Forms

Forms

Certificate of living

Annex to Request for Exception from Application of the Czech Social Security Legislation pursuant to Article 16 of EP and Council Regulation (EC) 883/2004 and Article 17 of Council Regulation (EEC) 1408/71

Affirmation for foreign employers

 

Other forms – Certificate of living

 

Bilateral Agreements

Application for the Czech pension for persons residing in contracting state

  • Albania
  • Australia
  • Canada
  • India
  • Israel
  • Japan
  • Korea 
  • Moldova
  • Québec
  • Russia 
  • Tunisia
  • USA

Application for persons residing in the Czech Republic for pension from contracting state

  • Albania
  • Australia
  • Canada
  • India
  • Israel
  • Japan
  • Korea
  • Moldova
  • Québec
  • Russia
  • Tunisia
  • USA

 

Application for Czech pension for persons residing in contracting state

ALBANIA

Form AL/CZ 202

Please, send the form filled-in with block letters or electronically to the below-mentioned institution or its regional office depending on your place of residence:

Instituti i Sigurimeve Shoqërore (Social Insurance Institute)
Rruga e Durrësit, nr. 83
1001 Tiranë
Shqipëri (Albania)

http://www.issh.gov.al/

Where appropriate the institution will contact you for any missing information or documentation. Once your application is complete, it will be forwarded it to the CSSA.

 

 

AUSTRALIA

Form CZ/AU 202

Please, send the form filled-in with block letters or electronically to the below-mentioned institution or its regional office depending on your place of residence:

Centrelink International
GPO Box 273
Hobart, Tasmania 7001
AUSTRALIA
http://www.centrelink.gov.au/

Where appropriate the institution will contact you for any missing information or documentation. Once your application is complete, it will be forwarded it to the CSSA.

 

CANADA

Form CAN-CZ 1 (czech-french version)
Form CAN-CZ (czech-english version)

Please fill in the application and return it to the institution mentioned below or to its nearest local office to the following address:

International Operations – AB
Service Canada
P.O. Box 2710, Main Station
Edmonton, Alberta T5J 4C2
CANADA

fax: +1-780-495-5753
http: www.servicecanada.gc.ca



Where appropriate the institution will contact you for any missing information or documentation.Once your application is complete, it will be forwarded it to CSSA.

INDIA

Form CZ/IN 202
Please, send the form filled-in with block letters to your (last) employer who shall forward it to the EPFO (Indian Employees Provident Fund Organisation).

Where appropriate you might be contacted for any missing information or documentation.
Once your application is complete, the EPFO will forward it to the CSSA.

ISRAEL

Form IZR-CZ

Please fill in the application and return it to the institution mentioned below or to its nearest local office to the following address:

National Insurance Institute
Liaison Office for International Conventions
13, Weizmann Avenue
P.O.Box 90009
91909 Jerusalem, ISRAEL
E-mail: btlfeed@btl.gov.il
http: www.btl.gov.il

Where appropriate the institution will contact you for any missing information or documentation.Once your application is complete, it will be forwarded it to the CSSA.

JAPAN

Form J/CZ 202

Please fill in the application and return it to the institution mentioned below or to its nearest local office to the following address:

Japan Pension Service
3-5-24 Takaido-nishi
Suginami-ku
Tokyo 168-8505
JAPAN
http: http://www.nenkin.go.jp/n/www/english/index.jsp


Where appropriate the institution will contact you for any missing information or documentation. Once your application is complete, it will be forwarded it to the CSSA.

KOREA

Form CZ/KR 202
Please fill in the application and return it to the institution mentioned below or to its nearest local office to the following address:

National  Pension  Service
7-16, Shincheon-Dong
Songpa-Gu, Seoul
138-725 KOREA
http: http://www.nps.or.kr/

Where appropriate the institution will contact you for any missing information or documentation. Once your application is complete, it will be forwarded it to the CSSA.

MOLDOVA

Form CZ/MD 202

Please, send the form filled-in with block letters or electronically to the below-mentioned institution or its regional office depending on your place of residence:

Casa Naţională de Asigurări Sociale
strada Gheorghe Tudor 3
MD-2028
Chisinau
Republica Moldova

http://www.cnas.md/index.php?l=ro

Where appropriate the institution will contact you for any missing information or documentation. Once your application is complete, it will be forwarded it to the CSSA.

QUÉBEC

Form QUÉ-RTC 3

Please fill in the application and return it to the institution mentioned below or to its nearest local office to the following address:

Bureau des ententes de sécurité sociale
Régie des rentes du Québec
1055, boul. René-Lévesque est, 13e étage
Montréal (Québec)
Canada H2L 4S5
Tel.: (514) 866-7332
E-mail: isp-psr.mail-poste@hrdc-drhc.gc.ca
http: www.rrq.gouv.qc.ca

Where appropriate the institution will contact you for any missing information or documentation.Once your application is complete, it will be forwarded it to CSSA.

