Canada / Poland Agreement · 2020. 3. 2. · Canada / Poland Agreement Version (2019-12-12) Applying for a Polish retirement pension Here is some important information you need to

Canada / Poland Agreement

Version (2019-12-12)

Applying for a Polish retirement pension Here is some important information you need to consider when completing your application.

Please ensure you sign the application. If you are signing with a mark, (for example: “X”) the signature of a witness is required.

Your application must be supported by documentation. Please submit the documents requested. Failure to complete the application and provide the requested documentation may result in delays in processing your application.

Where original documents are specifically requested, originals must be submitted with your application. You should keep a certified true copy of any originals you send us for your records. Some countries require original documentation which will not be returned to you.

You may submit the original or a photocopy that is certified as true for any of the documents where originals are not required. It is better to send certified copies of documents rather than originals. If you choose to send original documents, send them by registered mail. We will return the original documents to you. We can only accept a photocopy of an original document if it is legible and if it is a certified true copy of the original. Our staff at any Service Canada centre will photocopy your documents and certify them free of charge. If you cannot visit a Service Canada Centre, you can ask one of the following people to certify your photocopy:

Accountant; Chief of First Nations Band; Commissioner for Oaths; Employee of a Service Canada Centre acting in an official capacity; Funeral Director; Justice of the Peace; Lawyer, Magistrate, Notary; Manager of Financial Institution; Medical and Health Practitioners: Chiropractor, Dentist, Doctor, Naturopathic Doctor, Nurse Practitioner, Ophthalmologist, Optometrist, Pharmacist, Psychologist, Registered Nurse; Member of Parliament or their staff; Member of Provincial Legislature or their staff; Minister of Religion; Municipal Clerk; Official of a federal government department or provincial government department, or one of its agencies; Official of an Embassy, Consulate or High Commission; Officials of a country with which Canada has a reciprocal Social Security Agreement; Police Officer; Professional Engineer; Social Worker; Teacher, University Professor.

People who certify photocopies must compare the original document to the photocopy, state their official position or title, sign and print their name, give their telephone number and indicate the date they certified the document.

They must also write the following statement on the photocopy: This photocopy is a true copy of the original document which has not been altered in any way.

If a document has information on both sides, both sides must be copied and certified. You cannot certify photocopies of your own documents, and you cannot ask a relative to do it for you.

Return your completed application, forms and supporting documents to:

International Operations Service Canada P.O. Box 2710 Station Main Edmonton, AB T5J 2G4 CANADA

Disclaimer:

This application form has been developed by external sources in cooperation with Employment and Social Development Canada. The content and language contained in the form respond to the legislative needs of those external sources.

UMOWA O ZABEZPIECZENIU SPOŁECZNYM MIĘDZY RZECZĄPOSPOLITĄ POLSKĄ A KANADĄ AGREEMENT ON SOCIAL SECURITY BETWEEN THE REPUBLIC OF POLAND AND CANADA

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WNIOSEK APPLICATION

O POLSKĄ EMERYTURĘ O POLSKĄ RENTĘ Z TYTUŁU NIEZDOLNOŚCI DO PRACY FOR POLISH RETIREMENT PENSION FOR POLISH INABILITY TO WORK PENSION

Formularz w pkt od 1 do 7 wypełnia wnioskodawca drukowanymi literami wpisując tekst w miejscach wykropkowanych

oraz zaznaczając krzyżykiem odpowiednią kratkę. Formularz w pkt 8 wypełnia instytucja kanadyjska.

Applicants must complete Sections 1 to 7 of the form in block letters using the dotted lines and placing a cross in boxes. The Canadian competent institution completes section 8 of this form.

1. Informacje dotyczące osoby ubezpieczonej/ Information concerning the insured person

1.1 Nazwisko/ Family name ……………………………………………………………………………………………………………………...

1.2 Nazwisko rodowe/ Family name at birth ……..……….…………………………………………………………………………………..

1.3 Inne używane nazwiska/ Other family names used ………………………………………………………………………………………

1.4 Imiona/ Given names …………………….……………………………………………………………………………………………………

1.5 Data urodzenia/ Date of birth │ │ │ │ │ │ │ │ │ (1) Miejsce urodzenia/ Place of birth ………..................................

1.6 Imię ojca/ Father’s given name ………….……. …………………. Imię matki/ Mother’s given name .......……………………………

1.7 Płeć/ Sex mężczyzna/ male kobieta/ female

1.8 Stan cywilny/ Etat civil

wolny/a żonaty/zamężna rozwiedziony/a

single married divorced

w separacji wdowiec/ wdowa

separated widowed

1.9 Adres zamieszkania w Kanadzie/ Current address in Canada ..…………………………………………………………………………

……………………………………………………………………………………………………………………………………………………

1.10 Ostatni adres zamieszkania w Polsce/ Last home address in Poland ..………………………………………………………………….

……………………………………………………………………………………………………………………………………………………

1.11 Numer identyfikacyjny w Polsce (2) / Polish Identification Number (2) ………………………………………………………….............

1.12 Numer ubezpieczenia w Kanadzie/ Canadian Social Insurance Number ......................................................................................

1.13 Zgłaszałem/am poprzednio w polskiej instytucji ubezpieczeniowej wniosek o emeryturę – rentę z tytułu niezdolności do pracy I already filed an application for a retirement pension or in respect of my inability to work with an insurance institution in Poland

tak/ yes nie/ no

Jeśli tak, podać/ If yes, please indicate:

nazwę instytucji/ name of the institution ………………………………………………………………………………………..................

adres instytucji/ address of the institution ..……………………………………………………………………………………………......

numer sprawy/ file number …………………………………………………………………………………………...................................

1.14 Ubiegam się o rentę z tytułu niezdolności do pracy spowodowanej/ I apply for a pension for my inability to work due to:

- wypadkiem przy pracy lub chorobą zawodową/ an accident at work or an occupational disease

tak (3)/ yes (3) nie/ no - wypadkiem w drodze do pracy lub z pracy/ accident on the way to or from work

tak (4)/ yes (4) nie/ no

1.15 Ubiegam się o rentę rolniczą z tytułu niezdolności do pracy spowodowanej wypadkiem przy pracy rolniczej lub rolniczą chorobą zawodową/ I am applying for an agricultural pension since my inability to work was caused by an accident at work in agricultural functions or caused by an agricultural occupational disease

tak (5)/ yes (5) nie/ no

w związku z wypadkiem przy pracy rolniczej w dniu │ │ │ │ │ │ │ │ │ (1)

in connection with an accident at work on agricultural functions

Prawo do jednorazowego odszkodowania jest/ było rozpatrywane przez jednostkę KRUS w ………………………………………. Right to a single compensation is /was considered by the Agricultural Social Insurance Fund in

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2. Informacje dotyczące przebiegu ubezpieczenia/ Information concerning the insurance periods

W okresie/ During which periods Podać kolejno, co Pan/ i robił/ a od ukończenia 15 lat życia:

studia, praca najemna, praca na własny rachunek, służba wojskowa,

pozostawanie bez pracy,

wychowywanie dzieci (6)

Please indicate in chronological order information on your career from age 15:

studies, work and self-employment, military service, inactivity,

parental leave (6)

Dokładnie określić rodzaj

wykonywanego zawodu lub pracy

Please specify the nature of your

profession or activity

Państwo wykonywanej

pracy

Country where the profession or activity occurred

Wymienić dołączone

dowody (7)

Please list the documents

attached (7)

od/ From (rok–miesiąc–dzień) (Year-Month-Day)

do/ To (rok–miesiąc–dzień) (Year-Month-Day)

