1037
| ID | 1037 |
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| Data | 2012-10-19 |
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| Symbol | 2012/10/19/1037 |
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| Instytucja | Zakład Ubezpieczeń Społecznych |
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| Nazwa | Zaświadczenie o ubezpieczeniu - Umowa między Rzecząpospolitą Polską a USA - PL-USA 1 |
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| Czy Aktualny | 1 |
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Ustawy (1)
| URI://Dziennik_Ustaw/2009/46/376/4/2 | Art. 4 ust. 2 Porozumienia Administracyjnego z 2 kwietnia 2008 r. w sprawie stosowania Umowy o zabezpieczeniu społecznym między Rzecząpospolitą Polską a Stanami Zjednoczonymi (Dz. U. z 2009 r., Nr 46, poz. 376) |
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Pliki
Styl
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PL/USA 1 (Formularz) - Zakład Ubezpieczeń Społecznych
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<div style="left:21px; top:14px; width:840px; height:1212px; border-style: none; position:absolute;">
<div style="left:200px; top:77px; font-size:14px; font-weight:normal; font-family:verdana; display:block; position:absolute; overflow:hidden;"> UMOWA O ZABEZPIECZENIU SPOŁECZNYM<br/>MIĘDZY RZECZĄPOSPOLITĄ POLSKĄ A STANAMI ZJEDNOCZONYMI AMERYKI</div>
<div style="left:200px; top:117px; font-size:14px; font-weight:normal; font-family:verdana; display:block; position:absolute; overflow:hidden;"> AGREEMENT ON SOCIAL SECURITY<br/>BETWEEN THE REPUBLIC OF POLAND AND THE UNITED STATES OF AMERICA</div>
<div style="left:322px; top:206px; font-size:14px; font-style:italic; font-family:arial; display:block; position:absolute; overflow:hidden;"> Art. 6 Umowy <br/>Art. 5 Porozumienia Administracyjnego</div>
<div style="left:322px; top:252px; font-size:14px; font-style:italic; font-family:arial; display:block; position:absolute; overflow:hidden;"> Art. 6 of the Agreement <br/>Art. 5 of Administrative Arrangement</div>
<div style="left:607px; top:161px; font-size:12px; font-weight:bold; font-family:arial; display:block; position:absolute; overflow:hidden;">(1)</div>
<div style="left:310px; top:167px; font-size:14px; font-weight:bold; font-family:verdana; display:block; position:absolute; overflow:hidden;">ZAŚWIADCZENIE O UBEZPIECZENIU</div>
<div style="left:340px; top:184px; font-size:14px; font-weight:bold; font-family:verdana; display:block; position:absolute; overflow:hidden;">CERTIFICATE OF COVERAGE</div>
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<div style="left:61px; top:336px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">1.</div>
<div style="left:53px; top:428px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">1.1 Nazwisko:</div>
<div style="left:74px; top:444px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">Name</div>
<div style="left:122px; top:378px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">Pracownik</div>
<div style="left:124px; top:393px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">Employee</div>
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<div style="left:262px; top:378px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">Osoba pracująca na własny rachunek</div>
<div style="left:264px; top:393px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">Self-employed person</div>
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<xsl:if test="//wnio:TrescDokumentu/wnio:InformacjeDotyczacePracodawcyDzialalnosci/wnio:Pracodawca ='true'">
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<div style="left:127px; top:808px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">Pracodawca</div>
<div style="left:129px; top:823px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">Employer</div>
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<div style="left:267px; top:808px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">Działalność na własny rachunek</div>
<div style="left:269px; top:823px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">Work performed as self-employed</div>
<div style="left:91px; top:322px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">Informacje dotyczące osoby ubezpieczonej</div>
<div style="left:91px; top:337px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">Information concerning the insured person</div>
<div style="left:73px; top:481px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">Given name(s)</div>
<div style="left:74px; top:515px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">Date of birth</div>
<div style="left:69px; top:560px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">Place of residence</div>
<div style="left:72px; top:641px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">Personal identification number in Poland</div>
<div style="left:53px; top:466px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">1.2 Imię (imiona):</div>
<div style="left:51px; top:501px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">1.3 Data urodzenia:</div>
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<div style="font-size:11px; font-family:verdana; left:184px; top:533px; display:block; position:absolute; overflow:hidden;">(2)</div>
<div style="left:50px; top:540px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">1.5 Adres zamieszkania :</div>
<div style="left:372px; top:513px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">Citizenship</div>
<div style="left:347px; top:498px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">1.4 Obywatelstwo</div>
<div id="55" style="left:452px; top:494px; width:373px; height:25px; display:block; border-style: solid; border-width: 1px; position:absolute; overflow:hidden; background-color:#ffffff;">
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<div style="font-size:11px; font-family:verdana; left:253px; top:617px; display:block; position:absolute; overflow:hidden;">(3)</div>
