Certificate of Coverage Request via Letter - Individuals (minus Denmark, Iceland, Netherlands, Norway, Slovenia, Sweden & Uruguay)

Agreement Between
The U.S.
And Australia

Contacting Social Security
Visit our website
Our website, www.socialsecurity.gov,
is a valuable resource for information
about all of Social Security’s programs.
At our website you also can get forms
to request important documents such as
a Social Security Statement, a replacement Social Security or Medicare card or
a letter to confirm your benefit amount.
You can find our publications online
as well.

For more information
To file a claim for U.S. or Australian
benefits under the agreement, follow
the instructions on pages 24-25.
To find out more about U.S. Social
Security benefits or for information
about a claim for benefits, contact any
U.S. Social Security office or call our
toll-free number at 1-800-772-1213.
If you live outside the United States,
write to:
Social Security Administration
OIO—Totalization
P.O. Box 17049
Baltimore, MD 21235-7049
USA
For more information about
Australia’s Social Security programs:
• If you live in Australia, contact your
nearest Centrelink office or call
Centrelink toll free at 131673;

• If you live outside Australia and
want information about benefits, write to:
Centrelink International Services
GPO Box 273
Hobart, Tasmania, 7001
AUSTRALIA
• If you live in the United States,
you may call Centrelink toll
free at 1-866-343-3086 or e-mail
Centrelink using the Internet at
international.service@centrelink.gov.au;
• If you need information
about paying Superannuation
Guarantee (SG) contributions,
visit the Australian Taxation
Office Internet site at www.ato.
gov.au/super.
If you do not wish to file a claim
for benefits but would like more
information about the agreement,
write to:
Social Security Administration
Office of International Programs
P.O. Box 17741
Baltimore, MD 21235-7741
USA
For additional information
visit our website:
www.socialsecurity.gov/international

OMB Approval Number: 0960-0554

What’s inside
Introduction . . . . . . . . . . . . . 4
The agreement may help
you, your family and
your employer . . . . . . . . . . . . . . .5

Eliminating dual coverage
for employment . . . . . . . . . . 6
Summary of agreement rules . . .7

Certificate of coverage
for employment . . . . . . . . . . 9
U.S. certificates . . . . . . . . . . . . . .9
Australian certificates . . . . . . . .11

Eliminating dual coverage
for self-employment . . . . . . 12
Effective date
of exemption . . . . . . . . . . . . 13
Monthly benefits . . . . . . . . . 14
How benefits can be paid . . . . . .19
How credits get counted . . . . . .21
Computation of U.S. benefit
under the agreement . . . . . . . . . .21
Computation of Australian
benefit under the agreement . . .22

An Australian pension may
affect your U.S. benefit . . . . 22

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What you need to know
about Medicare . . . . . . . . . . 23
Claims for benefits . . . . . . . 24
Payment of benefits . . . . . . . . . .26
Absence from
U.S. territory . . . . . . . . . . . . . . . .26
Appeals . . . . . . . . . . . . . . . . . . . . .27

Authority to collect
information for a certificate
of coverage . . . . . . . . . . . . . . 27
Privacy Act . . . . . . . . . . . . . . . . .27
Paperwork Reduction
Act Notice . . . . . . . . . . . . . . . . . .28

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Introduction
An agreement effective
October 1, 2002, between the
United States and Australia
improves Social Security protection for people who spend part of
their working life in both countries. It helps many people who,
without the agreement, would not
be eligible for monthly retirement,
disability or survivors benefits
under the Social Security system
of one or both countries. It also
helps people who would otherwise
have to pay contributions to both
countries on the same earnings.
For the United States, the
agreement covers Social Security
contributions (including the U.S.
Medicare portion) and Social
Security retirement, disability and
survivors insurance benefits. It
does not cover benefits under
the U.S. Medicare program or
the Supplemental Security
Income program.
For Australia, the agreement covers “Superannuation
Guarantee” (SG) contributions
that employers must make to
retirement plans for their employees. (Australia’s Social Security
program, which is separate from
the SG program, is supported by
general tax revenues not covered
by the agreement.) Australian
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Social Security benefits covered by
the agreement include the Social
Security age pension, disability
support pension for the severely
disabled, pensions payable to widowed persons and carer payment.
This booklet covers highlights of
the agreement and explains how it
may help you while you work and
when you apply for benefits.

