Certificate of Coverage Request--Private Sector 20 CFR 404.1913

ONLINE CERTIFICATE OF COVERAGE SERVICE--INTRODUCTION

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Go To Online Request Forms
Welcome to SSA's Online Certificate of Coverage Service. Employers who use this service can
expect to receive Certificates several weeks faster than by mail. The online system eliminates
delays due to data rekeying and provides automated error checking, resulting in fewer rejected
applications.
This is one of several online processes SSA is making available as part of our efforts to provide
World Class Service to the public. Let us have your FEEDBACK on this service (but please do
NOT send confidential information, such as a Social Security number, through our Feedback
form).
WHAT ARE CERTIFICATES OF COVERAGE?

SSA issues Certificates of Coverage pursuant to bilateral Social Security agreements with
foreign countries. These agreements are sometimes called "Totalization" agreements. They
eliminate dual Social Security coverage, the situation that occurs when an employee from
one country works in another country and is required--together with the employer--to pay
Social Security taxes to both countries on the same earnings. A Totalization agreement
assigns coverage to just one country and exempts the employer and employee from Social
Security taxes in the other country.
If an agreement assigns coverage of an employee's work to the United States, a Certificate of
U.S. Coverage issued by SSA serves as proof that the employee and employer are exempt
from Social Security taxes in the other country.
You can request Certificates of Coverage under Totalization agreements with the following
21 countries: Australia, Austria, Belgium, Canada, Chile, Finland, France, Germany,
Greece, Ireland, Italy, Japan, Korea (South), Luxembourg, the Netherlands, Norway,
Portugal, Spain, Sweden, Switzerland, and the United Kingdom.

WHO SHOULD USE THE ONLINE CERTIFICATE REQUEST FORMS
If you are a U.S. employer sending an employee to work in an agreement country for 5 years or
less, you can use the online form corresponding to that agreement to request a Certificate of U.S.
Coverage. If you have an employee working in Italy, under certain conditions you can use the
online form for that country even if the employee will be working there for more than 5 years.

https://s044a90.ssa.gov/apps6z/coc_db/allforms.html

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CONFIDENTIALITY
SSA is taking all reasonable and appropriate measures, including encryption, to ensure that
personal information you send us using the online forms is not disclosed to any third
party. However, the Internet is an open system and we cannot absolutely guarantee that the
information you are sending will not be intercepted by others and decrypted. Although this
possibility is remote, it does exist.
If you are not comfortable with these risks, please see one of our articles on individual Totalization
agreements to learn how to request a Certificate of Coverage by mail or fax.

WHERE WE WILL MAIL THE CERTIFICATE
If the employee qualifies for a Certificate, we will mail the Certificate to the U.S. address you
furnish in the section of the form entitled YOUR U.S. LOCATION. If you would like the
Certificate mailed to a different U.S. address, also complete the section entitled MAILING
ADDRESS at the end of the form.

EMPLOYEES OF FOREIGN AFFILIATES
If you are a U.S. employer, and you are sending an employee to work for a foreign affiliate of your
company (rather than directly for you), please read this IMPORTANT NOTE.

HOW TO FILL OUT THE FORM

Please complete the form as completely and accurately as possible or the processing of your
request could be delayed. Most of the information requested is required under the terms of
the Totalization agreements, and you will not be able to transmit your request to our server
unless these required data fields are completed.
Each data field is limited to a maximum number of characters. On most forms, we have
designated the field's maximum size in parentheses. Please DO NOT exceed this size or your
entry will be truncated.
Online Help is available for filling out each item on the forms. Just click on the "hypertext"
heading.

HOW TO REACH US
If you have any questions or comments, you can reach us

by e-mail at: certificate@ssa.gov
by writing to:
SOCIAL SECURITY ADMINISTRATION
Office of International Programs
P.O. Box 17741
Baltimore, MD 21235-7741

https://s044a90.ssa.gov/apps6z/coc_db/allforms.html

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ONLINE CERTIFICATE OF COVERAGE SERVICE--INTRODUCTION

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USA

by telephone at (410) 965-7306 or by FAX at (410) 966-1861.