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3. Ustalenie podstawy wymiaru emerytury–renty (8) (9)/ Determination of the retirement pension (8) (9)

3.1 Do ustalenia podstawy wymiaru emerytury–renty proszę przyjąć/ To determine the base of your retirement pension, please choose:

przeciętną podstawę wymiaru składki na ubezpieczenie społeczne lub na ubezpieczenia emerytalne i rentowe

na podstawie przepisów prawa polskiego w okresie 10 kolejnych lat kalendarzowych, wybranych z ostatnich 20 lat kalendarzowych poprzedzających bezpośrednio rok zgłoszenia wniosku, tj. od …….....................…… do .....................……….......

the average basis of the contributions made to the social insurance, pension or inability to work scheme under the Polish law within 10 consecutive calendar years chosen from the past 20 calendar years immediately preceding the year of notification of the

proposal from …….....................…… to …….....................……


na podstawie przepisów prawa polskiego w okresie 20 lat kalendarzowych przypadających przed rokiem zgłoszenia wniosku, wybranych z całego okresu podlegania ubezpieczeniu/

the average basis of the contribution made to the social insurance, pension or inability to work scheme under the Polish law chosen from 20 calendar years immediately preceding the year of filing the application and selected through all of your insurance periods


na podstawie przepisów prawa polskiego w okresie 10 kolejnych lat kalendarzowych poprzedzających bezpośrednio rok, w którym rozpocząłem/ęłam ubezpieczenie za granicą po raz pierwszy, ponieważ w okresie 20 lat kalendarzowych poprzedzających bezpośrednio rok zgłoszenia wniosku nie byłem/am ubezpieczona w Polsce/

the average basis of the contributions made to the social insurance, pension or inability to work scheme under Polish law within 10 consecutive calendar years preceding the year I first registered to social insurance abroad, because during the period of 20 calendar years immediately preceding the year of filing the application, I have not contributed to any social insurance scheme in Poland

podstawę wymiaru składki na podstawie przepisów prawa polskiego z okresu faktycznego podlegania ubezpieczeniu,

tj. od ………………………… do …………………………

the average basis of the contribution base as required by Polish law during the period of insurance

from …….....................……. to …….....................……

podstawę wymiaru wcześniej pobieranej emerytury lub renty z tytułu niezdolności do pracy

the average basis of benefits previously collected from the social insurance, pension or inability to work scheme

podstawę wymiaru emerytury przyjętej do ustalenia świadczenia przedemerytalnego/

the average basis of the pension base established at the time of the approval of a pre-retirement benefit

Jeżeli Pan/i nie zaznaczy odpowiedniej kratki, podstawa wymiaru emerytury–renty zostanie ustalona przez ZUS na podstawie przedłożonych dokumentów – w wariancie najkorzystniejszym./ If you do not mark the appropriate boxes, the base-retirement pension will be determined by the ZUS on the basis of the submitted documents and at the most advantageous option for the applicant.

4. Oświadczenie wnioskodawcy/ Declaration of the applicant

Oświadczam, że/ I declare that:

4.1 Nadal wykonuję działalność zawodową/ I am still performing a professional activity tak/ yes nie/ no

Data, od której ustała lub ustanie działalność zawodowa │ │ │ │ │ │ │ │ │ (1)

Current date or date of termination of the occupation

Miesięczna wysokość przychodu z tytułu wykonywanej działalności zawodowej ………………………………………………….. Please indicate the monthly income of this occupation or professional activity

4.2 Pobieram/ I am currently receiving

wynagrodzenie za czas niezdolności do pracy, zasiłek chorobowy z ubezpieczenia społecznego lub świadczenie

rehabilitacyjne (10) tak/ yes nie/ no

the payment of wages for a disease or a disease or rehabilitation benefit from a social insurance scheme (10)

Data zaprzestania pobierania tych świadczeń │ │ │ │ │ │ │ │ │ (1)

Date of cessation of collection of these benefits

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4.3 Pobieram polską emeryturę–rentę tak/ yes nie/ no

I am currently receiving a Polish retirement pension


nazwę instytucji wypłacającej świadczenie/ name of the institution …………………………………………………………….............

adres instytucji/ address of the institution …………………………………………………………………………………………………

numer świadczenia/ pension number or file number ..………………………………………………………………………………........

4.4 Jestem/ I am Nie jestem/ I am not

członkiem otwartego funduszu emerytalnego (OFE) (11) / a member of the open pension fund (OFE) (11)

4.5 Wnoszę o przekazanie środków zgromadzonych na rachunku w OFE – za pośrednictwem ZUS – na dochody budżetu

państwa (12)/ I would like to transfer funds accumulated in my account at OFE; via ZUS; in the State Budget (12)

tak/ yes nie/ no

4.6 Zgłaszałem/am wniosek o ustalenie kapitału początkowego (11) tak/ yes nie/ no

I filed an application to set my initial capital (11)

Jeśli tak, należy podać oddział ZUS ………………………………………………………………………………………………………. If yes, please indicate with which ZUS unit

4.7 Jestem/ I am Nie jestem/ I am not

właścicielem, współwłaścicielem lub posiadaczem gospodarstwa rolnego o powierzchni ……………................ ha położonego

w Polsce, w Kanadzie lub w innym państwie (13) (14)

owner, co-owner or holder of a farm of ..………..………… hectares located in Poland, in Canada or in any country (13) (14)

5. Informacje dotyczące małżonki/ a osoby ubezpieczonej (13)/ Information concerning the spouse of the insured (13)

5.1 Nazwisko/ Family name ………………………………………………………………………………………...……………………………

5.2 Imiona/ Given names ……………………………………………………………………………………………………………………….

5.3 Data urodzenia/ Date of birth │ │ │ │ │ │ │ │ │ (1) Miejsce urodzenia/ Place of birth ……….......…..................

5.4 Małżonka/ małżonek Spouse

jest/ is nie jest/ is not

właścicielem, współwłaścicielem lub posiadaczem gospodarstwa rolnego o powierzchni ……………………………… ha

położonego w Polsce, w Kanadzie lub w innym państwie (14)

owner, co-owner or holder of a farm of ………………………… hectares located in Poland, in Canada or in any country (14)


ma/ his nie ma/ his not

ustalonego prawa do emerytury–renty/ receiving a retirement pension


nazwę instytucji wypłacającej świadczenie/ name of the institution ………………………………………………………………………

numer świadczenia/ pension number ………………………………………………………………………………………..................


podlega/ is subject to nie podlega/ is not subject to

obowiązkowemu ubezpieczeniu społecznemu rolników/ compulsory social security scheme for farmers

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6. Identyfikacja bankowa/ Bank information

6.1 Należności z tytułu przysługującej emerytury–renty proszę przekazywać na rachunek bankowy/ Please pay the amounts due for my retirement in this bank account:

6.2 Pełna nazwa banku/ Full name of the bank …………………………………………………………………………………………………

6.3 Pełny adres banku/ Full address of the bank ………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………………

6.4 Kod identyfikacyjny banku (BIC/SWIFT)/ Bank identification code (BIC/SWIFT) ……………………………………………………….

6.5 Numer rachunku bankowego (15)/ Bank account number (15) …………………………..………………………………………………..

6.6 Oświadczam, że jestem nie jestem

I declare that I am I am not

właścicielem lub współwłaścicielem ww. rachunku bankowego owner or co-owner of above-mentioned bank account

Do wniosku dołączam ....……............ dowodów I am including with this application documents

7. Świadomy/a odpowiedzialności karnej za składanie nieprawdziwych zeznań oświadczam, że wszystkie dane zawarte we wniosku podane zostały zgodnie z prawdą, co potwierdzam własnoręcznym podpisem/ I am aware of the criminal liability for

making false statements and I can certify that all the information contained in this application form is true.

