TN 3 (03-09)

A. Process for issuing a certificate of coverage

The following steps describe the process for issuing a certificate of coverage:

1. The employer (in the case of employment) or the worker (in the case of self-employment) writes to the appropriate authority requesting a certificate.

   NOTE: The employer's or worker's representative (e.g., attorney or accounting firm) may request the certificate on the employer's or worker's behalf.

2. The Social Security Administration (in the case of U.S. certificates) or the Czech Social Security Administration (in the case of Czech certificates) issues the certificate, if appropriate.

3. The issuing agency sends the original and one copy to the requestor.

4. If the person is employed, the employer or worker presents the certificate to the tax authorities in the other country when requested to do so.

5. If the person is a self-employed U.S. citizen who is subject only to Czech laws under the agreement, he or she must attach a photocopy of the Czech certificate to his or her U.S. income tax return each year.

B. Procedure for requesting a certificate of coverage

1. Required information

Advise the person to provide the following information when writing to get a certificate of coverage:

• Full name of worker;

• Date and place of birth;

• U.S. Social Security number;

• Czech Birth Certificate number, if known;

• Country of citizenship;

• Country of permanent residence;

• Name and address of employer in both countries, if employed, or address of trade or business in both countries, if self-employed;

• Nature of trade or business, if self-employed;

• Date and place of hire by employer transferring the employee, if employed;

• Beginning date and ending date of employment or self-employment in the other country;

• A statement indicating whether the employee remains an employee of the U.S. company while working in the Czech Republic or becomes an employee of a Czech company.

  NOTE: If the worker is an employee of a Czech affiliate of an American employer, the request must indicate whether the American employer has entered into an agreement with the Internal Revenue Service under section 3121(l) of the Internal Revenue Code and, if yes, the effective date of such an agreement.

2. Where to send the request for a certificate

Advise the person to send the request to the appropriate address below.

a. For U.S. certificates

Advise the person to send the request for a U.S. certificate of coverage (form USA/CZ 1, Certificate of Coverage) to the following address:

If preferred, the request may be sent by fax to (410) 966-1861. Please note this fax number is only for requesting U.S. certificates of coverage.

NOTE: Employers who have access to the Internet can request U.S. certificates of coverage over the Internet. For more information about requesting U.S. certificates of coverage via the Internet, see www.socialsecurity.gov/international . Only an employer can use the online form to request a certificate of coverage. A self-employed person must submit a request by mail or fax.

b. For Czech certificates

Advise the person who wants to get a Czech certificate of coverage (form CZ/USA 1, Certificate of Coverage) to write to the following address in the Czech Republic:

C. Reference

RS 01901.070, Employment Outside the United States for a Foreign Affiliate or Subsidiary of an American Employer