If you are a U.S. employer sending an employee to work in Japan 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 Japan. 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.-Japanese agreement, visit the home page of SSA's Office of International Programs.
1) First Name Middle Initial
2) Last Name
3) U.S. Social Security Number Social Security Number
4) Date of Birth: Month 4-digit year of birth January February March April May June July August September October November December Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year
5) Country of Birth
6) Country of Citizenship
7) Country of Permanent Residence
8) Date of Hire: Month Enter Year of Hire January February March April May June July August September October November December Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year
9) Country of Hire
10) Beginning date of assignment in Japan:
Month Beginning date of assignment in Japan select month from the twelve month list Beginning date of assignment in Japan select day from the thirty one day list Beginning date of assignment in Japan Enter 4-digit year January February March April May June July August September October November December Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year
11) Expected ending date of assignment in Japan:
Month January February March April May June July August September October November December Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year
12) Will the Employee and any Accompanying Family Members be Covered under Private Health Insurance while in Japan?
Yes No
AMERICAN EMPLOYER OR FOREIGN AFFILIATE?
13) Please select one of the options below:
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 January February March April May June July August September October November December Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year .
YOUR U.S. LOCATION
14) 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
15) 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
16) City Employer's U.S. City - this field is mandatory and can include up to 26 characters
17) State Employer's U.S. State - this field is mandatory and please select from the list Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Virgin Islands Washington West Virginia Wisconsin Wyoming
18) ZIP Employer's U.S. ZipCode 5-digits Employer's U.S. ZipCode additional 4-digits, optional -
YOUR LOCATION IN Japan
19) Company Name in Japan (Start with Block 1 and use Block 2 if necessary):
Block 1 Employer's Company Name in Japan, this field is mandatory and can include up to 60 characters
Block 2 Employer's Company Name in Japan block 2 this field is optional and can include up to 40 characters
20) Street Address in Japan (Start with Block 1 and use Block 2 if necessary):
Block 1 Employer's Japanese Street Address
Block 2 Employer's Japanese Street Address block 2 optional
21) City Employer's Japanese City
22) Postal Code Employer's Japanese Postal Code
23) Your Name enter contact person's full name
24) Your Title contact person's title
25) 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 ( ) -
26) Extension (if any)
27) 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
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.
28) Name of Person to Receive Correspondence
29) 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
30) 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
31) City recipient's city
32) State Select recipient's state from the list. Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Virgin Islands Washington West Virginia Wisconsin Wyoming
33) 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) Optional, additional information, please explain briefly, You can include up to 960 characters
Please do not fill the field below, it is for displaying submit status
SSA forms are subject to periodic revisions. You can be assured that this SSA Internet Server Page will always have the latest edition. Please check this Page to make certain that you have the latest edition.
Revision Date: September 1, 2005