Ssa-2960

Form Approved
OMB No. 0960-0448
USA / UK3

SOCIAL SECURITY ADMINISTRATION

U.S. - U.K. AGREEMENT ON SOCIAL SECURITY
TRANSMITTAL / REQUEST / CERTIFICATION
DATE OF ORIGINAL (Month / Day / Year)

(

/

DATE(S) OF FOLLOWUP(S) (Month / Day / Year)

/ )

TO: Retirement Request:
Department of Work and Pension
PRIB Room TC214
Tyneview Park, Whitley Road
Benton, Newcastle - Upon - Tyne NE98 1BA
England

1. ( /
/ )
2. (
FROM:
Social Security Administration
Division of International Operations
P.O. Box 17769
Baltimore, MD 21235-7769 USA

/

/

)

American Embassy
London, England

1. INFORMATION ABOUT THE CLAIM
a) Name of Worker
b) Full Name at Birth
c) U.K. National Insurance Number
d) U.S. Social Security Number

-

-

e) Father's Name
f) Mother's Maiden Name
g) Name of Claimant
h) Address of Claimant
i) Telephone Number
j) Type of Benefit Claimed
Retirement
Disability
Survivors
k) Date Claim Filed (Month / Day / Year)

U.S.

/

U.K.

/

2. CERTIFICATION OF DATA
a)

Date of Birth

Name

Worker
Spouse / Widow(er)
Child
Child
Child
b) Number Holder's Date of Death
c) Date of Marriage
d) Date of Divorce

Verified

Date (Month / Day / Year)
/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

/

3. INFORMATION PROVIDED
a)
b)
c)
d)

Coverage Record
Medical Evidence
Information Requested On (Month / Day / Year)
Other – (see Remarks)

/

/

4. INFORMATION NEEDED
a)
b)
c)
d)

5.

Coverage Record
Medical Evidence
Status of Request Dated (Month / Day / Year)
Other – (see Remarks)
REMARKS:

/

/

Signature

Form SSA-2960-UK (05-01)

Date:
April 6, 2012

Stamp