Form SSA-2960 U.S - [Country] Agreement on Social Security Transmittal

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)

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

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

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

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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

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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.

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U.K.

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

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

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

5.

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

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Signature

Form SSA-2960-UK (05-01)

Date:
April 6, 2012

Stamp