10
(over)
Agreement Between The United States And France
Authority to collect information
for a certicate of coverage
(see pages 4-5)
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 certicate of coverage. Without
the certicate, 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 may also
disclose information to another person or to
another agency in accordance with approved
routine uses, which include but are not limited to
the following:
• To enable a third party or an agency to assist
Social Security in establishing rights to Social
Security benets or coverage;
• To comply with federal laws requiring
the release of information from Social
Security records (e.g., to the Government
Accountability Ofce, General Services
Administration, National Archives Records
Administration, and the Department of
Veterans Affairs);
• To make determinations for eligibility in
similar health and income maintenance
programs at the federal, state, and local
level; and
• To facilitate statistical research, audit, or
investigative activities necessary to assure
the integrity of Social Security programs.
We may also 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 benet 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 online
at www.socialsecurity.gov or at any Social
Security ofce.
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 Ofce 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 certicate of coverage.
Contacting Social Security
Visit our website
The most convenient way to conduct Social
Security business from anywhere at any
time, is to visit www.socialsecurity.gov.
There, you can:
• Apply for retirement, disability, and
Medicare benets;
• Find copies of our publications;
• Get answers to frequently asked
questions; and
• So much more!