RUSSIA


Form CZ/RU 202/3.1


Pension Fund of Russian Federation
Šabolovka č. 4
119991 Moscow
Russian Federation


www.pfrf.ru
Send the form filled-in with block letters to the above mentioned institution or its regional office depending on your place of residence:
This institution will consequently send your application for Czech pension benefits to the Czech Social Security Administration to Prague. If necessary, the Administration will ask you to provide more information.

TUNISIA

Form TN/CZ 202

Please, send the form filled-in with block letters or electronically to the competent below-mentioned institution or its regional office depending on your place of residence:

La Caisse Nationale de Sécurité Sociale
49, Avenue Taïeb M´hiri
1002 Tunis
La République tunisienne
www.cnss.tn/fr

La Caisse Nationale de Retraite et de Prévoyance Sociale
12, Avenue Jean Jaurès
1001 Tunis
La République tunisienne
www.cnrps.nat.tn

Where appropriate the institution will contact you for any missing information or documentation. Once your application is complete, it will be forwarded it to the CSSA.

USA

Form CZ/USA 202

Send the form filled-in with block letters or electronically to the below-mentioned institution or its regional office depending on your place of residence:


U.S. Social Security Administration
OIO –Totalization
P.O. Box 17769
Baltimore, MD 21235-7769
U.S.A.
www.ssa.gov

The American party will consequently send your application for Czech pension benefits along with the proof of your insurance periods in the USA to the Czech Social Security Administration to Prague. If necessary, the Administration will ask you to provide more information.

 

Application for persons residing in Czech Republic for pension from contracting state

ALBANIA

Form CZ/AL 202 - Claim for a pension from Albania
Form CZ/AL 207 - Request for certification of insurance periods in Albania
Albanian version, Czech version - List of equivalent periods in Albania  (Supplement to the form CZ/AL 207)

Please, fill-in the form „Claim for a pension from Albania“ with block letters or electronically and if necessary attach also the filled-in form „Request for certification of insurance periods in Albania” to it. Post the completed forms and any supporting documentation to the respective office of the Regional Social Security Administration or to the Prague Social Security Administration (if you live in Prague). This institution will forward your application for Albanian pension to

ČSSZ
Křížová 25
225 08 Prague 5
Tel.: 00420 257 061 111
E - mail: posta@cssz.cz

The Czech Social Security Administration will attach the proof of your insurance periods in the Czech Republic and after filling-in any other necessary information all documents will be sent to the Social Insurance Institute in Albania.

AUSTRALIA

Form AUS140CZ_1107

Please, fill-in the form „Claim for Australian Age Pension under the Agreement between Australia and the Czech Republic on Social Security“ with block letters or electronically and attach also the filled-in supplement ”Income and Assets” to it. Both forms must be completed and signed by your partner too (if you have one). Post your completed forms and any supporting documentation to the respective office of the Regional Social Security Administration or to the Prague Social Security Administration (if you live in Prague). This institution will forward your application for Australian age pension to

ČSSZ
Křížová 25
225 08 Prague 5
Tel.: 00420 257 061 111
E - mail: posta@cssz.cz

ČSSZ (Czech Social Security Administration) will attach the proof of your insurance periods in the Czech Republic and after filling-in any other necessary information all documents will be sent to the Australian institution Centrelink. Centrelink can contact you (in writing, by telephone or e-mail) in case it will be necessary to provide more details or some other information.

CANADA

Form GE-CAN (Czech-English version)
Form GE-CAN 1 (Czech-French version)


Please fill in the application and return it to the institution mentioned below or to its nearest local office to the following address:

ČSSZ Praha
Křížová 25
225 08 Praha 5
Tel.: 00420 257 061 111
E –mail: posta@cssz.cz

Where appropriate the institution will contact you for any missing information or documentation. Once your application is complete, it will be forwarded it to the Canadian Institution for social security.

INDIA

Form IN/CZ 4
This form is used as an application for an Indian retirement or survivor or total permanent disability pension.
Form IN/CZ 1 for old-age pension and disability pension or Form IN/CZ 2 for survivors´ pension.
These forms will be used in case the applicant or the deceased person was a member of the Indian Provident Fund.
Form IN/CZ 3
This form is used as an application for Indian withdrawal benefit under employees´ pension scheme (1995) in case the applicant is under 50 years old and he/she is not going to continue working in India.
Form IN /CZ 5
This form is used as an application for an Indian assurance benefit by survivor if the insured person died during the work.
Please return the filled-in forms and any supporting documentation to the respective regional office of the Czech Social Security Administration. This institution will forward your application for Indian pension to:
ČSSZ
Křížová 25
225 08 Prague 5
Tel.: 00420 257 061 111
E-mail: posta@cssz.cz

The Czech Social Security Administration will attach the proof of your insurance periods completed in the Czech Republic and after filling-in any other necessary information all documents will be sent to the Indian institution EPFO.