Data ……………………………………… Podpis wnioskodawcy …………………….……………………………. Date Signature of the applicant

8. WYPEŁNIA INSTYTUCJA KANADYJSKA/ TO BE COMPLETED BY THE LIAISON AGENCY IN CANADA

8.1 Potwierdzamy, że dane osobowe zawarte w tym formularzu są zgodne z danymi zawartymi w oryginalnych dokumentach przedłożonych przez wnioskodawcę/ We confirm that the personal information contained in this form is consistent with the data contained in the original documentation submitted by the applicant.

8.2 Data złożenia wniosku │ │ │ │ │ │ │ │ │ (1)

Date of claim

8.3 Pieczątka 8.4 Data …………………………………………………………… Stamp Date

8.5 Podpis urzędnika …………………………………..………… Signature of the authorized agent

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UWAGI / NOTES

(1) Datę należy wpisać podając rok, miesiąc, dzień np. │2│0│0│9│1│2│0│1│.

Please write the date in the following order: year, month, day. Example: │2│0│0│9│1│2│0│1│.

(2) Należy podać numer ewidencyjny PESEL, a jeżeli nie nadano PESEL, należy podać serię i numer dowodu osobistego lub

paszportu. Należy podać również NIP w przypadku osoby, dla której identyfikatorem podatkowym jest NIP. Enter PESEL record number or, if PESEL not granted, enter the series and number of the personal ID or passport. Enter also NIP, if NIP is your tax identification number.

(3) W odniesieniu do wypadku przy pracy należy dołączyć protokół powypadkowy sporządzony przez pracodawcę lub kartę wypadku

sporządzoną przez inne właściwe podmioty dotyczącą ustalenia okoliczności i przyczyn wypadku, a w odniesieniu do choroby zawodowej – decyzję o stwierdzeniu choroby zawodowej wydaną przez państwowego inspektora sanitarnego. In case of an accident please attach a report of the accident prepared by the employer or a report established by another competent body on the circumstances and causes of this accident or in case of an occupational disease: a decision report confirming the existence of an occupational disease established by a national competent institution.

(4) Należy dołączyć kartę wypadku w drodze do pracy lub z pracy. Please attache report of accident on way to or from work.

(5) Należy dołączyć dokument potwierdzający rolniczą chorobę zawodową.

Please provide evidence that the occupational disease was caused by agricultural functions.

(6) Należy wymienić wszystkie formy i okresy aktywności (lub jej braku) od ukończenia 15 lat życia również wówczas, gdy nie wynikają

one z przedłożonych dokumentów. Please list all types and periods of activity (or inactivity) from the age of 15, even if it is not apparent from the documents presented.

Osoby wykonujące pracę na własny rachunek będące rolnikami (domownikami) powinny podać miejsce położenia gospodarstwa rolnego (miejscowość, powiat, województwo). Persons performing work on their own account on a farm should specify the location of the farm (town, district, province).

(7) Przyznanie świadczeń uzależnione jest od udokumentowania okresów ubezpieczenia. It is necessary to submit the supporting documents relating to the periods of insurance in order to be entitled to a benefit.

Dokumentami potwierdzającymi okresy ubezpieczenia w Polsce są m.in.: zaświadczenia o zatrudnieniu wydawane przez pracodawców lub następców prawnych, legitymacje ubezpieczeniowe, dowody potwierdzające ubezpieczenie z tytułu prowadzenia działalności na własny rachunek, książeczka wojskowa, jak również zaświadczenie uczelni stwierdzające fakt ukończenia studiów wyższych i programowy ich wymiar – w przypadku nauki w szkole wyższej, skrócony akt urodzenia dziecka – w przypadku niewykonywania pracy z powodu opieki nad dzieckiem w wieku do lat 4. In Poland, the evidence concerning periods of insurance are: employment certificates issued by employers or their legal successors, insurance booklets confirming insurance under self-employment, military record, certificate issued by a college confirming the fact of having completed their studies and duration of the program, certificate of birth of a child – In case of inactivity caused by parental leave for the care of a child until the age of 4 years.

Dokumentami potwierdzającymi okresy prowadzenia gospodarstwa rolnego lub pracy w nim przed dniem 1.07.1977 r. są: zaświadczenie urzędu gminy, zeznania świadków, inne. Evidence accepted for working periods in a farm before 1.07.1977 are as follows: certificate from municipal office or the testimony of witnesses.

Wszelkie dokumenty należy przedłożyć w oryginale albo ich kopie poświadczone przez kanadyjską instytucję ubezpieczeniową, notariusza lub konsula RP. Uwierzytelnieniu podlega każda strona sporządzonej kopii dokumentu. Kopie dokumentów uwierzytelnione przez inną instytucję lub osobę, niż wymienione wyżej, nie będą honorowane. All documents submitted must be in original or copies certified by the Canadian pension institution, a notary or a consul of the Republic of Poland. Each page of the copy of the document must be certified. Copies of documents certified by another institution or person not listed above will not be accepted.

Nieudokumentowanie okresów ubezpieczenia w Polsce spowoduje brak możliwości ustalenia prawa do polskiego świadczenia. Please note that if you do not provide documentation about your periods of insurance in Poland, the Polish competent institution will not be able to establish your right to a pension.

(8) Dla celów ustalenia podstawy wymiaru emerytury – renty:

- w przypadku pracowników najemnych należy dołączyć zaświadczenie zawierające dane o podstawie wymiaru składki na ubezpieczenie społeczne lub ubezpieczenia emerytalne i rentowe albo zaświadczenie o wynagrodzeniu wystawione przez pracodawcę (lub następcę prawnego) na druku ZUS Rp-7 lub legitymację ubezpieczeniową zawierającą wpisy o wysokości wynagrodzenia;

- w przypadku osób pracujących na własny rachunek należy podać numer konta płatnika składek, a jeżeli działalność była wykonywana przed objęciem jej obowiązkowym ubezpieczeniem społecznym – zaświadczenie organizacji społeczno-zawodowej (np. Cechu Rzemiosł).

For purposes of determining the base of your retirement pensions:

- In the case of a non self-employed worker, these documents should accompany your application: a certificate containing information about contributions to a social insurance scheme or a pension fund, a certificate of earnings issued by your employer (or successor) on form ZUS Rp-7 or an insurance card that contains entries of your salary;

- In the case of the self-employed worker, please provide your account number where you paid your contributions, and if the activity was carried out before taking the compulsory social insurance – a certificate of socio-professional organizations (i.e. the Guild of Handicraft).

Dokumenty należy przedłożyć w oryginale albo ich kopie poświadczone przez kanadyjską instytucję ubezpieczeniową, notariusza lub konsula RP. Uwierzytelnieniu podlega każda strona sporządzonej kopii dokumentu. Kopie dokumentów uwierzytelnione przez inną instytucję lub osobę, niż wymienione wyżej, nie będą honorowane. All documents must be submitted in original or copies certified by the Canadian pension institution, a notary or a consul of the Republic of Poland. Each page of the copy of the document must be certified. Copies of documents certified by another institution or person not listed above will not be accepted.

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(9) Nie dotyczy osób wnioskujących o polską emeryturę – rentę z tytułu niezdolności do pracy z systemu ubezpieczenia społecznego

rolników. Does not apply for persons applying for a Polish retirement pension base on inability to work with the Agriculture social security scheme.

