TN 4 (06-09)

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 Polish ZUS or KRUS competent authorities (in the case of Polish ZUS or KRUS 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 or national who is subject only to Polish laws under the agreement, he or she must attach a photocopy of the Polish 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;

• Country of permanent residence;

• Country of citizenship;

• U.S. Social Security number;

• Polish Number Identyfikacji Podatkowej (NIP) number (10 digit individual or business tax identification number);

• Polish Rejestr Gospodarki Narodowej (REGON) number (9 digit employer statistical number-not needed for self-employment);

• Name and address of employer in both countries if employed o raddress 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; and

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

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

2. Where to send 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/PL 1- Certificate of Coverage Under Article 6 of the Agreement on Social Security Between the United States of America and the Republic of Poland) to the following address:

Social Security Administration

Office of International Programs

P.O. Box 17741

Baltimore, Maryland 21235-7741

U.S.A.

If preferred, send the request by fax to 410-966-1861. Please note this FAX number is only for requesting U.S. certificates of coverage.

NOTE: Employers (or the representative of the U.S. company) who have access to the Internet can request U.S. certificate(s) of coverage over the Internet. See www.socialsecurity.gov/international for more information about requesting U.S. certificates of coverage via the Internet. Only an employer (or the representative of the U.S. company) 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 Polish certificates

Advise the employer or the self-employed person seeking a Polish certificate of coverage (form PL/USA 1 – Certificate of Coverage Under Article 6 of the Agreement on Social Security Between the Republic of Poland and the United States of America) to write to the following address in Poland for ZUS:

Zaklad Ubezpieczen Spolecznych

Department Ubezpieczen i Saladek

ul. Szamocka 3, 5

00 – 748 Warszawa

POLAND

Advise the employer (farmer) or agricultural worker seeking a Polish certificate of coverage (form PL/USA 1 – Certificate of Coverage Under Article 6 of the Agreement on Social Security Between the Republic of Poland and the United States of America) to write to the following address in Poland for KRUS:

Centrala Kasy Rolniczego Ubezpieczenia

Spolecznego - Biuro Ubezpienczen

Al. Niepodleglosci 190

00-608 Warszawa

POLAND

C. Reference

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