TN 20 (01-12)

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) must request the certificate on the employer or worker’s behalf. A request from an employee is not acceptable

2. The Social Security Administration (in the case of U.S. certificates) or the Belgian Office National de Securite Sociale or National Social Insurance Institute for the Self-Employed (in the case of Belgian certificates) issues the certificate, if appropriate.

3. The issuing agency sends the original and one copy to the person who submits the request.

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.

   NOTE: A self-employed U.S. national subject to only Belgian social security laws under the agreement, must attach a photocopy of the Belgian 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 employer, worker, worker’s representative or self-employed worker 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;

• Country of birth;

• Country of citizenship;

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

• Nature of the business activity, 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 Belgium or becomes an employee of the Belgian company,

NOTE: If the worker is an employee of the Belgian 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 employer or self-employed worker to send the request to the appropriate address below.

a. For U.S. certificates

Advise the employer or self-employed worker to send the request for a U.S. certificate of coverage (form USA/BEL 101 Certificate of Coverage) to the following address:

Social Security Administration

Office of International Programs

P.O. B ox 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 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/CoC . 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. Employee who wants a Belgian certificate

Advise the person who wants to get a Belgian certificate of coverage (form B/USA 1, Certificate of Coverage) for a worker who is an employee to write to the following address in Belgium:

Office National de Sécurité SocialeDirection des Relations Internationales Place Victor Horta, 11B-1060 Brussels

BELGIUM

c. Self-Employed wants a Belgian certificate

Advise the person who wants to get a Belgian certificate of coverage (form BG/USA 1, Certificate of Coverage) for a worker who is self-employed to write to the following address in Belgium:

National Social Insurance Institute for the Self-Employed

Jan Jacobsplein 6

B-1000 Brussels

BELGIUM

C. Related reference

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