(10) Należy wypełnić, jeśli osoba wnioskująca o polską emeryturę – rentę pobiera świadczenie związane z czasową niezdolnością do

pracy – chorobą (bez względu na podmiot wypłacający to świadczenie) lub też świadczenie rehabilitacyjne wypłacane po wyczerpaniu zasiłku chorobowego w przypadku, gdy osoba jest nadal niezdolna do pracy, a dalsze leczenie lub rehabilitacja rokują odzyskanie zdolności do pracy. To be completed if the person applying for Polish Retirement Pension base on the provision of temporary incapacity to work – or a disease (irrespective of paying a service), or on the provision of rehabilitation after the exhaustion of a paid sick pay if the person is still unfit for work or if further treatment and prognosis for recovery or rehabilitation of their ability to work is needed.

(11) Dotyczy wyłącznie osób urodzonych po 31.12.1948 r. This applies only to persons born after December 31st 1948.

(12) Wypełnia osoba ubezpieczona, która jest członkiem OFE. Osobie urodzonej po 31.12.1948 r. przysługuje emerytura w wieku

niższym niż powszechnie obowiązujący, tj. niższym niż 60 lat – dla kobiet i 65 lat dla mężczyzn (art. 46, 50, 50a, 50e lub art.184 ustawy z dnia 17.12.1998 r. o emeryturach i rentach z Funduszu Ubezpieczeń Społecznych, art. 88 ustawy z dnia 26.01.1982 r. – Karta Nauczyciela, art. 3 ustawy z dnia 27.07.2005 r. o zmianie ustawy o emeryturach i rentach z FUS oraz ustawy – Karta Nauczyciela) pod warunkiem nie przystąpienia do otwartego funduszu emerytalnego. Warunek ten jest spełniony także wówczas, gdy osoba, która przystąpiła do OFE, wystąpi o przekazanie środków zgromadzonych na rachunku w OFE, za pośrednictwem ZUS, na dochody budżetu państwa. To be completed by a member of the OFE. A person born after 31.12.1948 entitled to a retirement age below the age being in force, less than 60 years for women and less than 65 years for men (art. 46, 50, 50a, 50e, or art. 184 17.12.1998 Law on pensions and pension fund Social Security, art. 88 of the Law of 26.01.1982 -, art. 3 of the Law of 27.07.2005 on changes to the law on pensions and pension fund Social Security and the Law – on condition of not being a member of OFE. This condition is satisfied if the person is a member of OFE files a request to transfer funds accumulated in his account at OFE – via ZUS – the state budget.

(13) Dotyczy wyłącznie osób wnioskujących o polską emeryturę – rentę z tytułu niezdolności do pracy z systemu ubezpieczenia

społecznego rolników.

This applies only to applicants for a Polish Retirement Pension for their inability to work with the social security system for farmers.

(14) Przez „posiadanie gospodarstwa rolnego” należy rozumieć faktyczne władanie takim gospodarstwem, jak np. użytkowanie,

dzierżawienie. The term "owner of a farm" should be understood as: the actual possession of the farm.

(15) Należy dołączyć zaświadczenie banku potwierdzające podany numer rachunku bankowego.

Please attach the certificate from the bank confirming your bank account number.

The Social Security Agreement between the Republic of Poland and the Canada

A guide for completing an application for a Polish pension

on a CAN-PL 1 form

If you live in Canada and you wish to apply for Polish pension from the Social

Insurance Institution (ZUS) or from the Agricultural Social Insurance Fund

(KRUS) on the basis of the Polish-Canadian Agreement on Social Security, you

must complete and submit the CAN-PL 1 application form

1. How to fill in form CAN-PL 1?

Please accurately and legibly complete sections 1 to 7 of the application form. Section

8 should not be completed as it will be completed by the Canadian insurance institution.

Put an “X” in the appropriate boxes. Places with a dotted line should be completed in

capital letters with the required information.

Be sure to refer to the comments at the end of the application form. The comments

contain additional information and explanations, which will facilitate and help to

complete the form points marked with footnotes (1) to (15). They will also indicate

which document you should attach to your application.

You must be honest and truthful while you provide the information and data that are

necessary to identify you rights and calculate the amount of your Polish pension.

Important: Do not forget to complete the CAN-PL 1 Annex titled "Declaration

of the applicant" and attach it to the completed CAN-PL 1 application form.

You can find CAN-PL form along with the Annex on the following websites:

www.zus.pl or www.krus.gov.pl/bip/

2. What documents must I attach to the CAN-PL 1 application form?

To ensure your application is considered efficiently and properly by the ZUS or the KRUS, you

must provide documents confirming your periods of employment and insurance in Poland, as

well as the amount of earnings, as this will determine the amount of your pension. To facilitate

the collecting of the required documentation, the following are documents which generally can

be used to prove the periods of employment and insurance in Poland, as well as the amount of

earnings achieved at this time.

If you were born after 31.12.1948 and you have your initial capital established by ZUS, you do

not need to document your employment and insurance periods in Poland, as well as the amounts

of your earnings.

http://www.zus.pl/

2

1) Which documents shall I attach for the confirmation of periods of employment

and insurance in Poland?

The basic documents confirming periods of employment are primarily: the certificates

of work; a written certificate by the workplace (the employer); the insurance card containing

the entries made by the employers, which shows a start and end date of work, hours of work,

type of work performed, and the entries are confirmed by a stamp of the workplace/employer

and the signature and official stamp of employer or authorized officer.

Periods of employment can also be confirmed with other, indirect evidences, such as:

employment contracts and annexes to these contracts (subsequent engagements); the entries in

the identity card; business cards; ID cards of trade unions; a letter addressed by the employer

to the employee in the duration of employment (such as recruitment, appointment, change of

the contract, grant award, grant leave). If these indirect evidences suggest the fact of

employment, on their basis it is possible to determine the duration of employment.

If you are unable to obtain evidences confirming periods of employment, you can

confirm it by the testimony of witnesses. However, this applies only to periods of employment

completed before 14th November 1991. You should file a statement that he/she has no

documents to prove the employment periods.

Forms “The statement of a claimant of the lack of documentation” and “The testimonies of a

witness for pension case” can be found on the ZUS website: www.zus.pl

Documents that confirm the periods of an self-employment are mainly: evidence on the

periods of social security contribution payments (e.g. a payment card, confirmations from

ZUS). If you do not have such evidence, please indicate payer's account number (NKP) and the

seat of your company and the periods when you were self-employed.

Documents confirming the periods of running a farm or working on the farm before

1st July 1977 (prior to that date, farmers were not subject to social insurance) are documents

stating the title of owning a farm. For example, the notarial deed, the deed of the land, the lease

contract.

People who have worked on the farm of parents (or grandparents) as the members of the

household before the introduction of compulsory social insurance for those people (before

1st January 1983), and then took over the farm should submit a statement of working on it. In

another case, the applicant should also provide a certificate of the local authority confirming

the place of residence and the existence of a farm within a specified period. If the local authority

cannot confirm these facts, written testimonies from at least two witnesses must be submitted.

The forms A statement of the applicant on the lack of evidence and Witness testimony are

available on the website: http://www.krus.gov.pl/bip/formularze-i-wnioski/swiadczenia/

The documents confirming being the subject to social insurance of farmers during the

period from 1st July 1977 to 31st December 1990 and from 1st January 1991, in the case of

persons submitting an application for an occupational pension (from the ZUS), is a certificate

issued by the KRUS.

