Certificate of Coverage Request via Internet - Individuals (Poland)

U.S.-POLISH SOCIAL SECURITY AGREEMENT
If you are a U.S. employer sending an employee to work in Poland 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 Poland. 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.-Polish 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
Employee's Name
1) First Name

Middle Initial
2) Last Name

3) U.S. Social Security Number

4) Date of Birth
Month Select Month of Birth

Day Select Day of Birth

Year Enter Year of Birth

5) Country of Birth

6) Country of Citizenship

7) Country of Permanent Residence

8) Address in Poland (if known; start with Block 1 and use Block 2, if necessary)
Block 1 Address in Poland (if known; start with Block 1 and use Block 2, if necessary)
Block 2 Address in Poland (if known; start with Block 1 and use Block 2, if necessary)
City Address in Poland City
9) Date of Hire
Month Select Month of Hire

Day Select Day of Hire

Year
Enter Year of Hire
10) Country of Hire

11) Beginning date of assignment in Poland
Month Select Month for Beginning Date of Foreign Assignment

Day Select Day for Beginning Date of Foreign Assignment

Year Enter Year for Beginning Date of Foreign Assignment

12) Expected ending date of assignment in Poland
Month Select Month for Ending Date of Foreign Assignment

Day Select Day for Ending Date of Foreign Assignment

Year Enter Year for Ending Date of Foreign Assignment

INFORMATION ABOUT THE EMPLOYER
AMERICAN EMPLOYER OR FOREIGN AFFILIATE?
13) 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 Poland.
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 Select Month for Effective Date of the 3121(1) Agreement
Day Select Day for Effective Date of the 3121(1) Agreement
Year Enter Year for Effective Date of the 3121(1) Agreement
YOUR U.S. LOCATION
14) Company Name used in the U.S. (Start with Block 1 and use Block 2 if necessary)
Block 1 U.S. Company Name - this field is mandatory and can include up to 60 characters

Block 2 U.S. Company Name - this field is optional and can include up to 40 characters

15) U.S. Street Address (Start with Block 1 and use Block 2 if necessary)
Block 1 Employer's U.S. Street Address - this field is mandatory and can include up to 30 characters

Block 2 Employer's U.S. Street Address - this field is optional and can include up to 30 characters

16) City Employer's U.S. City - this field is mandatory and can include up to 26 characters

17) State Employer's U.S. State - this field is mandatory and please select from the list

18) Zip Employer's U.S. ZipCode

YOUR LOCATION IN POLAND
19) Company Name in Poland (Start with Block 1 and use Block 2 if necessary)
Block 1 Employer's Company Name in Poland, this field is mandatory and can include up to 60
characters

Block 2 Employer's Company Name in Poland block 2 this field is optional and can include up to 40
characters
20) NIP#/REGON#/PESEL#
NIP Region

21) Street Address in Poland (Start with Block 1 and use Block 2 if necessary)

Block 1 Employer's Polandn Street Address
Block 2 Employer's Polandn Street Address block 2 optional
22) City Employer's Polandn City

23) Postal Code Employer's Polandn Postal Code
INFORMATION ABOUT THE CONTACT PERSON
24) Your Name enter contact person's full name

25) Your Title contact person's title

26) Your Telephone Number contact person's phone number

27) Extension (if any)
28) Your E-Mail Address
(required if you wish to be notified by e-mail when your request is approved) Provide e-mail address
if you wish to be notified when 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 28 thru 33. Otherwise, we will use the address provided in the YOUR U.S. LOCATION
section.
29) Name of Person to Receive Correspondence
30) Company Name (Start with Block 1 and use Block 2 if necessary)

Block 1 recipient's company name for person
Block 2 recipient's company name block 2 optional
31) Street Address (Start with Block 1 and use Block 2 if necessary)
Block 1 recipient's Street Address
Block 2 recipient's company street address block 2 optional
32) City recipient's city
33) State Select recipient's state from the list.
34) Zip recipient's zipcode
ADDITIONAL COMMENTS
Is there anything else we need to know?
(Comments are limited to 960 characters - about 16 lines of text) Optional, additional information,

please explain briefly, You can include up to 960 characters
Submit

Previous

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

See Revised Privacy Act
Statement Attached

SSA will insert the following revised Privacy Act Statement into the screens as soon as
possible:
Privacy Act Statement
Collection and Use of Personal Information
Section 233 of the Social Security Act, as amended, allows us to collect this information.
Furnishing us this information is voluntary. However, failing to provide all or part of the
information may prevent us from making an accurate and timely decision on your request for a
certificate of coverage.
We will use the information you provide to determine if you are subject to United States social
security coverage and taxation. We may also share your information for the following purposes,
called routine uses:
•

To the Social Security Administration of a foreign country, to carry out the purpose of an
international Social Security agreement entered into between the United States and the
other country, pursuant to section 233 of the Social Security Act; and

•

To any source that has, or is expected to have to have, information that the Social
Security Administration needs in order to establish or verify a person’s coverage under a
Social Security agreement authorized by section 233 of the Social Security Act.

In addition, we may share this information in accordance with the Privacy Act and other Federal
laws. For example, where authorized, we may use and disclose this information in computer
matching programs, in which our records are compared with other records to establish or verify a
person’s eligibility for Federal benefit programs and for repayment of incorrect or delinquent
debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notice
(SORN) 60-0059, entitled Earnings Recording and Self-Employment Income System, as
published in the Federal Register (FR) on January 11, 2006, at 71 FR 1819. Additional
information, and a full listing of all of our SORNs, is available on our website at
www.ssa.gov/privacy.