Agreement 

Between The U.S. 

And Belgium
Contacting Social Security

Visit our website

Our website, www.socialsecurity.gov, 

is a valuable resource for information 

about all of Social Security’s programs. 

At our website you can also: 

•	 Get a replacement Social Security or 

Medicare card or a letter to confirm 

your benefit amount;

•	 Get forms to request a Social

Security card; and

•	 Find and get copies of our

publications.

Call our toll-free number

In addition to using our website, 

you can call our toll-free number at 

1-800-772-1213. We treat all calls 

confidentially. We can answer specific 

questions from 7 a.m. to 7 p.m., 

Monday through Friday. We provide 

service 24 hours a day. If you are deaf 

or hard of hearing, you may call our 

TTY number, 1-800-325-0778. We 

also want to make sure you receive 

accurate information and courteous 

service. That is why we have a second 

Social Security representative monitor 

some telephone calls.
For more information

To file a claim for U.S. or Belgian 

benefits under the agreement, follow 

the instructions on pages 25-26.

If you live outside the United States, 

write to:

Social Security Administration

OIO—Totalization

P.O. Box 17769

Baltimore, MD 21235-7769

USA

For more information about 

Belgium’s social security programs, 

visit any social security office in 

Belgium. If you do not live in Belgium, 

write to:

National Social Security Office

Waterloolaan 76

B-1000 Brussels

BELGIUM

If you do not wish to file a claim 

for benefits but would like more 

information about the agreement, 

write to:

Social Security Administration

Office of International Programs

P.O. Box 17741

Baltimore, MD 21235-7741

USA

For additional information, 

visit our website:

www.socialsecurity.gov/international

OMB Approval Number: 0960-0554
4

What’s inside

Introduction . . . . . . . . . . . . . . 6

The agreement may help 

you, your family and 

your employer . . . . . . . . . . . . . . . 6

Eliminating dual coverage 

for employment . . . . . . . . . . 7

Summary of agreement rules . . 9

Certificate of coverage 

for employment . . . . . . . . . . 12

U.S. certificates . . . . . . . . . . . . 12

Belgian certificates . . . . . . . . . . 14

Certificates for 

self-employed people . . . . . . . . 14

Effective date of 

coverage exemption . . . . . . . . . 16

Monthly benefits . . . . . . . . 17

How benefits can be paid . . . . . 21

How credits get counted . . . . . 22

Computation of U.S. benefit 

under the agreement . . . . . . . . . 23

A Belgian pension may 

affect your U.S. benefit . . . . 23

What you need to know

about Medicare . . . . . . . . . . 24
5

Claims for benefits . . . . . . . 25

Payment of benefits . . . . . . . . . 27

Absence from U.S. territory . . . 27

Appeals . . . . . . . . . . . . . . . . . . . . 27

Authority to collect 

information for a 

certificate of coverage . . . . . 28

Privacy Act . . . . . . . . . . . . . . . . 28

Paperwork Reduction 

Act Notice . . . . . . . . . . . . . . . . . 31
6

Introduction

An agreement effective July 1, 1984, 

between the United States and 

Belgium improves social security 

protection for people who work or 

have worked in both countries. It 

helps many people who, without the 

agreement, would not be eligible for 

monthly retirement, disability or 

survivors benefits under the social 

security system of one or both 

countries. It also helps people who 

would otherwise have to pay social 

security taxes to both countries on 

the same earnings.

For the United States, the 

agreement covers Social Security 

taxes (including the U.S. Medicare 

portion) and Social Security 

retirement, disability and survivors 

insurance benefits. It does not cover 

benefits under the U.S. Medicare 

program or the Supplemental 

Security Income program. 

This booklet covers highlights of 

the agreement and explains how it 

may help you while you work and 

when you apply for benefits.

The agreement may help you, 

your family and your employer

•	 While you work—If both the U.S. 

and Belgian social security systems 

cover your work, you (and your 

employer, if you are employed) 

would normally have to pay social 

security taxes to both countries 
7

for the same work. However, the 

agreement eliminates this double 

coverage so you pay taxes to only 

one system. The section titled 

“Eliminating dual coverage for 

employment” explains these rules. 