Persons applying for an agricultural pension (from the KRUS) do not have to submit a

certificate confirming being subject to the agricultural insurance in the above mentioned

periods, as such information is in the records of the KRUS.

http://www.zus.pl/

http://www.krus.gov.pl/bip/formularze-i-wnioski/swiadczenia/

3

However, it may happen that the KRUS will not be able to confirm periods of social insurance

for farmers during the period from 1st July 1977 to 31st December 1990, as the data of the

applicant have not been provided by the local authority (the cases of insurance and contribution

payment were managed by these authorities before the establishment of organizational units of

the KRUS). Then the interested persons shall present to the ZUS or to the KRUS, a certificate

concerning being subject to the social insurance of farmers in the above mentioned period,

issued by the competent local authority, on the territory of which the farm was located.

If the local authority does not have documentation allowing confirmation of the insurance

period from 1st July 1977 to 31st December 1990, a person applying for an agricultural pension

from the KRUS shall submit documents confirming the existence of a farm and running it (e.g.

a book of sales of agricultural products, a document stating the acquisition or possession of a

farm, a certificate of a local authority confirming the place of residence and the existence of a

farm in the specified period, the testimony of the witnesses).

Important: Applicants for the agricultural pension (from the KRUS) born before

31st December 1948 shall attach to the application the documents confirming the

periods of being subject also to social insurances other than agricultural and non-

contributory periods (see the list of documents required to prove the contributory

and non-contributory periods). While people born after 31st December 1948 shall

attach to the application the documents proving only the periods of work on a

farm or running this farm and being subject because of these to the social

insurance of farmers and payment of contributions.

Documents confirming non-contributory periods (e.g. periods of receiving a sickness

benefits, of study in high school and doctoral studies, periods of parental leaves and child care)

are generally: certificates of contributions payers or other documents to the competent

authorities.

Important: detailed information about the types of documents required to prove

certain contributory and non-contributory periods can be found in the list at the

end of this guide. This information is available for customers on the ZUS

homepage at the following address: http://www.zus.pl/swiadczenia/emerytury/okresy-uwzgledniane-przy-ustalaniu-

prawa-do-emerytury-i-renty-i-obliczaniu-wysokosci-tych-swiadczen

and on the homepage of the KRUS:

http://www.krus.gov.pl/zadania-krus/swiadczenia/swiadczenia-z-ubezpieczenia-

emerytalno-rentowego/dokumentacja-wymagana-przy-ubieganiu-sie-o-ustalenie-

prawa-do-rolniczych-swiadczen-emerytalno-rentowych-renta-rodzinna/

2) Which documents shall I attach for the confirmation of earnings in Poland?

The basic documents that confirm the amount of the wage, income, remuneration and

salary are: certificates issued on the ZUS Rp-7 form by the employer or his successor, based on

payroll documentation, which is in his possession; the insurance card with entries about the

periods of employment and earnings in these periods; another document, from which the amount

of remuneration, income, revenue or salary can be determined.

http://www.zus.pl/swiadczenia/emerytury/okresy-uwzgledniane-przy-ustalaniu-prawa-do-emerytury-i-renty-i-obliczaniu-wysokosci-tych-swiadczen

http://www.zus.pl/swiadczenia/emerytury/okresy-uwzgledniane-przy-ustalaniu-prawa-do-emerytury-i-renty-i-obliczaniu-wysokosci-tych-swiadczen

http://www.krus.gov.pl/zadania-krus/swiadczenia/swiadczenia-z-ubezpieczenia-emerytalno-rentowego/dokumentacja-wymagana-przy-ubieganiu-sie-o-ustalenie-prawa-do-rolniczych-swiadczen-emerytalno-rentowych-renta-rodzinna/



4

If you are unable to submit the aforementioned documents, you can provide other

documentation that confirms the amount of achieved earnings (e.g. employment contract, letter

of recruitment, appointment);

The equivalent evidence that confirm the amount of the remuneration are photocopies of

payroll documents issued by archives or other units involved in retention of documents of

liquidated employment enterprises, certified by the person directing the archives or companies

that store documents (e.g., payrolls, remuneration sheet, contracts with a monthly salary).

Important: If there are no documents confirming the salary for the period of

employment, the ZUS takes a minimum wage according to the working time.

3) Which documents shall I attach for the purposes of a retirement pension

payment?

To persons who are living in Canada – depending on their choice - the pension can be paid:

to a bank account in Poland - if you chose so, you should attach a certificate containing

the information about account number and that you are the owner or a co-owner of the bank

account;

into the hands of an authorized person resident in Poland - if you chose so, you should

attach a power of Attorney, which specifies a person entitled to receive the pension on your behalf

(power of attorney should contain precise data: first name, last name, PESEL, a full address that

contains the zip code, city, street, house number, apartment number);

to a bank account in Canada - if you chose so, a certificate issued by a Canadian bank,

which contains the following information, should be attached to the application form:

exact name and address of the bank,

identification code of the bank (SWIFT/BIC),

full bank account number to the international transactions of a clear determination

of the correct order of the string of digits,

a statement that you are the owner or a co-owner of the bank account.

Important: All required documents attached to the application must be original.

If you want to keep the original documents, you can attach copies thereof to the

application. However the copies must be authenticated to be in conformity to the

originals of the documents. The authentication of the copied documents for

conformity to the originals of the documents can make an official of the Canadian

insurance institution (Service Canada), as well as the Consul of the Republic of

Poland or a notary.

4) Where to get information about the personal and payment documents and the

liquidated workplaces?

If you are looking for your personal and wage documents, you can use a database: "Base of

liquidated or transformed workplaces". It contains an alphabetical list of liquidated or

abolished employment enterprises and information of the location where the personal and payroll

documentation of former employees is held. In the database are included different organizational

units: enterprises, trade unions and parties, cooperatives, state farms and other. The base is

available to search in at any ZUS unit, as well as on the website of the ZUS:

5

http://www.zus.pl/swiadczenia/emerytury/baza-zlikwidowanych-lub-przeksztalconych-

zakladow-pracy

You can obtain the information about where the personal and salary documents are stored from

the Personal and Salary Documentation Archive in Milanowek (Archiwum Dokumentacji

Osobowej i Płacowej w Milanówku, 05-822 Milanówek, ul. St. Okrzei 1). In the Archive there

is a consultation and information point which can be reach under the telephone number (22) 635

68 22. The Archive also runs Poland's largest online database of the storage places of personal

and payroll documentation - its address is: https://ewidencja.warszawa.ap.gov.pl/miejsca.php

3. Where to submit an application for the pension?

The completed application form for a Polish retirement pension CAN-PL 1, along with

the CAN-PL 1 Annex and all required evidence documents, should be submitted to the Canadian

insurance institution, Service Canada. The Canadian institution, after confirmation in section 8

of the CAN-PL 1 application form of your personal data, will submit your completed application

for consideration to the relevant Polish institution i.e. ZUS or KRUS.

Completed application for the Polish retirement pension can also be submitted directly

to the Polish institution, i.e. to the ZUS (address: Oddział ZUS w Łodzi, ul. Zamenhofa 2, 90-431

Łódź) or to the KRUS (address: Regionalny KRUS w Krakowie – Wydział Świadczeń

Zagranicznych w Nowym Sączu, ul. Młyńska 8, 33-300 Nowy Sącz). If you are sending the

application directly to the ZUS or KRUS, you must attach the originals or certified copies of

documents proving your personal data (e.g. identity card, copies of the civil status act) to the

application.

