Justification for the Non-Substantive Changes to 0960-0448

2

Justification for Non-Substantive Changes to Forms SSA-2490-BK and SSA-2960

Application for Benefits Under a U.S. International Social Security Agreement

and Transmittal/Request/Certification Form

20 CFR 404.1925

OMB No. 0960-0448

Background

The SSA-2960 is a transmittal form that the Social Security Office of International Operations (OIO), the Foreign Service Posts (FSPs) and the Canadian Border Offices complete during the Totalization process to:

• Transmit claims and related material to the appropriate foreign agencies

• Request information from those agencies, and

• Respond to requests from those agencies.

We inadvertently neglected to add the SSA-2960 to the Totalization agreement package when SSA initially began using the form. The current Information Collection Request (ICR) for the Totalization agreements (0960-0448) includes provisions for exchanging information. Since we use the SSA-2960 specifically to facilitate the exchange of information between SSA and countries with which we have Totalization agreements, we are adding this form to the ICR. In adding this form, we will bring it into compliance under the law.

Summary of Form SSA-2960

• Section1, Information about the Claim section, requests the following information:

  • Name of worker

  • Full name at birth

  • foreign SSN / pension number

  • U.S. SSN

  • Father’s name

  • Mother’s Maiden Name

  • Name of claimant

  • Other names used

  • Address of Claimant

  • Telephone Number

  • Type of Benefits Claimed ( retirement, Disability, Survivors)

  • Date Claim filed

• Section 2, Certification of Data, requests the following:

  • Certifying Date of birth for the worker, spouse/widower, and children

  • Additional certification includes:

    • Number holder’s date of death

    • date of marriage

    • citizenship

    • date of divorce if applicable.

• Section 3, Information Provided, requests coverage record, medical evidence, information requested date and Other information (not listed).

• Section 4, Information Needed, includes requests for coverage record, medical evidence, status of request date and Other information (not listed).

• Section 5, Remarks, may include any additional information that would be helpful or needed to process a claim.

Updated Burden Chart for 0960-0448 to Include the SSA-2960

Form Number	Number of Respondents	Frequency of Response	Average Burden per Response (minutes)	Total Annual Burden (hours)
SSA-2490-BK (MCS)	14,000	1	30	7,000
SSA-2490-BK (paper)	2,000	1	30	1,000
SSA-2960	11,000	1	3	550
Totals	27,000			8,550