The agreement may help you,
your family and your employer
• While you work—If your
employment is covered by
both U.S. Social Security and
Australian SG, you and your
employer would normally
have to pay contributions to
the U.S. program and your
employer would also have to
pay SG contributions for the
same work. However, the agreement includes rules that eliminate double coverage so that
contributions are paid to just
one country. These rules are
explained in the section titled
“Eliminating dual coverage for
employment.” If you are selfemployed, see pages 12-13.
• When you apply for benefits—
You may have some Social
Security credits in both the
U.S. and Australia but not have
enough to be eligible for benwww.socialsecurity.gov

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efits in one country or the other.
The agreement makes it easier
to qualify for benefits by letting
you add together your Social
Security credits in both countries. For more details, see the
section on “Monthly benefits”
beginning on page 14.

Eliminating dual coverage
for employment
Before the agreement, employers
could, under certain circumstances, be required to pay both U.S.
Social Security contributions and
Australian SG contributions for
the same work.
Under the agreement, if you
work as an employee in the U.S.,
you normally will be covered
by the U.S., and you and your
employer will pay Social Security
contributions to the U.S. and no
SG contributions will be required.
If you work as an employee in
Australia, you normally will be
covered by Australia and your
employer will pay only Australian
SG contributions and neither you
nor your employer will have to
pay U.S. Social Security.
On the other hand, if your
employer sends you from one
country to work for that employer
or an affiliate in the other country
for five years or less, you will con6

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tinue to be covered by your home
country and you will be exempt
from coverage in the other country.
For example, a U.S. citizen sent by
a U.S. company to work for that
employer or an affiliate in Australia
for no more than five years will
continue to pay U.S. Social
Security while working there. The
U.S. employer will also pay to U.S.
Social Security (the employer’s
share), but will be exempt from
Australian SG contributions.

Summary of agreement rules
The following table shows
whether your work as an employee is covered under U.S. Social
Security or the Australian SG
program. If you are covered under
U.S. Social Security, you and your
employer must pay U.S. Social
Security contributions. If you are
covered under the Australian SG
program, your employer must
comply with the SG contribution
requirements. If you are covered
under one country’s program, the
next section explains how to get
a form from that country that will
prove you are exempt in the other
country.
*

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Your work status You are subject
only to the
laws of:
You are working in Australia:
For a U.S. employer who:
• Sent you to work
in Australia for
five years or less
• Sent you to work
in Australia for
more than five
years
• Hired you in
Australia

U.S.
Australia

Australia

Australia
For a non-U.S.
employer
You are working in the U.S.:
For an employer in Australia who:
• Sent you to work Australia
in the U.S. for five
years or less
• Sent you to work U.S.
in the U.S. for
more than five
years
• Hired you in the
U.S.
U.S.
U.S.
For a non-

Australian
employer
If this table does not seem to describe
your employment situation and you are:
• Working in the
U.S.
• Working in
Australia

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Social

Write to the U.S.
address on page 10
for further information.
Contact the
Australian Taxation
Office at www.ato.
gov.au/
super on the
Internet for further
information.

Security

NOTE: As the table indicates,
a U.S. worker assigned temporarily to Australia can be covered by
U.S. Social Security only if he or
she works for a U.S. employer. A
U.S. employer includes a corporation organized under the laws of
the United States or any state, a
partnership if at least two-thirds
of the partners are U.S. residents,
a person who is a resident of the
U.S. or a trust if all the trustees
are U.S. residents. The term also
includes a foreign affiliate of a
U.S. employer if the U.S. employer has entered into an agreement
with the Internal Revenue Service
(IRS) under section 3121(l) of the
Internal Revenue Code to pay
Social Security taxes for U.S.
citizens and residents employed
by the affiliate.

Certificate of coverage
for employment
A certificate of coverage issued
by one country serves as proof of
exemption from Social Security
or SG contributions on the same
earnings in the other country.

