Birth

Number Holder

Spouse/Widow(er)

Child

Child

b. Number Holder’s Date of Death

Enter the number holder’s date of death, and check the verified field to confirm verification of information if applicable.

c. Date of Marriage

Enter the number holder’s date of marriage, and check the verified field to confirm verification of information if applicable.

d. Date of Divorce

Enter the number holder’s date of divorce, and check the verified field to confirm verification of information if applicable.

3. Information Provided

Check the appropriate information the claimant provided below.

a. Application

b. Evidence of Coverage Periods

c. Medical Evidence

d. Residence Documents

Note: Quebec 2960 does not have d. Residence Documents

e. Request for Appeal

(Please note that this numbering (e. – g.) does not reflect the numbering on SSA-e2960-QC. )

f. Information Requested On

Enter the name of the person the information is being provided for (if appropriate)

g. Other

Complete this field for other information provided that is not already listed.

4. Information Required

Check the appropriate information we are requesting below. Do not complete item b. when requesting information from Ottawa. We have agreed not to routinely request medical evidence from Ottawa.

a. Evidence of Coverage Periods

b. Medical Evidence

c. Status of Request Date

d. Other

Complete this field for other information we require that is not on the form.

e. No Information Required

Place a check mark in this field if no information is required or /requested.

Remarks

• Keep remarks to a minimum. When needed, remarks should be clear and concise. Do not use technical jargon or abbreviations.

• Enter the year the worker last worked in Canada, if known.

Signature

Your name will propagate in this field along with the current date and the Social Security emblem.