Certificate of Coverage Request via Letter - Individuals (Poland)

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.