U.S. certificates
To establish an exemption from
Australian SG contributions, your
employer must request a certifi-

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cate of coverage (form USA/AUS
1) from the U.S. at this address:
Social Security Administration
Office of International Programs
P.O. Box 17741
Baltimore, MD 21235-7741
USA
If preferred, the request may
be sent by FAX to (410) 966-1861.
Please note this FAX number
should only be used to request
certificates of coverage.
No special form is required
to request a certificate but the
request must be in writing and
provide the following information:
• Full name of worker;
• Date and place of birth;
• Citizenship;
• Country of worker’s permanent
residence;
• U.S. Social Security number;
• Date of hire;
• Country of hire;
• Name and address of the
employer in the U.S. and
Australia; and
• Date of transfer and anticipated
date of return.
In addition, your employer must
indicate if you remain an employee
of the U.S. company while working in Australia or if you become
an employee of the U.S. company’s
affiliate in Australia. If you become
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an employee of an affiliate, your
employer must indicate if the U.S.
company has an agreement with
the IRS under section 3121(l) of
the Internal Revenue Code to pay
U.S. Social Security taxes for U.S.
citizens and residents employed by
the affiliate and, if yes, the effective date of the agreement.
Your employer can also request
a certificate of U.S. coverage for
you over the Internet using a special online request form available
at www.socialsecurity.gov/coc.
Only an employer can use the
online form to request a certificate
of coverage.
When the Social Security
Administration issues a certificate
of U.S. coverage, it mails two copies (one for the employer and one
for the employee) to the requesting
employer. The employer should
retain a copy of the certificate
and present it to the Australian
authorities only when requested to
do so.

Australian certificates
To establish your exemption
from U.S. Social Security contributions during temporary assignments in the United States, your
employer in Australia must request
a certificate of coverage (form
AUS/USA 1) from the Australian
Taxation Office. This can only
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be done over the Internet using a
special online request form that is
available at www.ato.gov.au/super.
Certificates of coverage issued
by Australia should be retained by
the employer in the U.S. in case
of an audit by the IRS. No copy
should be sent to the IRS unless
specifically requested by the IRS.

Eliminating dual coverage
for self-employment
Under U.S. law, self-employed
workers are covered by U.S. Social
Security if they are U.S. citizens
or U.S. resident aliens. The agreement does not have any effect
on the coverage of self-employed
U.S. residents—they remain covered by U.S. Social Security. Since
self-employment is not covered
under Australia’s SG program, selfemployed U.S. residents (including
Australian citizens) do not need any
documentation to show that they
are exempt from SG contributions.
The agreement exempts selfemployed U.S. citizens who reside
in Australia from U.S. Social
Security coverage. As a result,
if you are a self-employed U.S.
citizen and reside in Australia,
you do not have to pay U.S. Social
Security contributions on your
self-employment income. To
document the exemption from the
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payment of U.S. Social Security
self-employment contributions,
you must get a letter of exemption from the U.S. Social Security
Administration by writing to the
address on page 10.
Be sure to provide the following
information in your letter:
• Full name;
• Date and place of birth;
• Citizenship;
• Country of permanent residence;
• U.S. Social Security number;
• Nature of self-employment
activity;
• Date the activity began; and
• Name and address of your trade
or business.
You should attach a photocopy
of the exemption letter to your
U.S. income tax return each year
as proof of the U.S. exemption.

Effective date of exemption
The certificate of coverage or
letter of exemption you receive
will show the effective date of
your exemption from paying U.S.
Social Security contributions or
your employer’s exemption from
paying Australian SG contributions. Generally, this will be the
beginning date of your temporary
assignment in the other country,
or the beginning date of your selfwww.socialsecurity.gov

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employment activity there, but no
earlier than the effective date of
the agreement. To avoid any difficulties, your employer (or you
if you are self-employed) should
request a certificate or exemption
letter as early as possible, preferably before your work in the other
country begins.
If you or your employer request
a certificate of coverage or exemption letter, you should read
the Privacy Act and Paperwork
Reduction Act statements at the
end of this booklet.

Monthly benefits
The following table shows the
various types of benefits payable
under the U.S. and Australian
Social Security systems and briefly
describes the eligibility requirements that normally apply for each
type of benefit. If you do not meet
the normal requirements for these
benefits, the agreement may help
you to qualify (see pages 19-22).
• As the table shows, you need a
minimum number of work credits to qualify for U.S. benefits.
Under U.S. Social Security, you
may earn up to four credits each
year depending on the amount
of your covered earnings. For
example, in 2005, you get one

