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 |
File Type | application/msword |
File Title | ADDENDUM TO SUPPORTING STATEMENT |
Author | Naomi |
Last Modified By | 889123 |
File Modified | 2012-04-09 |
File Created | 2012-04-09 |