•	 When you apply for benefits—You 

may have some social security 

credits in both the U.S. and 

Belgium but not have enough to be 

eligible for benefits in one country 

or the other. The agreement makes 

it easier to qualify for benefits by 

letting you combine your social 

security credits in both countries. 

For more details, see the section on 

“Monthly benefits” beginning on 

page 17.

Eliminating dual coverage 

for employment 

Before the agreement, employees, 

employers and self-employed people 

could, under certain circumstances, 

be required to pay social security 

taxes to both the United States and 

Belgium for the same work.

Under the agreement, if you work 

as an employee in the United States, 

normally you and your employer will 

pay Social Security taxes only to the 

United States and not to Belgium. If 

you work as an employee in Belgium, 

you normally will pay only Belgian 

social security taxes and neither you 

nor your employer will have to pay 

U.S. Social Security taxes. 
8

On the other hand, if your 

employer sends you from one country 

to work for that employer or an 

affiliate in the other country for 

five years or less, you will continue 

coverage in your home country and 

you will be exempt from coverage in 

the other country. For example, if a 

U.S. company sends an employee to 

work for that employer or an affiliate 

in Belgium for no more than five 

years, the employer and the employee 

will continue to pay only U.S. Social 

Security taxes and will not have to 

pay in Belgium.

If you are self-employed in only 

one country, your work generally is 

subject to social security coverage 

and taxes only in that country. 

Special rules apply, however, if you 

are self-employed in both countries 

or if you normally work in one 

country but are self-employed in the 

other country on a temporary basis 

(see page 11).

NOTE: In addition to old-age, 

survivors and disability benefits, 

Belgian social security taxes cover 

several other programs including 

short-term sickness, unemployment, 

work accident, occupational illness, 

health insurance and family 

allowances. As a result, workers 

exempted from Belgian social 

security coverage by the agreement 

pay no social security taxes for 

these programs and generally 

cannot receive benefits from them. 
9

If the agreement exempts you from 

Belgian coverage, you and your 

employer may wish to arrange for 

alternative benefit protection.

Summary of agreement rules

The following table shows 

whether U.S. or Belgian social 

security covers your work. If U.S. 

Social Security covers your work, 

you and your employer (if you are 

an employee) must pay U.S. Social 

Security taxes. If the Belgian system 

covers your work, you and your 

employer (if you are an employee) 

must comply with the Belgian 

contribution requirements. If one 

country’s program covers your work, 

the next section explains how to 

get a certificate of coverage from 

the country that will prove you are 

exempt in the other country.
10

Your work status Coverage and taxes

You are working in Belgium:

For a U.S. employer who:

* Sent you to work 

in Belgium for five 

years or less

U.S.

* Sent you to work in 

Belgium for more 

than five years

Belgium

* Hired you in 

Belgium Belgium

For a non-U.S. 

employer Belgium

For the U.S. government and you are a:

* U.S. national 

U.S. (either Social 

Security or federal 

retirement program)

* Belgian national Belgium

You are working in the U.S.:

For an employer in Belgium who:

* Sent you to work 

in the U.S. for five 

years or less

Belgium

* Sent you to work in 

the U.S. for more 

than five years

U.S.

* Hired you in the 

U.S. U.S.

For a non-Belgian 

employer U.S.

For the Belgian government and you are a:

* Belgian national Belgium

* U.S. national U.S.
11

Your work status Coverage and taxes

You are self-employed and you:

* Work only in the 

U.S.

U.S.

* Normally work 

in the U.S. but are 

self-employed in 

Belgium for five 

years or less

U.S.

* Work in both 

countries but reside 

in the U.S.

U.S.

* Work only in 

Belgium

Belgium 

* Normally work in 

Belgium but are 

self-employed in 

the U.S. for five 

years or less

Belgium 

* Work in both 

countries but reside 

in Belgium

Belgium 

If this table does not seem to describe 

your situation and you are:

* Working in the U.S. Write to the U.S. 

address on page

12 for further 

information.