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credit for each $920 of your
annual earnings up to a maximum of four credits for the year.
• Under the Australian Social
Security system, you must usually have resided in Australia for
a minimum length of time to
qualify for benefits. Also, most
benefits are subject to income
and assets tests.
To simplify the information in
the table, U.S. work credit requirements and Australian residence
requirements are shown in years.
This table is only a general
guide. You can get more specific
information about U.S. benefits
at any U.S. Social Security office
or by calling our toll-free number
at 1-800-772-1213 or by visiting
Social Security’s website at www.
socialsecurity.gov. You
can get more detailed information
about the Australian system by
writing to the Australian address
on the inside cover or by visiting the website of “Centrelink,”
Australia’s social security
agency, at www.centrelink.gov.au
or by calling Centrelink toll-free
at 1-866-343-3086.
NOTE: Since the benefit
provisions of the agreement
do not apply to Australia’s
Superannuation Guarantee (SG)

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legislation, benefits arising from
SG contributions are not included
in the table.
Retirement or old-age benefits
United States

Australia**

Worker—Full benefit at full retirement
age.* Reduced benefit as early as age
62. Required work
credits range from
one and one-half to
10 years (10 years
if age 62 in 1991 or
later).

Worker—Age pension payable at age
65 for men and age
62 for women as of
2002. (Age requirement for women
will gradually
increase to age 65
in 2013.) Normally
requires at least 10
years of residence
between age 16
and retirement age,
including a continuous period of at
least five years.

Disability benefits
United States

Australia**

Worker—Benefit
payable if permanently blind or if disability will prevent
work, training and
rehabilitation for at
least two years. No
minimum residence
requirement if disability occurs while
a permanent resident
of Australia. If disability occurs outside Australia, must
have at least 10 years
of residence, including a continuous
period of at least five
years.
*Full retirement age for people born in 1938
is age 65 and 2 months. The full retirement
age increases gradually until it reaches age
67 for people born in 1960 or later.
Worker—Under full
retirement age* can
get benefit if unable
to do any substantial gainful work for
at least a year. One
and one-half to 10
years credit needed,
depending on age at
date of onset. Some
recent work credits
also needed unless
worker is blind.

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Family benefits to dependents of
retired or disabled people
United States

Australia**

Carer payment—No Carer payment—
provision.
Payable to a partner
who provides constant
care at home for a
person receiving either
an Australian age or
disability pension.
Wife—Full benefit at Wife—No provision
full retirement age* since July 1995.
or at any age if caring
for worker’s entitled
child under age 16 (or
disabled before age
22). Reduced benefit
as early as age 62 if
not caring for a child.
Husband—Same as Husband—No proWife’s.
vision.
Divorced spouse— Divorced spouse—
Parenting payment if
Full benefit at full
caring for at least one
retirement age.*
dependent child under
Reduced benefit
age 16. No minimum
as early as age 62.
Must be unmarried residence requirement
and have been mar- if couple was residing
ried to worker for at in Australia on the
date of the divorce.
least 10 years.
Otherwise, couple
must have been
Australian residents
and in Australia for at
least two years.
Children—If unmar- Children—No provision. However,
ried, up to age 18
supplement payable
(age 19 if in an
for dependent chilelementary or secdren under age 16.
ondary school full
time) or any age if
disabled before age
22.
**Normally, a person must be resident and
physically present in Australia to file a valid
claim for Australian Social Security benefits.
Benefit amounts are generally reduced if
income or resources exceed specified levels.

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Survivors benefits
United States
Widow or widower—
Full benefit at full
retirement age* or at
any age if caring for
the deceased’s entitled child under age
16 (or disabled before
age 22). Reduced benefit as early as age 60
(or age 50 if disabled)
if not caring for child.
Benefits may be continued if remarriage
occurs after age 60 (or
age 50 if disabled).

Australia**
Widow or widower—
Parenting payment
if caring for at least
one dependent child
under age 16. No
minimum residence
requirement if couple was residing in
Australia on the date
of death. Otherwise,
widowed person
must have been
Australian resident
and in Australia for
at least two years.

Divorced widow or
widower—Same as
widow or widower
if marriage lasted at
least 10 years.
Children—Same as
children of retired
or disabled worker.

Divorced widow or
widower—Same as
widow or widower.

Children—
Supplement payable
to person receiving
widow(er) benefit
for dependent children under age 16.
Lump-sum death
Lump-sum death
benefit—A onebenefit—A onetime bereavement
time payment not
to exceed $255 pay- payment of 14
able on the death of times the difference
an insured worker. between a single
and couples pension payable to the
surviving partner of
a pensioner couple.
A bereavement
allowance equal to
age pension rate for
single person payable for 14 weeks
to surviving partner not entitled
to a pension. No
minimum residence
requirement if

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Survivors benefits (continued)
United States

Australia**
couple was residing
in Australia at time
of death. Otherwise
surviving partner
must have been
Australian resident
and in Australia for
at least 2 years.