PRIVACY ACT AND PAPERWORK REDUCTION ACT STATEMENTS
The Privacy Act requires us to notify you that we are authorized to collect this information by section
233 of the Social Security Act. While it is not mandatory for you to furnish the information to the
Social Security Administration (SSA), a certificate of coverage cannot be issued unless a request has
been received. The information is needed to enable SSA to determine if current work should be covered
only under the U.S. Social Security system in accordance with a Totalization agreement. Without the
certificate, current work may continue to be subject to coverage and taxation under both the U.S. and the
See below for revised PRA and PA
foreign Social Security systems.
statements.
This information collection meets the clearance requirements of 44 U.S.C. §3507, as amended by
section 2 of the Paperwork Reduction Act of 1995. You are not required to answer these questions
unless we display a valid Office of Management and Budget control number. We estimate that it will
take you about 30 minutes to read the instructions, gather the necessary facts, and answer the questions.

ONLINE REQUEST FORMS
After reading the above, if you are ready, we invite you to request a Certificate of Coverage for
any of the countries listed below:
Australia | Austria | Belgium | Canada | Chile | Finland | France | Germany
Greece | Ireland | Italy | Japan | Korea (South) | Luxembourg | Netherlands
Norway | Portugal | Spain | Sweden | Switzerland | United Kingdom

Future Revised Editions
SSA forms are subject to periodic revisions. You can be assured that this SSA Internet Server Page will
always have the latest edition. Please check this Page to make certain that you have the latest edition.
Revision Date: September 1st, 2005
SSA Online Home | International Page | Privacy Policy

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| Search | Feedback (please, no confidential information)

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CERTIFICATE OF COVERAGE REQUEST FORM--AUSTRALIA

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Certificate of Coverage Request Form-U.S.-AUSTRALIAN SOCIAL SECURITY AGREEMENT
If you are a U.S. employer sending an employee to work in Australia for 5 years or less, you can use this
form to request a Certificate of U.S. Coverage under the Social Security agreement between the United
States and Australia. Before completing the form, however, PLEASE READ THE IMPORTANT
INTRODUCTORY MESSAGE if you have not already done so.
If you would like more information about the U.S.-Australian agreement, visit the home page of SSA's
Office of International Programs.
For online help completing any of the following fields, click on the number immediately preceding the
field.

INFORMATION ABOUT THE EMPLOYEE
1) First Name

Middle Initial

2) Last Name
3) U.S. Social Security Number
4) Date of Birth: Month

Day

Year

5) Country of Birth
6) Country of Citizenship

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7) Country of Permanent Residence
8) Date of Hire: Month

Day

Year

9) Country of Hire
10) Beginning date of assignment in Australia:
Month

Day

Year

11) Expected ending date of assignment in Australia:
Month

Day

Year

INFORMATION ABOUT THE EMPLOYER
AMERICAN EMPLOYER OR FOREIGN AFFILIATE?
12) Please select one of the options below:
We are a U.S. employer for whom the employee named above will be working directly (for example,
in a branch office) while in Australia.
The employee named above will be working for a foreign affiliate of our company, and the affiliate
is covered by a section 3121(l) agreement. The date on which the section 3121(l) agreement became
effective for this affiliate is:
Month

Day

Year

.

YOUR U.S. LOCATION
13) Company Name used in the U.S. (Start with Block 1 and use Block 2 if necessary):
Block 1
Block 2
14) U.S. Street Address (Start with Block 1 and use Block 2 if necessary):
Block 1
Block 2
15) City
16) State

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CERTIFICATE OF COVERAGE REQUEST FORM--AUSTRALIA

17) ZIP

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-

YOUR LOCATION IN AUSTRALIA
18) Company Name in Australia (Start with Block 1 and use Block 2 if necessary):
Block 1
Block 2
19) Street Address in Australia (Start with Block 1 and use Block 2 if necessary):
Block 1
Block 2
20) City
21) Postal Code