* Working in 

Belgium

Write to the Belgian 

address on pages 

14 or 15 for further 

information.

NOTE: As the table indicates, the 

agreement can assign U.S. coverage 

to a U.S. worker temporarily working 

in Belgium only if he or she works 

for a U.S. employer. A U.S. employer 

includes a corporation organized 

under the laws of the United States 

or any state, a partnership if at least 
12

two-thirds of the partners are U.S. 

residents, a person who is a resident 

of the United States or a trust if 

all the trustees are U.S. residents. 

The term also includes a foreign 

affiliate of a U.S. employer if the 

U.S. employer has entered into an 

agreement with the Internal Revenue 

Service (IRS) under section 3121(l) 

of the Internal Revenue Code to pay 

Social Security taxes for U.S. citizens 

and residents the affiliate employs.

Certificate of coverage 

for employment

A certificate of coverage issued 

by one country serves as proof of 

exemption from social security 

taxes on the same earnings in the 

other country.

U.S. certificates 

To establish an exemption from 

compulsory coverage and taxes under 

the Belgian system, your employer 

must request a certificate of coverage 

(form USA/BEL 101) from the United 

States at this address:

Social Security Administration

Office of International Programs

P.O. Box 17741

Baltimore, MD 21235-7741

USA
13

If preferred, send the request 

by FAX to (410) 966-1861. Please 

note this FAX number is only for 

requesting certificates of coverage. 

To request a certificate, the request 

must be in writing and provide the 

following information:

•	 Full name of worker (including 

maiden name for a married woman);

•	 Marital status;

•	 Date and place of birth;

•	 Citizenship;

•	 Country of worker’s 

permanent residence;

•	 U.S. Social Security number;

•	 Date of hire;

•	 Country of hire;

•	 Name and address of the employer in 

the United States and Belgium; and

•	 Date of transfer and anticipated 

date of return.

In addition, your employer must 

indicate if you will remain an 

employee of the U.S. company while 

working in Belgium or if you will 

become an employee of the U.S. 

company’s affiliate in Belgium. If you 

become an employee of an affiliate, 

your employer must indicate if the 

U.S. company has an agreement with 

the IRS under section 3121(l) of the 

Internal Revenue Code to pay U.S. 

Social Security taxes for U.S. citizens 

and residents employed by the 

affiliate and, if yes, the effective date 

of the agreement.
14

Your employer also can request a 

certificate of U.S. coverage for you 

over the Internet using a special 

online request form available at 

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.

Belgian certificates

To establish your exemption 

from coverage under the U.S. Social 

Security system, your employer in 

Belgium must request a certificate of 

coverage (form B/USA) from Belgium 

at this address:

Office of National de Sécurité 

Sociale

Place Victor Horta, 11

B-1030 Brussels

BELGIUM

You need the same information 

required for a certificate of coverage 

from the United States to get a 

certificate from Belgium except 

you must show your Belgian social 

security number rather than your 

U.S. Social Security number. 

Certificates for 

self-employed people

If you are self-employed and 

normally would have to pay social 

security taxes to both the United 
15

States and Belgian systems, you can 

establish your exemption from one of 

the taxes.

•	 If the United States covers your 

work (see table on page 10), write to 

the Social Security Administration 

at the address on page 12; or

•	 If Belgium will cover your work 

(see table on page 10), write to the 

National Social Insurance Institute 

for the Self-Employed at the 

following address:

National Social Insurance

 Institute for the Self-Employed

Jan Jacobsplein 6

B-1000 Brussels

BELGIUM

Be sure to provide the following 

information in your letter:

•	 Full name (including maiden name 

for a married woman);

•	 Marital status;

•	 Date and place of birth;

•	 Citizenship;

•	 Country of permanent residence;

•	 U.S. and/or Belgian social security 

number;

•	 Nature of self-employment activity;

•	 Dates the activity was or will be 

performed; and

•	 Name and address of your trade or 

business in both countries.
16

Effective date of 

coverage exemption

The certificate of coverage you 

receive from one country will show 

the effective date of your exemption 

from paying social security taxes 

in the other country. Generally, 

this will be the date you began 

working in the other country but no 

earlier than the effective date of the 

agreement.