Important: A properly completed application CAN-PL 1, together with the CAN-

PL 1 Annex and all the required evidence documents will allow for faster

consideration of the application by the ZUS or the KRUS. If you application turns

out to be incomplete, it will be necessary to conduct additional investigation,

which extends the consideration process time of the your application.

http://www.zus.pl/swiadczenia/emerytury/baza-zlikwidowanych-lub-przeksztalconych-zakladow-pracy

http://www.zus.pl/swiadczenia/emerytury/baza-zlikwidowanych-lub-przeksztalconych-zakladow-pracy

6

Detailed information on the documents required to prove

the respective contributory and non-contributory periods

2.1 Contributory periods and the required documentation

Contributory Periods Required documentation

1) The periods of paying contributions to the

retirement pension and social security insurance

after 31 December 1998 and periods of non-

payment of contributions to the retirement pension

and social security insurance due to overdraft the

amount of the annual contribution base during the

calendar year

the confirmation made by the ZUS or the

contribution payer (work certificate,

certificate or other document)

2) the periods of payment of social security

contributions in the amount specified in the

regulations on the organization and financing of

social insurance, in the regulations on retirement

benefits of creators, insurance of people

performing work under an agency contract or a fee-

for-task agreement, insurance of members of

agricultural production cooperatives and farmers’

association, insurance of people doing business,

insurance of clergy, as well as in the provisions on

the Bar, on employment and combating

unemployment and social assistance from 15th

November 1991 to 31st December 1998.

the confirmation made by the ZUS or the

contribution payer (work certificate,

certificate or other document)

7


1) 3) the periods credited as social insurance periods

of clergy:

periods of being clergy before 1st July 1989,

under the condition of paying social security

contributions for the period being subject to this

insurance from 1st July 1989 to 31st December

1998.

periods of residence of the clergy in the mission

and carry out their pastoral activity among the

Polish community, falling after 14th November

1991 to 31st December 1998.

certificate confirming being the clergy issued

by the competent diocesan or monastic

authority

4) periods of active military service in the Polish

Army or equivalent periods or periods of

alternative forms of service

certificate of service or a certificate from

relevant authorities, in which the professional

service was done, for the remaining periods

the certificate of the Military Replenishment

Council or service papers

5) periods of activity as a veteran, activities similar

to it, as well as the periods included in the periods

of this activity and periods of being subject to the

repression of war and post-war time, as defined in

the regulations on combatants and certain persons

being victims of repression of war and post-war

period

Certificate of the Head of the Bureau for

Veterans and People Repressed

6) the periods of the service fulfilled in Poland:

in Police (Citizen’s Militia),

in the Office for State Protection, Internal

Security Agency and Foreign Intelligence

Agency, Military Counterintelligence

Service and the Military Intelligence Service

and the Central Anticorruption Bureau (in the

organs of public security)

in Border Guards

in Prison Service

in State Fire Service

in Customs Service

in Government Protection Bureau

certificate of service or a certificate of the

relevant bodies

7) periods of receiving the maternity allowance a certificate of the employer or of the ZUS

8


8) periods of detention in prisons and other places

of detention on Polish territory under a conviction

or without a conviction after 31st December 1956

for political activities

certificate of the President of the District

Court confirming the detention in prisons or

other places of detention under a conviction,

and for the periods of detention in these

places without a conviction, a certificate of

the President of the Institute of National

Remembrance - Commission for Prosecution

of Crimes against the Polish Nation

9) periods of employment abroad of persons who at

the time were not Polish citizens, when they

returned to the country after 22nd July 1944 and

were considered as repatriates

the document confirming the status of

repatriate and evidences of employment

10) periods of work after 1956 for political

organizations and trade unions, illegal within the

meaning of the provisions in force until April 1989.

the decision of the head of the Bureau for

Veterans and People Repressed issued after

submission of documents or testimony of

witnesses

2.2 For the contributory periods shall also be considered following periods before 15th

November 1991 for which social insurance contribution is paid or for which there was no

obligation to pay contributions for this insurance:


1) periods of employment after completing 15

years:

of employment in the Polish state - of not less

than half of full-time work, if in these periods the

worker was receiving compensation or social

security benefits: sickness, maternity or sickness

care or disease pension

certificate of employment, certificate or

entry in the insurance card, and in their

absence the entry in the national identity "old

type", the testimony of the witnesses,

business card, membership card of trade

unions or a letter to call, appoint, engage,

release, award, granting leave and

confirmation of the ZUS, if an employer

entered an employee named to the social

insurance

of Polish citizens abroad - in the Polish

diplomatic representations and consular offices,

permanent representations at the United Nations

and other missions or special missions, as well as

in other Polish posts, institutions or enterprises,

to which they are posted or directed, this also

applies to family members of the posted or

a certificate of the competent authorities

9


directed employee who entered the employment

in these posts during stay abroad

of employment Polish citizens abroad - in

international organizations, foreign institutions

and establishments, to which they were sent on

the basis of international cooperation, or in which

they were employed with the approval of the

competent Polish authorities, the approval is not

required for employees who went abroad before

9th May 1945.

a certificate of the directing unit

of Polish citizens abroad - working by other

foreign employers, if during the period of work

abroad were paid social insurance contributions

in Poland

confirmation of the ZUS for periods of

payment of social security contributions

2) periods of forced labour:

performed on behalf of Nazi Germany during

World War II

performed on the territory of the Union of Soviet

Socialist Republics during the period from 17th

September 1939 to 31st December 1956.

carried out on the orders of the Allied authorities,

to 31st December 1945.

documents or testimony of witnesses

carried out in the coal mines, quarries, uranium

conversion facilities and in the construction

battalions while serving military service in the

Polish Army

a certificate of Military Replenishment

Council

3) periods of employment of junior workers in the

territory of a Polish State under the conditions laid

down in the Polish legislation in force before 1st

January 1975.

Certificate of employment, apprenticeship

contract, contract to learn a specific work,

contract to make the initial employment,

certificate of an employment enterprise or

the testimony of witnesses, if the employer

states the lack of documentation of this

period and the lack of opportunities to

confirm that with young employees were

contract concluded or the employer confirms

that concluded contracts with young

employees, but cannot confirm the fact of

employment the specific young employee.

4) periods of work performed while serving in the

territory of the Polish state the prison sentence, the

penalty of arrest for the offense and during the

a certificate issued by the prison or the

remand

10


detention - in the time not less than half of the full

working time specified for such work

5) periods of inactivity after the termination of

employment, if for these periods under the

provisions of the Labour Code a salary or

compensation was paid

a court decision, a certificate of the

employer

6) periods of being out of work in the territory of

the Polish state due to the inability of getting work

or the inability to undertake a vocational training,

including periods of receiving benefits from the

Vocational Activation Fund, of receiving

unemployment benefits and training allowances

paid from the Labour Fund

a certificate of the employment department

of the employment agency

7) periods of inactivity before 4th June 1989 as a

result of political repression

a decision of the Head of the Bureau for

Veterans and People Repressed

8) the periods of holding a mandate as a Member of

Parliament or senator in the Polish state

a certificate of the competent authority

9) periods of internment on the basis of art. 42 of

the Decree of 12th December 1981 on martial law

(Journal of Laws no. 29, item 154; Journal of Laws

of 1982 no. 3, item 18 and of 1989 no. 34, item 178)

certificate of the Institute of National

Remembrance - Commission for

Prosecution of Crimes Against the Polish

Nation, to which the documents on

internment were provided by the Police

Department

10) periods of the creative and artistic activities in

the territory of the Polish state:

covered by the obligation of social insurance, for

which social insurance contributions were paid or

in which the insured person was exempt from the

payment of these contributions

a confirmation of the ZUS for periods of

payment of social security contributions or

the period of exemption from the payment of

these contributions

prior to 1st January 1974, acknowledged by the

Commission for Authors’ Pension Entitlement,

acting with the Minister competent for Cultural

Affairs, provided that the creator or artist paid

social security contributions after 31st December

1973.