*Full retirement age for people born in 1938
is age 65 and 2 months. The full retirement
age increases gradually until it reaches age
67 for people born in 1960 or later.
**Normally, a person must be resident and
physically present in Australia to file a valid
claim for Australian Social Security benefits.
Benefit amounts are generally reduced if
income or resources exceed specified levels.

***
**
****

How benefits can be paid
If you have Social Security work
credits in the U.S. and periods of
residence in Australia, you may
be eligible for benefits from one
or both countries. If you meet all
the basic requirements under one
country’s system, you will get a
regular benefit from that country. If you do not meet the basic
requirements, the agreement may
help you qualify for a benefit as
explained below.

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• Benefits from the U.S.—If you
do not have enough work credits under the U.S. system to
qualify for regular benefits, you
may be able to qualify for a partial benefit from the U.S. based
on both U.S. and Australian
credits. Australian credits for
this purpose include your periods of residence in Australia
between age 16 and retirement
age during which you were
covered under the SG program
or you were employed or selfemployed. To be eligible to have
your Australian credits counted,
however, you must have earned
at least six credits (generally
one and one-half years of work)
under the U.S. system. If you
already have enough credits
under the U.S. system to qualify
for a benefit, the U.S. cannot
count your Australian credits.
• Benefits from Australia—As
noted in the table, you must
normally be resident and physically present in Australia to
file a valid claim for Australian
benefits. But the agreement
lets you file a claim from the
U.S. and certain other countries that have agreements with
Australia. Social Security credits
from both countries can also
be counted, when necessary,
to meet the eligibility require20

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ments for Australian benefits.
Unless you are in Australia, you
must have at least 12 months of
residence in Australia—at least
six months of which must have
been continuous—to be eligible
to have your U.S. and Australian
credits added together.

How credits get counted
If we need to count your credits
under the Australian system to
help you qualify for a U.S. benefit,
we will get the necessary information directly from Australia when
you apply for benefits. However,
you will need to provide evidence
of the periods when you worked
in Australia or were covered by
Australia’s SG legislation. The
Australian authorities will provide
us with a certification of the periods they can verify. If Australian
authorities need to count your
U.S. credits to help you qualify
for an Australian benefit, they
will get a copy of your U.S. record
directly from the Social Security
Administration when you apply
for the Australian benefit.

Computation of U.S. benefit
under the agreement
When a U.S. benefit becomes
payable as a result of counting
both U.S. and Australian Social
Security credits, an initial benefit
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is determined based on your U.S.
earnings as if your entire career
had been completed under the U.S.
system. This initial benefit is then
reduced to reflect the fact that
Australian credits helped to make
the benefit payable. The amount
of the reduction will depend on
the number of U.S. credits: the
more U.S. credits, the smaller the
reduction; the fewer U.S. credits,
the larger the reduction.

Computation of Australian
benefit under the agreement
If you are outside Australia
and your Australian benefit
becomes payable as a result of
the agreement, your benefit may
be reduced (i.e., paid at a proportional rate) if you have less than
25 years of Australian working
life residence. Remember that an
Australian benefit may also be
reduced if you have income or
assets that exceed the amounts
specified in Australian law.

An Australian pension may
affect your U.S. benefit
If you have earned enough work
credits in the U.S. to qualify for a
regular Social Security benefit and
you also qualify for an employerprovided pension from Australia,
including a pension that your
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employer is required to provide
under Australia’s SG program,
the amount of your U.S. benefit
may be reduced. This is a result
of a provision in U.S. law that
can affect the way your benefit is
figured if you also receive a pension based on work that was not
covered by U.S. Social Security.
Receipt of an Australian Social
Security pension, which is based on
residence in Australia rather than
work, will not affect the way your
benefit is figured. For more information, call our toll-free number,
1-800-772-1213, and ask for the
publication, Windfall Elimination
Provision, (Publication No. 0510045). If you are outside the
United States, you may write to us
at the address on the inside cover.