The employer in the United States 

should retain a copy of the certificate 

of coverage issued by Belgium in 

case of an audit by the IRS. The 

employer should not send copies to 

IRS unless specifically requested by 

IRS. However, a self-employed person 

must attach a photocopy of the 

certificate to his or her income tax 

return each year as proof of the U.S. 

exemption.

Social Security will provide copies 

of certificates of coverage issued by 

the United States for both the 

employee and the employer. It will be 

the employee/employer responsibility 

to present the certificate to the 

Belgian authorities when requested to 

do so. To avoid any difficulties, your 

employer (or you, if you are 

self-employed) should request a 

certificate as early as possible, 

preferably before your work in the 

other country begins.

If you or your employer requests a 

certificate of coverage, you should 
17

read the Privacy Act and Paperwork 

Reduction Act statements at the end 

of this booklet.

Monthly benefits 

The following table shows the 

various types of social security 

benefits payable under the U.S. and 

Belgian social security systems 

and briefly describes the eligibility 

requirements that normally apply for 

each type of benefit. If you do not 

meet the normal requirements for 

these benefits, the agreement may 

help you qualify (see pages 21-22). 

This table is only a general 

guide. You can get additional 

information about U.S. benefits by 

visiting Social Security’s website at 

www.socialsecurity.gov. You also 

may visit any U.S. Social Security 

office or call our toll-free number at 

1-800-772-1213. You can get more 

detailed information about the 

Belgian system by writing to the 

Belgian address on page 3.

Under U.S. Social Security, you 

may earn up to four credits each 

year depending on the amount of 

your covered earnings. The amount 

needed to earn a work credit goes 

up slightly each year. The Belgian 

system measures credits in months. 

To simplify the information, the 

table shows requirements in years 

of credits.
18

Retirement or old-age benefits

United States Belgium

Worker—Full benefit 

at full retirement 

age.* Reduced benefit 

as early as age 62. 

Required work credits 

range from one and 

one-half to 10 years 

(10 years if age 62 in 

1991 or later).

Worker—Full benefit 

payable at age 65 

with at least 45 

years of coverage. 

Reduced benefit as 

early as age 60 with 

35 years of coverage. 

Special retirement 

ages and work credit 

requirements for 

miners and seamen.

* Full retirement age is 66 for people born in 

1943-1954 and will gradually increase to 

age 67 for people born in 1960 or later.

Disability Benefits

United States Belgium

Worker—Under full 

retirement age* can 

get benefit if unable 

to do any substantial 

gainful work for at 

least a year. One 

and one-half to 10 

years credit needed, 

depending on age at 

date of onset. Some 

recent work credits 

also needed unless 

worker is blind.

Worker—Must be 

at least two-thirds 

disabled for 12 

months. Some recent 

work credits required.

* Full retirement age is 66 for people born in 

1943-1954 and will gradually increase to 

age 67 for people born in 1960 or later.
19

Family benefits to dependents 

of retired or disabled people

United States Belgium

Spouse—Full benefit 

at full retirement 

age* or at any age 

if caring for the 

worker’s entitled 

child under age 16 (or 

disabled before age 

22). Reduced benefit 

as early as age 62 if 

not caring for a child.

Spouse—No specific 

provision. However, 

a retired worker 

with a dependent 

spouse may receive a 

spouse’s supplement. 

Divorced wife—

Full benefit at full 

retirement age.* 

Reduced benefit as 

early as age 62. Must 

be unmarried and 

have been married 

to worker for at least 

10 years.

Divorced wife—

No provision.

Divorced husband—

Same as divorced wife.

Divorced husband—

No provision.

Children—If 

unmarried, up to 

age 18 (age 19 if in 

an elementary or 

secondary school full 

time) or any age if 

disabled before age 22.

Children—No 

provision. However, 

benefits may be 

payable under the 

Family Allowance 

Program.