IZRAEL

Form – Claim for the old-age pension
Form – Claim for the disability pension
Form – Claim for the survivors‘ pension

Please fill in the application and return it to the institution mentioned below or to its nearest local office to the following address:

ČSSZ Praha
Křížová 25
225 08 Praha 5
Tel.: 00420 257 061 111
E –mail: posta@cssz.cz

Where appropriate the institution will contact you for any missing information or documentation. Once your application is complete, it will be forwarded it to the institution for social security in Israel.

JAPAN

Form CZ/J 1

Please fill in the application and return it to the institution mentioned below or to its nearest local office to the following address:

ČSSZ Praha
Křížová 25
225 08 Praha 5
Tel.: 00420 257 061 111
E –mail: posta@cssz.cz

Where appropriate the institution will contact you for any missing information or documentation. Once your application is complete, it will be forwarded it to the Japanese institution for social security.

KOREA

Form KR/CZ 2

Please fill in the application and return it to the institution mentioned below or to its nearest local office to the following address:

ČSSZ Praha
Křížová 25
225 08 Praha 5
Tel.: 00420 257 061 111
E –mail: posta@cssz.cz

Where appropriate the institution will contact you for any missing information or documentation. Once your application is complete, it will be forwarded it to the Korean institution for social security.

MOLDOVA

Form MD/CZ 202

Please, fill-in the form „Claim for a pension from Moldova“ with block letters or electronically. Post the completed form and any supporting documentation to the respective office of the Regional Social Security Administration or to the Prague Social Security Administration (if you live in Prague). This institution will forward your application for Moldovan pension to

ČSSZ
Křížová 25
225 08 Prague 5
Tel.: 00420 257 061 111
E - mail: posta@cssz.cz

The Czech Social Security Administration will attach the proof of your insurance periods in the Czech Republic and after filling-in any other necessary information all documents will be sent to the institution for social security in Moldova.

QUÉBEC

Please fill in the application designated for Canada and return it to the institution mentioned below or to its nearest local office to the following address:

ČSSZ Praha
Křížová 25
225 08 Praha 5
Tel.: 00420 257 061 111
E –mail: posta@cssz.cz

Where appropriate the institution will contact you for any missing information or documentation. Once your application is complete, it will be forwarded it to the institution for social security in Québec.

RUSSIA

Form RU 3/CZ 202

Fill in the form with block letters. Hand in the filled-in form at the respective office of the Regional Social Security Administration or in Prague at the Prague Social Security Administration or in Brno at Municipal Social Security Administration. This institution will forward your application for pension benefits to:
ČSSZ
Křížová 25
225 08 Praha 5
Tel.: 00420 257 061 111
E –mail: posta@cssz.cz

The Czech Social Security Administration will attach the proof of your insurance periods completed in the Czech Republic and after filling-in any other necessary information, all documents will be sent to the Pension Fund of Russian Federation.

TUNISIA

Form CZ/TN 202 - Claim for a pension from Tunisia
Form CZ/TN 207 – Declaration regarding the history of insurance periods

Please, fill-in the form „Claim for a pension from Tunisia“ with block letters or electronically and if necessary attach also the filled-in form „Declaration regarding the history of insurance periods ” to it. Post the completed forms and any supporting documentation to the respective office of the Regional Social Security Administration or to the Prague Social Security Administration (if you live in Prague). This institution will forward your application for Tunisian pension to

ČSSZ
Křížová 25
225 08 Prague 5
Tel.: 00420 257 061 111
E - mail: posta@cssz.cz

The Czech Social Security Administration will attach the proof of your insurance periods in the Czech Republic and after filling-in any other necessary information all documents will be sent to the competent social security institution in Tunisia.

USA

Form  SSA 2490 –BK
Translation of Form SSA 2490 –BK into Czech. 

Please, fill-in the form Application for Benefits under a U.S. Agreement with block letters or electronically and attach also the filled-in supplement ”Supplement to Claim for U.S. Benefit (WZ0-CZ-01) to it. Please, do not fill-in the Czech translation of Form SSA 2490 –BK, since it shall only make understanding of the original English form SSA 2490 –BK easier for you. Hand in the filled-in forms at the respective office of the Regional Social Security Administration or in Prague at the Prague Social Security Administration. This institution will forward your application for pension benefits to

ČSSZ
Křížová 25
225 08 Prague 5
Tel.: 00420 257 061 111
E –mail: posta@cssz.cz

ČSSZ (Czech Social Security Administration) will attach the proof of your insurance periods in the Czech Republic and after filling-in any other necessary information all documents will be sent to the American insurance institution. The American insurance institution or its contact office for the central Europe in Warsaw (Federal Benefits Unit Warsaw) can contact you (in writing, by telephone or e-mail) in case it will be necessary to provide more details or some other information.