Decision of the Commission for Authors’

Pension Entitlement

11) periods of work of lawyers carried on in the

territory of the Polish state:

11



which the social insurance contributions were

paid or in which the exemption from the payment

of these contributions occurred

a certificate of the law office, and, in case of

lawyers engaged in profession individually

confirmation of the ZUS about the periods of

contribution payment or periods of

exemption from the contribution payment

before the day of coverage by the obligation of

social insurance because of this activity

a certificate or other document

12) periods of exercise in the territory of a Polish

state the outwork:





a confirmation for periods of payment of

social security contributions or for the period

of exemption from the payment of these

contributions or other document



if in these periods the person performing such work

had a remuneration of at least half the current lowest

remuneration determined in the provisions of the

labour code

a certificate of the employing entity or other

document

13) periods of work in the territory of the Polish

state in agricultural production cooperatives and in

other cooperatives affiliated in the Central

Association of Agricultural Production

Cooperatives, in team farms of farmers’ association

cooperatives affiliated in the National Union of

Farmers, Farmers’ Associations and Agricultural

Organizations, and work for the benefit of these

cooperatives:







confirmation of a cooperative for days

actually worked

14) periods of work in the territory of the Polish

State carried out on behalf of the units of the

socialized economy based on an agency agreement

or fee-for-task agreement and the cooperation by

the implementation of such an agreement:

12


covered by the obligation of social insurance and

periods of continuation of this insurance, for




a confirmation of the contribution payer or

other document

conducted before 1st January 1976, if the

agreement correspond to the terms and

conditions of insurance in force at that date

a certificate or other document of the

competent entity for which the agency

agreement or fee-for-task agreement was

carried out

15) periods of non-agricultural economic activities

in the territory of the Polish state:

covered by the obligation of social insurance and

periods of continuation of this insurance, for






the periods of exemption from the payment

of these contributions

conducted before the day of being covered by the

obligation of insurance in this respect, if the

economic activity corresponds to the conditions

of insurance

a certificate of a proper organization, guild

16) periods of cooperation in the conducting of non-

agricultural economic activities in the territory of

the Polish state covered by the duty of social

insurance and periods of continuing the insurance

for which the contribution were paid for this

insurance, or in which the exemption from the

payment of these contributions occurred





17) periods of social insurance of the clergy in the

territory of Polish state, for which the social

insurance contributions were paid or in which the

exemption from the payment of these contributions

occurred





18) periods of receiving the athletic scholarship in

respect of practicing competitive sports in the

territory of the Polish state after the age of 15, with

the exception of periods of scholarship received by

learners or studying persons in the system of full-

time study

a certificate of a sports club or entities

paying such a scholarship

13

2.3 Non-contributory periods and the required documentation

Non-contribution periods Required documentation

1) periods of remuneration for the period of

incapacity for work paid under the provisions of the

Labour Code

a certificate of the employer

2) periods of receiving of social security benefits:

sickness or care allowance

a certificate of the employer or of the ZUS

3) periods of receiving the rehabilitation benefit a decision of the ZUS or certificate of the

employer

4) periods of receiving of sickness and care benefits

and rehabilitation benefit after the termination of the

insurance obligation

a decision of the ZUS or certificate of the

ZUS

5) periods of the disease allowance after having

been employed in part-time work not less than the

half of the current working time in a given

profession or after the termination of the obligation

of social insurance from another title

a decision of the ZUS or a certificate of the

ZUS

6) periods of inactivity after the termination of

employment, if for these periods under the

provisions of the Labour Code a salary or a

compensation was paid

a court decision, a certificate of the

employer

7) falling before the entitlement to retirement or

disability pension the periods of parental leave,

unpaid leave granted on the basis of the provisions

on unpaid leaves for working mothers caring for

young children, other granted to this end, unpaid

leaves and periods of inactivity because of the care

on a child:

up to the age of 4 years – up to 3 years for each

child and a total, regardless of the number of

children up to 6 years

a certificate of employment or certificate of

employer about the maternity or unpaid

leave, and in respect of periods of inactivity

due to care – a statement of the person

concerned and a copy of the birth certificate

of the child

who due to its physical, mental or psycho-

physical state is entitled to a nursing allowance –

in addition up to 3 years for each child

a certificate of employment or certificate of

employer about the maternity or unpaid

leave, and in respect of periods of inactivity

due to care – a statement of the person

concerned, medical documentation

14


including the medical certificate about the

state of child’s health and a copy of the birth

certificate of the child

8) falling before the entitlement to retirement or

disability pension periods of care on war invalid

assigned to a 1st group of disabled people or deemed

as completely unable to work and independent

existence, by a member of his/her family at the age

of over 16 years, who during the period of care has

not achieved a revenue exceeding the half the

monthly lowest salary

a statement of the carer and the certificate of

the ZUS medical board for disability and

employment or ZUS appointed doctor (ZUS

medical board) and a certificate attesting the

status of war invalid

9) falling before entitlement to pension, periods of

inactivity of up to 6 years, due to the need to care

for other than the child a family member assigned to

a 1st group of disabled people or deemed as

completely unable to work and independent

existence or recognized as a disabled person in a

large degree, by a member of his family at the age

of over 16 years, who during the period of care has

not achieved a revenue exceeding the half the

monthly lowest salary

a statement of the carer and the certificate of

the ZUS medical board for disability and

employment or ZUS appointed doctor (ZUS

medical board) or a certificate of a Team for

the Decision on Incapacity

10) periods of an unpaid leave and breaks in

employment, if an unpaid leave was not granted to

spouses of employees sent to work in diplomatic

missions, consular offices, the permanent

representations to the United Nations and other

special missions abroad, institutes, centers of

information and culture abroad.

a certificate confirming the granting of

unpaid leave if the leave was granted and a

certificate of institutions sending to work

abroad

11) periods of study at university level in one

direction, subject to the completion of this study, the

size specified in the study program

a certificate confirming the university

graduation, their duration and size specified

in the study program or diploma if those

studies were completed with getting the

diploma, and the diploma shows the duration

and size specified in the study program

12) periods of professional training of doctors in

clinics of medical academies and departments of

scientific institutes as a volunteer - within 1 year

A certificate of the clinic of the medical

school or the research institute

13) periods of receiving the pre-retirement

allowance or pre-retirement benefit

a certificate of the employment agency for

periods of receiving the pre-retirement

benefit or pre-retirement allowance, paid by

the agency or confirmation of the ZUS of the

periods of payment of such benefits

15


14) periods of documented incapacity for work for

which were paid from the Labour Fund:

unemployment benefits, training benefits or grants

a certificate of the employment agency

15) periods of doctoral studies and postgraduate

scientific studies in dimension specified in the

decision on their establishment

a certificate issued by the entity leading the

studies

16) periods for junior preparatory studies a certificate issued by the entity leading the

studies


Documents and/or information required to support your application [CAN-PL 1] for a Polish retirement pension

Complete the attached forms:

Canadian Residence [ISP-5013]

Declaration of the applicant [CAN-PL 1 – Annex]

NOTE: All of the following documents must be provided in their original form or as copies certified by one of the following: Service Canada in person centers, Notary or a Consul of the Republic of Poland. Copies of documents certified by other institutions or persons not listed above will not be recognized. Please note that every page of a document must be certified.