* Full retirement age is 66 for people born in 

1943-1954 and will gradually increase to 

age 67 for people born in 1960 or later.
20

Survivors benefits

United States Belgium

Widow(er)—Full 

benefit at full 

retirement age* or at 

any age if caring for 

the deceased’s entitled 

child under age 16 

(or disabled before 

age 22). Reduced 

benefit as early as 

age 60 (or age 50 if 

disabled) if not caring 

for child. Benefits 

may be continued if 

remarriage occurs 

after age 60 (or age 50 

if disabled).

Widow(er)—Benefit 

payable at age 45 

or at any age if 

either caring for a 

child(ren) or at least 

two-thirds disabled; 

must have been 

married to deceased 

for at least one year. 

Pension ceases on 

remarriage, or if the 

deceased worked in 

underground mines 

for at least 20 years.

Divorced widow—

Same as widow if 

marriage lasted at 

least 10 years.

Divorced widow—

Full benefit at age 65 

or reduced benefit 

as early as age 60. 

Must not be entitled 

on her own work 

record. Must not have 

remarried.

Divorced widower— 

Same as divorced 

widow.

Divorced widower—

No provision.

Children—Same as 

for children of retired 

or disabled worker.

Children—No 

provision. However, 

an orphan’s benefit 

may be payable under 

the Family Allowance 

Program.

Lump-sum death 

benefit—A one-time 

payment not to 

exceed $255 payable 

on the death of an 

insured worker.

Death benefit—A 

grant to cover 

funeral expenses is 

payable to the person 

who incurred the 

expenses.

* The full retirement age for survivors is age 

66 for people born in 1945-1956 and will 

gradually increase to age 67 for people born 

in 1962 or later. 
21

NOTE: Belgium accords legal 

same-sex marriages the same rights 

as heterosexual marriages. Therefore, 

a widow(er) of a legal same-sex 

marriage may receive Belgian social 

security benefits. However, registered 

partnerships (heterosexual and 

same-sex couples) remain separate 

for tax and social security purposes. 

Therefore, they do not receive any 

Belgian social security benefits.

NOTE: Belgium accords a 

divorced spouse of a previous legal 

same-sex marriage the same rights 

as a heterosexual divorced spouse.

How benefits can be paid

If you have social security 

credits in both the United States 

and Belgium, you may be eligible 

for benefits from one or both 

countries. If you meet all the basic 

requirements under one country’s 

system, you will get a regular benefit 

from that country. If you do not 

meet the basic requirements, the 

agreement may help you qualify for a 

benefit as explained below.

•	 Benefits from the United States—

If you do not have enough work 

credits under the U.S. system to 

qualify for regular benefits, you 

may qualify for a partial benefit 

from the United States based on 

both U.S. and Belgian credits. 

However, you must have earned at 

least six credits (generally one and 

one-half years of work) under the 
22

U.S. system for the United States to 

count your Belgian credits. If you 

already have enough credits under 

the U.S. system to qualify for a 

benefit, the United States cannot 

count your Belgian credits.

•	 Benefits from Belgium—Belgium 

also can count Social security 

credits from both countries when 

necessary, to meet the eligibility 

requirements for Belgian benefits. 

To be eligible to have your U.S. and 

Belgian credits counted, you must 

have at least 18 months of coverage 

under the Belgian system.

How credits get counted

You do not have to do anything 

to have one country count your 

credits in the other country. If we 

need to count your credits under the 

Belgian system to help you qualify 

for a U.S. benefit, we will get a copy 

of your Belgian record directly from 

Belgium when you apply for benefits. 

If Belgian officials need to count your 

U.S. credits to help you qualify for a 

Belgian benefit, they will get a copy 

of your U.S. record directly from the 

Social Security Administration when 

you apply for the Belgian benefit.

Although each country may count 

your credits in the other country, 

your credits do not actually transfer 

from one country to the other. They 

remain on your record in the country 

where you earned them and can be 

used to qualify for benefits there.
23

Computation of U.S. benefit 

under the agreement

When a U.S. benefit becomes 

payable as a result of counting both 

U.S. and Belgian social security 

credits, we determine an initial 

benefit based on your U.S. earnings 

as if you completed your entire career 

under the U.S. system. This reduces 

the initial benefit to reflect the fact 

that Belgian credits helped to make 

the benefit payable. The amount of 

the reduction will depend on the 

number of U.S. credits: the more U.S. 

credits, the smaller the reduction; 

and the fewer U.S. credits, the larger 

the reduction.

