Addendum to Supporting Statement 0960-0554

Addendum to the Supporting Statement for

Certificate of Coverage Request

20 CFR 404.1913

OMB No. 0960-0554

Collection Instrument in Use without OMB Approval

During our last clearance of the certificate of coverage, the Social Security Administration was unaware that we had not obtained OMB approval for the 24 Internet-based electronic forms created for obtaining a Certificate of Coverage. Therefore, SSA is making every possible effort to ensure we bring them into compliance with the PRA now.

Revision to the Collection Instrument

The 24 Internet-based forms available on the SSA website are only available electronically. We do not provide PDFs or paper versions of these forms. We are also adding the Privacy Act Statements to each form as provided by the SSA Office of General Counsel. The forms are available on our website at the following web address: https://secure.ssa.gov/apps6z/coc_db/allforms.html

The 24 web based forms ask the same questions with the exception for four countries which require additional questions. We discuss any applicable differences further below. Each form corresponds to an agreement held with a foreign country. We presently have a form for; Australia, Austria, Belgium, Canada, Chile, Czech Republic, Denmark, Finland, France, Germany, Greece, Ireland, Italy, Japan, South Korea, Luxembourg, Netherlands, Norway, Poland, Portugal, Spain, Sweden, Switzerland, and the United Kingdom.

Each form provides unvarying questions for the online application.

Questions on all forms:

INFORMATION ABOUT THE EMPLOYEE

1) First Name Middle Initial

2) Last Name

3) U.S. Social Security Number Social Security Number

4) Date of Birth: Month Day Year

5) Country of Birth

6) Country of Citizenship

7) Country of Permanent Residence

8) Date of Hire: Month Day Year

9) Country of Hire

10) Beginning date of assignment in [COUNTRY]:

Month Day Year

11) Expected ending date of assignment in [COUNTRY]:

Ending date of assignment in Australia select month from the twelve month list Ending date of assignment in Australia select day from the thirty one list Ending date of assignment in Australia Enter 4-digit year Month Day Year

INFORMATION ABOUT THE EMPLOYER

AMERICAN EMPLOYER OR FOREIGN AFFILIATE?

12) Please select one of the options below:

We are a U.S. employer for whom the employee named above will be working directly (for example, in a branch office) while in [COUNTRY].

The employee named above will be working for a foreign affiliate of our company, and the affiliate is covered by a section 3121(l) agreement. The date on which the section 3121(l) agreement became effective for this affiliate is:

3121(l) agreement effective date 2-digit month 3121(l) agreement effective date 2-digit day 3121(l) agreement effective date 4-digit year Month Day Year

YOUR U.S. LOCATION

13) Company Name used in the U.S. (Start with Block 1 and use Block 2 if necessary):

Block 1 U.S. Company Name - this field is mandatory and can include up to 60 characters

Block 2 U.S. Company Name - this field is optional and can include up to 40 characters

14) U.S. Street Address (Start with Block 1 and use Block 2 if necessary):

Block 1 Employer's U.S. Street Address - this field is mandatory and can include up to 30 characters

Block 2 Employer's U.S. Street Address - this field is optional and can include up to 30 characters

15) City

16) State

17) ZIP Employer's U.S. ZipCode 5-digits Employer's U.S. ZipCode additional 4-digits, optional

YOUR LOCATION IN [COUNTRY]

18) Company Name in [COUNTRY] (Start with Block 1 and use Block 2 if necessary):

Block 1 Employer's Company Name in Australia, this field is mandatory and can include up to 60 characters

Block 2 Employer's Company Name in Australia block 2 this field is optional and can include up to 40 characters

19) Street Address in [COUNTRY] (Start with Block 1 and use Block 2 if necessary):

Block 1 Employer's Australian Street Address

Block 2 Employer's Australian Street Address block 2 optional

20) City Employer's Australian City

21) Postal Code Employer's Australian Postal Code

INFORMATION ABOUT THE CONTACT PERSON

22) Your Nameenter contact person's full name

23) Your Title contact person's title

24) Your Telephone Number contact person: area code for phone number contact person: first 3-digits for phone number contact person: last 4-digits for phone number

25) Extension (if any)

26) Your E-Mail Address (required if you wish to be notified by e-mail when your request is approved) Provide e-mail address if you wish to be notified when request is approved

MAILING ADDRESS

If you would like the Certificate or other correspondence mailed to a U.S. address other than the employer address you provided in the section entitled "YOUR U.S. LOCATION,” please complete blocks 27 thru 32. Otherwise, we will use the address provided in the YOUR U.S. LOCATION section.

27) Name of Person to Receive Correspondence

28) Company Name (Start with Block 1 and use Block 2 if necessary):

Block 1 recipient's company name for person

Block 2 recipient's company name block 2 optional

29) Street Address (Start with Block 1 and use Block 2 if necessary):

Block 1 recipient's Street Address

Block 2 recipient's company street address block 2 optional

30) City recipient's city

31) State

32) ZIP recipient's 5-digit zipcode 4-digit zipcode for receiving person's address, optional

Is there anything else we need to know?
(Comments are limited to 960 characters - about 16 lines of text)

Differences in Questionnaires

Four countries have additional questions on the forms because of the terms of the negotiated agreements. The forms for Denmark, Netherlands, Norway, and Sweden require:

• The foreign country social insurance number of the worker and of the family members

• The family member’s names and their dates of birth

• The worker’s maiden name as applicable

Additional Agreements

Since the last time we renewed OMB approval for this collection, we added three new agreements for the Czech Republic, Denmark, and Poland. These additional agreements increase the burden for this information collection request.