Original or certified documents to be submitted:

Your birth certificate

Proof of the dates of your entry(ies) to Canada and departure(s) from Canada (such as: Immigration 1000, passport, visa, ship or airline tickets etc.)

Documents confirming your periods of insurance such as, certificates issued by your employers or their legal successors confirming employment, insurance cards, documents confirming self-employment or business insurance, or military document)

Documents confirming your non-contributory periods (i.e. parental leave, periods of disability, studies at the university level, etc.), if applicable

Documents confirming your earnings in Poland, if applicable

For farmers or persons that perform farm activity: documents confirming periods of farming or work activity on a farm prior to July 1, 1977, such as, a certificate from the administrative office of a communal council or depositions of witnesses attesting to the periods of farm activity, if applicable

For employed persons: a certificate containing information on the basis of calculation of contribution for social insurance, old age or disability insurance, or a statement of earnings issued by the employer (or a legal successor thereof), or a social insurance card containing a record of earnings, if applicable

For self-employed persons: the account number of the insurance payer and, if the activity was performed before enlisting it into the mandatory social insurance plan, a certificate of a socio-professional organization (e.g. a Trade Guild), if applicable

Certificate issued by your bank in Canada, containing the exact name and address of Canadian bank, the bank’s identification code (BIC/SWIFT), confirmation that you are the account holder or joint account holder and the complete number of the bank account for international transactions


Documents and/or information required to support your application [CAN-PL 1] for a Polish retirement pension

IMPORTANT: If you have already submitted any of the documents required when you applied

for a Canada Pension Plan or Old Age Security benefit, you do not need to resubmit them.

PROTECTED B (when completed)

SC ISP-5013 (2014-12-01) E 1 of 2

Service Canada

Personal Information Bank ESDC PPU 175

CANADIAN RESIDENCECanadian Social Insurance Number:

Mr. Mrs.

Ms. MissGiven Name and Initial Family Name

The following information is required to support your application for benefits under a social security agreement. If required, please provide additional information on a separate sheet of paper.

1. If you were born outside of Canada, please provide us with the following information:

Date of arrival in Canada (YYYY-MM-DD):

Place of arrival in Canada:

2. List all the places where you have lived in Canada after the age of 18 and provide proof of all your entries and departures (Permanent Resident card, Record of Landing (IMM 1000), complete passport, airline tickets, etc.):

From YYYY-MM-DD

To YYYY-MM-DD City Province/Territory

3. List all absences from Canada, which were longer than six months, during your Canadian residence listed in number 2 above:

Departure YYYY-MM-DD

Return YYYY-MM-DD Destination Reason

Service Canada delivers Employment and Social Development Canada programs and services for the Government of Canada.

Disponible en français

2 of 2SC ISP-5013 (2014-12-01) E

PROTECTED B (when completed)Canadian Social Insurance Number:

4. Please give us the names, addresses and telephone numbers of at least two people, not related to you by blood or marriage, who can confirm your Canadian residence:

Name Address City Telephone Number

DECLARATION OF APPLICANT

I declare that this information is true and complete.

NOTE: If you make a false or misleading statement, you may be subject to an administrative monetary penalty and interest, if any, under the Canada Pension Plan or the Old Age Security Act, or may be charged with an offence. Any benefits you received or obtained to which there was no entitlement would have to be repaid.

Signature Date (YYYY-MM-DD)

Telephone number

X

CAN-PL 1 – Załącznik/Annex

„Oświadczenie wnioskodawcy” * ubiegającego się o przyznanie polskiej emerytury albo renty z tytułu niezdolności do pracy

z zastosowaniem umowy o zabezpieczeniu społecznym między Rzecząpospolitą Polską a Kanadą

“Declaration of the applicant” *

applying for granting of the Polish old age pension or disability pension under the Agreement on Social Security between the Republic of Poland and Canada

1. Dane identyfikacyjne wnioskodawcy / Personal details of the applicant

1.1 Nazwisko / Surname………………………………………………………………………………………………………………………………

1.2 Imię / Name……………………………………………………………………………………………………………………………………………

1.3 Data urodzenia / Date of birth │ │ │ │ │ │ │ │ │(rok-miesiąc-dzień)/(year-month-day) 1.4 Numer identyfikacyjny w Polsce – PESEL (w przypadku braku nr PESEL, proszę podać serię i numer

dowodu osobistego lub paszportu) Identification number in Poland – your personal identity number (PESEL), if you do not have your PESEL number, please provide the series and number of your identity card or your passport number

……………………………………………………………………………………………………………………………………………………………..

1.5 Numer ubezpieczenia w Kanadzie / Social Insurance Number in Canada

……………………………………………………………………………………………………………………………………………………………..

2. Oświadczenie wnioskodawcy / Declaration of the applicant (proszę zaznaczyć właściwy kwadrat) / (please select the appropriate box) Oświadczam, że wniosek o przyznanie świadczenia zgodnie z ustawodawstwem kanadyjskim, który zgłosiłem/zgłosiłam w Service Canada po dniu 30.09.2009 r. jest jednocześnie wnioskiem o przyznanie odpowiedniego świadczenia zgodnie z ustawodawstwem polskim: I declare that the application for a benefit under the legislation of Canada submitted to Service Canada after 30th September 2009 is also the application for a corresponding pension under Polish legislation: 2.1 TAK / YES Jeżeli zaznaczył/zaznaczyła Pan/Pani „TAK” – to oznacza, że wniosek o przyznanie świadczenia zgodnie z ustawodawstwem kanadyjskim zostanie uznany za wniosek o przyznanie również odpowiedniego świadczenia zgodnie z ustawodawstwem polskim, o ile w chwili składania wniosku o świadczenie zgodnie z ustawodawstwem kanadyjskim wykazał Pan/Pani okresy ubezpieczenia przebyte w Polsce If you selected "YES" – this means that the application for a benefit under the Canadian legislation will be treated as the corresponding benefit under Polish legislation, if while applying for the Canadian benefit, you indicated insurance periods completed in Poland 2.2 ( NIE / NO Jeżeli zaznaczył/zaznaczyła Pan/Pani „NIE” – to oznacza, że w chwili składania wniosku o przyznanie świadczenia zgodnie z ustawodawstwem kanadyjskim nie zamierzał/nie zamierzała Pan/Pani ubiegać się o przyznanie odpowiedniego świadczenia zgodnie z ustawodawstwem polskim, odraczając tym samym ustalenie swojego prawa do świadczenia za okresy ubezpieczenia przebyte w Polsce If you selected "NO" – this means that while applying for the Canadian benefit, you did not intend to apply for the corresponding Polish benefit and thereby you postponed the determination of the right to a Polish benefit for the insurance periods completed in Poland

2.3 Data / Date Podpis wnioskodawcy / Signature of the applicant

…………………………………. …………………………………………………………………………………….

_______________________ * CAN-PL 1 – Załącznik „Oświadczenie wnioskodawcy” stanowi integralną część formularza CAN-PL 1 „Wniosek o polską emeryturę - o polską rentę z tytułu niezdolności do pracy”. CAN-PL 1 – Załącznik po wypełnieniu proszę dołączyć do wypełnionego formularza wniosku CAN-PL 1.

* CAN-PL 1 – Annex “Declaration of the applicant” constitutes the integral part of CAN-PL 1 form –“Application for Polish retirement pension – pension for Polish inability to work”. After you fill out CAN-PL 1 – Annex, please attach it to your completed CAN-PL 1 form.