Screen Shot Template for Denmark-Iceland-Netherlands-Norway-Sweden

.S.- DUTCH SOCIAL SECURITY AGREEMENT
If you are a U.S. employer sending an employee to work in the Netherlands for 5 years or less, you
can use this form to request a Certificate of U.S. Coverage under the Social Security agreement
between the United States and the Netherlands. Before completing the form, however, PLEASE
READ THE IMPORTANT INTRODUCTORY MESSAGE if you have not already done so.
If you would like more information about the U.S.- Dutch agreement, visit the home page of SSA's
Office of International Programs.
For online help completing any of the following fields, click on the number immediately preceding the
field.
INFORMATION ABOUT THE EMPLOYEE
Employee's Name
1) First Name
Middle Initial
2) Maiden Name
3) Last Name
4) U.S. Social Security Number
5) Date of Birth
Month Select Month of Birth
Day Select Day of Birth
Year Enter Year of Birth
6) Country of Birth
7) Country of Citizenship
8) Country of Permanent Residence
9) Date of Hire
Month Select Month of Hire
Day Select Day of Hire
Year
Enter Year of Hire
10) Country of Hire

11) Beginning date of assignment in the Netherlands
Month Select Month for Beginning Date of Foreign Assignment
Day Select Day for Beginning Date of Foreign Assignment
Year Enter Year for Beginning Date of Foreign Assignment
12) Expected ending date of assignment in the Netherlands
Month Select Month for Ending Date of Foreign Assignment
Day Select Day for Ending Date of Foreign Assignment
Year Enter Year for Ending Date of Foreign Assignment

INFORMATION ABOUT THE EMPLOYEE'S FAMILY
13) Information about employee's family members (include only if accompanying the employee to
the Netherlands):
Spouse Name
First Name
Maiden Name
Last Name
Date of Birth
Month Select Spouse Month of Birth
Day Select Day of Birth
Year Enter Year of Birth
First Child Name
First Name
Last Name
Date of Birth
Month Select Month of Birth
Day Select Day of Birth
Year Enter Year of Birth
Second Child Name
First Name
Last Name
Date of Birth
Month Select Month of Birth
Day Select Day of Birth

Year Enter Year of Birth
Third Child Name
First Name
Last Name
Date of Birth
Month Select Month of Birth
Day Select Day of Birth
Year Enter Year of Birth
Fourth Child Name
First Name
Last Name
Date of Birth
Month Select Month of Birth
Day Select Day of Birth
Year Enter Year of Birth
INFORMATION ABOUT THE EMPLOYER
AMERICAN EMPLOYER OR FOREIGN AFFILIATE?
14) 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 the Netherlands.
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:
Month Select Month for Effective Date of the 3121(1) Agreement
Day Select Day for Effective Date of the 3121(1) Agreement
Year Enter Year for Effective Date of the 3121(1) Agreement
YOUR U.S. LOCATION
15) 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
16) 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
17) City Employer's U.S. City - this field is mandatory and can include up to 26 characters

18) State Employer's U.S. State - this field is mandatory and please select from the list
19) Zip Employer's U.S. ZipCode
YOUR LOCATION IN THE NETHERLANDS
20) Company Name in the Netherlands (Start with Block 1 and use Block 2 if necessary)
Block 1 Employer's Company Name in the Netherlands, this field is mandatory and can include up to
60 characters
Block 2 Employer's Company Name in the Netherlands block 2 this field is optional and can include
up to 40 characters
21) Street Address in the Netherlands (Start with Block 1 and use Block 2 if necessary)
Block 1 Employer's Netherlandsn Street Address
Block 2 Employer's Netherlandsn Street Address block 2 optional
22) City Employer's Netherlandsn City
23) Postal Code Employer's Netherlandsn Postal Code
INFORMATION ABOUT THE CONTACT PERSON
24) Your Name enter contact person's full name
25) Your Title contact person's title
26) Your Telephone Number contact person's phone number
27) Extension (if any)
28) 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 29 thru 34. Otherwise, we will use the address provided in the YOUR U.S. LOCATION
section.
29) Name of Person to Receive Correspondence
30) 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
31) 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
32) City recipient's city
33) State Select recipient's state from the list.
34) Zip recipient's zipcode
ADDITIONAL COMMENTS
Is there anything else we need to know?
(Comments are limited to 960 characters - about 16 lines of text) Optional, additional information,

please explain briefly, You can include up to 960 characters
Submit
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will always have the latest edition. Please check this Page to make certain that you have the latest
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Revision Date: October 1, 2002
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SSA will insert the following revised Privacy Act Statement into the screens as soon as
possible:
Privacy Act Statement
Collection and Use of Personal Information
Section 233 of the Social Security Act, as amended, allows us to collect this information.
Furnishing us this information is voluntary. However, failing to provide all or part of the
information may prevent us from making an accurate and timely decision on your request for a
certificate of coverage.
We will use the information you provide to determine if you are subject to United States social
security coverage and taxation. We may also share your information for the following purposes,
called routine uses:
•

To the Social Security Administration of a foreign country, to carry out the purpose of an
international Social Security agreement entered into between the United States and the
other country, pursuant to section 233 of the Social Security Act; and

•

To any source that has, or is expected to have to have, information that the Social
Security Administration needs in order to establish or verify a person’s coverage under a
Social Security agreement authorized by section 233 of the Social Security Act.

In addition, we may share this information in accordance with the Privacy Act and other Federal
laws. For example, where authorized, we may use and disclose this information in computer
matching programs, in which our records are compared with other records to establish or verify a
person’s eligibility for Federal benefit programs and for repayment of incorrect or delinquent
debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notice
(SORN) 60-0059, entitled Earnings Recording and Self-Employment Income System, as
published in the Federal Register (FR) on January 11, 2006, at 71 FR 1819. Additional
information, and a full listing of all of our SORNs, is available on our website at
www.ssa.gov/privacy.