What you need to know
about Medicare
Medicare is the U.S. national
health insurance program for
people age 65 or older or who
are disabled. Medicare has two
parts: hospital insurance (also
called “Part A” Medicare) and
medical insurance (called “Part B”
Medicare). You are eligible for free
hospital insurance at age 65 if you
have worked long enough under
U.S. Social Security to qualify for
a retirement benefit. People born
in 1929 or later need 40 credits
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(about 10 years of covered work)
to qualify for retirement benefits.
Although the agreement
between the United States and
Australia allows the Social
Security Administration to count
your Australian credits to help you
qualify for U.S. retirement, disability or survivors benefits, the agreement does not cover Medicare
benefits. As a result, we cannot
count your credits in Australia
to establish entitlement to free
Medicare hospital insurance.
For more information about
Medicare, call our toll-free number,
1-800-772-1213, and ask for the
publication, Medicare, (Publication
No. 05-10043) or visit Medicare’s
website at www.medicare.gov.

Claims for benefits
If you live in the United States
and wish to apply for U.S. or
Australian benefits:
• Visit or write any U.S. Social
Security office; or
• Phone our toll-free number,
1-800-772-1213, 7 a.m. to
7 p.m. any business day. People
who are deaf or hard of hearing may call our toll-free TTY
number, 1-800-325-0778.
You can apply for Australian
benefits at any U.S. Social Security

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office by completing Form AUS/
USA 4 and Form Mod (i).
If you live in Australia and wish
to apply for U.S. or Australian benefits, contact:
• The Social Security Division,
Veterans Affairs Regional
Office, American Embassy,
1131 Roxas Boulevard, 0930
Manila, Philippines, to file for
U.S. benefits; or
• Any Centrelink Customer
Service Centre.
You can apply with one country
and ask to have your application
considered as a claim for benefits
from the other country. Information from your application will
then be sent to the other country.
Each country will process the
claim under its own laws—counting credits from the other country
when appropriate—and notify you
of its decision.
If you have not applied for
benefits before, you may need to
provide certain information and
documents when you apply. These
include the worker’s U.S. Social
Security number, proof of age
for all claimants, evidence of the
worker’s U.S. earnings in the past
24 months and information about
periods of residence and work in
Australia. You may wish to call
the Social Security office before
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25

you go there to see if any other
information is needed.

Payment of benefits
Each country pays its own
benefit. U.S. payments are made
by the U.S. Department of
Treasury each month and cover
benefits for the preceding month.
Payments under the Australian
system are made by Centrelink.
If you live in Australia, payments
are made every two weeks for the
previous two weeks. If you live
outside Australia, payments are
made every four weeks for the
previous four weeks.

Absence from U.S. territory
Normally, people who are not
U.S. citizens may receive U.S.
Social Security benefits while
outside the U.S. only if they meet
certain requirements. Under the
agreement, however, you may
receive benefits as long as you
reside in Australia regardless of
your nationality. If you are not a
U.S. citizen and live in a country
other than the U.S. or Australia,
you may not be able to receive
benefits. The restrictions on U.S.
benefits are explained in the publication, Your Payments While You
Are Outside The United States
(Publication No. 05-10137).

26

Social

Security

Appeals
If you disagree with the decision made on your claim for benefits under the agreement, contact
any U.S. Social Security office or
Australian Centrelink office. The
people there can tell you what you
need to do to appeal the decision.
The Australian Social Security
authorities will review your appeal
if it affects your rights under the
Australian system, while U.S.
Social Security authorities will
review your appeal if it affects your
rights under the U.S. system. Since
each country’s decisions are made
independently of the other, a decision by one country on a particular
issue may not always conform with
the decision made by the other
country on the same issue.

Authority to collect
information for a certificate
of coverage (see pages 9-13)
Privacy Act
The Privacy Act requires us to
notify you that we are authorized
to collect this information by
section 233 ofSee
the revised
Social Security
Privacy
Act and for
Act. While it is
not mandatory
you to furnishPaperwork
the information to
the Social Security
Administration,
Reduction
Act
a certificate ofbelow.
coverage cannot
be issued unless a request has
www.socialsecurity.gov

27

been received. The information is
needed to enable Social Security
to determine if work should be
covered only under the U.S. Social
Security system in accordance
with an international agreement.
Without the certificate, work may
be subject to taxation under both
the U.S. and the foreign Social
Security systems.

Paperwork Reduction
Act Notice
This information collection
meets the clearance requirements of 44 U.S.C. section 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 write down the information to
request a certificate of coverage.

28

Social

Security

Social Security Administration
SSA Publication No. 05-10176
ICN 469044
Unit of Issue - Package of 25
January 2004 (Recycle prior editions)

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
40
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.