A Belgian pension may affect 

your U.S. benefit

If you qualify for social security 

benefits from both the United States 

and Belgium and did not need the 

agreement to qualify for either 

benefit, U.S. law may reduce the 

amount of your U.S. benefit. This 

is a result of a provision in U.S. law 

that can affect the way the U.S. 

computes your benefit, if you also 

receive a pension based on work not 

covered by U.S. Social Security. For 

more information, visit our website 

at www.socialsecurity.gov, and 

get a copy of Windfall Elimination

Provision (Publication No. 05-10045) 

or call our toll-free number, 
24

1-800-772-1213, or, if you are outside 

the United States, you may write to 

us at the address on page 3.

What you need to know

about Medicare

Medicare is the U.S. national 

health insurance program for people 

age 65 or older or who are disabled. 

Medicare has four parts: 

•	 Hospital insurance (Part A) helps 

pay for inpatient hospital care and 

certain follow-up services; 

•	 Medical insurance (Part B) helps 

pay for doctor’s services, outpatient 

hospital care and other medical 

services;

•	 Medicare Advantage plans (Part C) 

are available in many areas. People 

with Medicare Parts A and B can 

choose to receive all of their health 

care services through a provider 

organization under Part C; and

•	 Prescription drug coverage (Part D) 

helps pay for medications doctors 

prescribe for medical treatment.

You are eligible for free hospital 

insurance at age 65 if you have 

worked long enough under U.S. 

Social Security to qualify for a 

retirement benefit. People born in 

1929 or later need 40 credits (about 

10 years of covered work) to qualify 

for retirement benefits.
25

Although the agreement between 

the United States and Belgium allows 

the Social Security Administration 

to count your Belgian credits to 

help you qualify for U.S. retirement, 

disability or survivors benefits, the 

agreement does not cover Medicare 

benefits. As a result, we cannot count 

your credits in Belgium to establish 

entitlement to free Medicare hospital 

insurance.

For more information about 

Medicare, call our toll-free number, 

1-800-772-1213, and ask for the 

publication, Medicare, (Publication 

No. 05-10043). Or visit Medicare’s 

website at www.medicare.gov.

Claims for benefits

If you live in the United States 

and wish to apply for U.S. or Belgian 

benefits: 

•	 Visit or write any U.S. Social 

Security office; or

•	 Phone our toll-free number, 

1-800-772-1213, 7 a.m. to 7 p.m., 

Monday through Friday. People 

who are deaf or hard of hearing 

may call our toll-free TTY number, 

1-800-325-0778.

You can apply for Belgian benefits 

at any U.S. Social Security office 

by completing an application 

form SSA-2490.

If you live in Belgium and 

wish to apply for U.S. or Belgian 

benefits, contact:
26

•	 The Federal Benefits Unit at the 

U.S. Embassy in London, England 

(phone 20-7499-9000) to file for 

U.S. benefits; or

•	 Any Belgian social security office 

to file for Belgian benefits.

You can apply with one country 

and ask to have your application 

considered as a claim for benefits 

from the other country. Information 

from your application then will 

be sent to the other country. Each 

country will process the claim under 

its own laws, count credits from the 

other country when appropriate, and 

notify you of its decision.

If you have not applied for benefits 

before, you may need to provide 

certain information and documents 

when you apply. These include:

•	 The worker’s U.S. and Belgian 

social security numbers; 

•	 Proof of age for all claimants; and 

•	 Evidence of the worker’s U.S. 

earnings in the past 24 months 

and information about the worker’s 

coverage under the Belgian system. 

You may wish to call the Social 

Security office before you go there to 

see if you will need to provide any 

other information.
27

Payment of benefits

Each country pays its own 

benefit. The U.S. Department of 

the Treasury issues U.S. payments 

each month covering benefits for the 

preceding month.

