TN 15 (02-95)

A. PROCESS

Following is a description of the certificate of coverage process.

1. U.S. Certificates

SSA issues certificates on form USA/NL 101. The process is as follows:

• SSA completes the certificate of coverage form and mails two copies to the U.S. employer that requested it. (Two copies are also mailed to a self-employed person.)

• SSA also sends a copy of the certificate to the Dutch Social Security authorities.

• The U.S. employer gives one copy of the certificate to the employee for his or her records and sends the other copy to its office in the Netherlands where the employee will be working.

• The employer in the Netherlands or the self-employed person presents the certificate to the Dutch tax authorities, if requested to do so, to verify the worker's exemption from Dutch Social Security tax.

2. Dutch Certificates

The Dutch agency issues certificates on form NL/USA 101. The process is as follows:

• The Dutch agency sends a copy to the person requesting the certificate.

• When the person is employed, the employer in the U.S. retains the certificate and presents it to the IRS upon request.

• When the person is self-employed, the worker attaches a photocopy of the certificate to the schedule SE that is filed with the income tax return each year. When preparing the schedule SE to determine the amount of the SECA tax, the worker indicates that the earnings are exempt under the agreement as evidenced by the attached certificate.

B. PROCEDURE - WHERE TO WRITE

Advise the employer or self-employed person to take the appropriate action below to obtain a certificate of coverage.

1. U.S. Certificates

To obtain a certificate from the United States, write to SSA at the address in RS 02001.635A.

2. Dutch Certificates

To obtain a certificate from the Netherlands, write to the Sociale Verzekeringsbank (Social Insurance Bank) at the address in
RS 02001.635A.

C. PROCEDURE - REQUIRED INFORMATION

Advise the person to provide the following information when writing to obtain a certificate of coverage:

• Full name of worker (including maiden name for married woman)

• Social Security number (U.S. number for U.S. certificate and Dutch number for Dutch certificate)

• Country of citizenship

• Date and place of birth

• Country of permanent residence

• Name (including maiden name of wife), relationship, and date of birth of any family members accompanying the worker to the Netherlands

• Name and address of employer in both countries (if self-employed, address of trade or business in both countries)

• Date and place of hire by employer transferring the employee, if employed

• Beginning date and ending date (if known) of employment or self-employment in the other country

• Statement indicating whether the employee will remain an employee of the U.S. company while working in the Netherlands or will become an employee of a Dutch company

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