INFORMATION ABOUT THE CONTACT PERSON
22) Your Name
23) Your Title
24) Your Telephone Number (

)

-

25) Extension (if any)
26) Your E-Mail Address (required if you wish to be notified by e-mail when your request is approved)

MAILING ADDRESS
If you would like the Certificate or other correspondence mailed to a U.S. address other than the
employer address you provided in the section entitled "YOUR U.S. LOCATION", please complete
blocks 27 thru 32. Otherwise, we will use the address provided in the YOUR U.S. LOCATION
section.
27) Name of Person to Receive Correspondence

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28) Company Name (Start with Block 1 and use Block 2 if necessary):
Block 1
Block 2
29) Street Address (Start with Block 1 and use Block 2 if necessary):
Block 1
Block 2
30) City
31) State
32) ZIP

-

Is there anything else we need to know?
(Comments are limited to 960 characters - about 16 lines of text)

SEND Form

CLEAR All Fields

Please do not fill the field below, it is for displaying submit status
Status: not submitted.

Future Revised Editions
SSA forms are subject to periodic revisions. You can be assured that this SSA Internet Server Page will
always have the latest edition. Please check this Page to make certain that you have the latest edition.
Revision Date: October 1, 2002

https://s044a90.ssa.gov/apps6z/coc_db/country_form.jsp?ctr_code=AL&ctr=Australia&c... 10/11/2007

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Privacy and Paperwork Reduction Act Statements
Top of Page
SSA Online Home Page
International Page
Search Our Web Site
Feedback (please, no confidential information)

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SSA will insert the following revised PRA Statement into the form at its
next scheduled reprinting:
Paperwork Reduction Act Statement - This information collection meets the
requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction
Act of 1995. You do not need to answer these questions unless we display a valid Office
of Management and Budget control number. We estimate that it will take about 30
minutes to read the instructions, gather the facts, and answer the questions. Send only
comments relating to our time estimate above to: SSA, 6401 Security Blvd, Baltimore,
MD 21235-6401, USA.

Certificate of Coverage Service for Employers, OMB Form No. 0960-0554; and
SSA Publication No. 05-10176
Privacy Act Statement
Collection and Use of Personal Information

Section 233 of the Social Security Act as amended, [42 U.S.C. 433] authorizes us to
collect this information. We will use the information you provide to determine if
your current work should be covered only under the U.S. Social Security system in
accordance with a Totalization agreement. The information you provide on this
form is voluntary. However, failure to provide all or part of the requested
information may prevent us from making an accurate and timely decision on your
request for a certificate of coverage. Without the certificate, current work may
continue to be subject to coverage and taxation under both the U.S. and the foreign
Social Security systems.

We rarely use the information you provide on this form for any purpose other than
for the reasons explained above. However, we may use it for the administration and
integrity of Social Security programs. We may also disclose information to another
person or to another agency in accordance with approved routine uses, which
include but are not limited to the following:
1. To enable a third party or an agency to assist Social Security in establishing
rights to Social Security benefits or coverage;

2. To comply with Federal laws requiring the release of information from
Social Security records (e.g., to the Government Accountability Office,
General Services Administration, National Archives Records Administration,
and the Department of Veterans Affairs);

3. To make determinations for eligibility in similar health and income
maintenance programs at the Federal, State, and local level; and

4. To facilitate statistical research, audit, or investigative activities necessary
to assure the integrity of Social Security programs.

We may also use the information you provide in computer matching programs.
Matching programs compare our records with records kept by other Federal, State,
or local government agencies. Information from these matching programs can be
used to establish or verify a person’s eligibility for Federally-funded or administered
benefit programs and for repayment of payments or delinquent debts under these
programs.

A complete list of routine uses for this information is available in our System of Records
Notice entitled, Earnings Records and Self-Employment Income System, 60-0059. This
notice, additional information regarding this form, and information regarding our

programs and systems, are available on-line at www.socialsecurity.gov or at any Social
Security office.