Under the Belgian system, Belgium 

makes payments at different times 

for different periods depending 

on the type of benefits. For more 

information, contact the Belgian 

authorities at the address on page 3.

Absence from U.S. territory

Normally, people who are not 

U.S. citizens may receive U.S. 

Social Security benefits while 

outside the United States only if 

they meet certain requirements. 

However, under the agreement, 

you may receive benefits as long 

as you reside in Belgium regardless 

of your nationality. If you are not 

a U.S. or Belgian citizen and live 

in a country other than the United 

States or Belgium, you may not 

be able to receive benefits. The 

publication, Your Payments While 

You Are Outside The United States

(Publication No. 05-10137), explains 

the restrictions on U.S. benefits.

Appeals

If you disagree with the decision 

made on your claim for benefits 

under the agreement, contact any 
28

U.S. or Belgian social security office. 

The people there can tell you what 

you need to do to appeal the decision.

The Belgian social security 

authorities will review your appeal 

if it affects your rights under the 

Belgian system, while U.S. Social 

Security authorities will review your 

appeal if it affects your rights under 

the U.S. system. Since each country 

makes decisions independently of 

the other, a decision by one country 

on a particular issue may not always 

conform with the decision made by 

the other country on the same issue.

Authority to collect 

information for a certificate of 

coverage (see pages 12-16)

Privacy Act

Section 233 of the Social Security

Act as amended, [42 U.S.C. 433]

authorizes us to collect this 

information. We will use the 

information you provide to determine 

if your current work should be 

covered only under the U.S. Social 

Security system in accordance with 

an international social security 

agreement. The information you 

provide on this form is voluntary. 

However, failure to provide all or part 

of the requested information may 

prevent us from making an accurate 

and timely decision on your request 

for a certificate of coverage. Without 
29

the certificate, current work may 

continue to be subject to coverage 

and taxation under both the U.S. and 

the foreign social security systems.

We rarely use the information 

you provide on this form for any 

purpose other than for the reasons 

explained above. However, we may 

use it for the administration and 

integrity of Social Security programs. 

We also may disclose information to 

another person or to another agency 

in accordance with approved routine 

uses, which include but are not 

limited to the following:

1. To enable a third party or an 

agency to assist Social Security 

in establishing rights to Social 

Security benefits or coverage;

2. To comply with Federal 

laws requiring the release of 

information from Social Security 

records (e.g., to the Government 

Accountability Office, General 

Services Administration, National 

Archives Records Administration, 

and the Department of 

Veterans Affairs);

3. To make determinations for 

eligibility in similar health 

and income maintenance 

programs at the federal, state, and 

local level; and

4. To facilitate statistical research, 

audit, or investigative activities 
30

necessary to assure the integrity of 

Social Security programs.

We also may use the information 

you provide in computer matching 

programs. Matching programs 

compare our records with records 

kept by other federal, state, 

or local government agencies. 

Information from these matching 

programs can be used to establish 

or verify a person’s eligibility for 

federally-funded or administered 

benefit programs and for repayment 

of payments or delinquent debts 

under these programs. 

A complete list of routine uses 

for this information is available 

in our System of Records Notice 

entitled, Earnings Records and 

Self-Employment Income System, 

60-0059. This notice, additional 

information regarding this form, 

and information regarding our 

programs and systems, are available 

at www.socialsecurity.gov or at any 

Social Security office.
31

Paperwork Reduction 

Act Notice

This information collection meets 

the clearance requirements of 44 

U.S.C. section 3507, as amended by 

section 2 of the Paperwork Reduction 

Act of 1995. You do not need to 

answer these questions unless we 

display a valid Office of Management 

and Budget control number. We 

estimate that it will take you about 

30 minutes to read the instructions, 

gather the necessary facts, and write 

down the information to request a 

certificate of coverage.
Social Security Administration

SSA Publication No. 05-10194

ICN 480202

Unit of Issue - Package of 25

December 2011 (Recycle prior editions)

Printed on recycled paper