<div style="left:51px; top:621px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">1.6 Numery identyfikacyjny w Polsce :</div>
<div style="left:748px; top:10px; width:95px; height:35px; border-style: solid; border-width: 1px; position:absolute;">
<div style="left:14px; top:10px; font-size:14px; font-weight:bold; font-family:verdana; display:block; position:absolute; overflow:hidden;">PL/USA 1</div>
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<xsl:value-of select="//wnio:TrescDokumentu/wnio:InformacjeDotyczaceOsobyUbezpieczonej/wnio:Nazwisko"/>
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<div id="56" style="left:222px; top:530px; width:603px; height:25px; display:block; border-style: solid; border-width: 1px; position:absolute; overflow:hidden; background-color:#ffffff;">
<div style="padding-left:5px; padding-top:3px;">
<xsl:value-of select="//wnio:TrescDokumentu/wnio:InformacjeDotyczaceOsobyUbezpieczonej/wnio:AdresZamieszkania"/>
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<div id="61" style="left:147px; top:908px; width:679px; height:25px; display:block; border-style: solid; border-width: 1px; position:absolute; overflow:hidden; background-color:#ffffff;">
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<xsl:value-of select="//wnio:TrescDokumentu/wnio:InformacjeDotyczacePracodawcyDzialalnosci/wnio:Adres"/>
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<div id="60" style="left:147px; top:857px; width:679px; height:25px; display:block; border-style: solid; border-width: 1px; position:absolute; overflow:hidden; background-color:#ffffff;">
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<div style="left:91px; top:762px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">Informacje dotyczące pracodawcy lub działalności na własny rachunek</div>
<div style="left:91px; top:777px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">Information concerning the employer or self-employment</div>
<div style="left:76px; top:940px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">Address</div>
<div style="left:55px; top:921px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">2.2 Adres :</div>
<div style="left:74px; top:1029px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">Business identification number in Poland</div>
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<div style="width:27px; left:62px; top:775px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">2.</div>
<div style="left:55px; top:860px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">2.1 Nazwa:</div>
<div style="left:76px; top:876px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">Name</div>
<div style="font-size:11px; font-family:verdana; left:111px; top:919px; display:block; position:absolute; overflow:hidden;">(2)</div>
<div style="left:52px; top:1013px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">2.3 Numery identyfikacyjne w Polsce (NIP i REGON):</div>
<div id="62" style="left:345px; top:999px; width:479px; height:25px; display:block; border-style: solid; border-width: 1px; position:absolute; overflow:hidden; background-color:#ffffff;">
<div style="padding-left:5px; padding-top:3px;">
<xsl:value-of select="//wnio:TrescDokumentu/wnio:InformacjeDotyczacePracodawcyDzialalnosci/wnio:NumerIdentyfikacyjnyWPolsce"/>
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<div id="54" style="left:195px; top:496px; height:25px; width:140px; display:block; border-style: solid; border-width: 1px; position:absolute; overflow:hidden; background-color:#ffffff;">
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<hr style="visibility: hidden;"/>
<div style="width:885px; margin-left:auto; margin-right:auto; position:relative; text-align:left; page-break-after:always;">
<div style="border-style: solid; border-width:1px; left:0px; width:885px; height:1270px; margin-bottom:10px; margin-left:0px; margin-top:0px; text-align:left;">
<div style="left:20px; border-style: none; top:10px; width:841px; height:1216px; position:absolute;">
<div style="left:52px; top:101px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">3.</div>
<div style="left:49px; top:145px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">3.1</div>
<div style="left:82px; top:87px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">Osoba wymieniona w punkcie 1</div>
<div style="left:82px; top:102px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">Person mentioned in point 1</div>
<div style="left:112px; top:329px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">temporarily transfers activity <br/>to the firm mentioned below</div>
<div style="left:81px; top:419px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">Name of the company on behalf of which insured person will be working in United States</div>
<div style="left:52px; top:301px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">3.3</div>
<div style="left:111px; top:136px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">została oddelegowana</div>
<div style="left:111px; top:150px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">was seconded</div>
<div style="left:290px; top:136px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">od</div>
<div style="left:290px; top:160px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">from</div>
<div style="left:463px; top:136px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">do</div>
<div style="left:463px; top:156px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">to</div>
<div style="left:123px; top:251px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">do</div>
<div style="left:125px; top:271px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">to</div>
<div style="left:112px; top:295px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">przenosi czasowo działalność <br/>do firmy wymienionej poniżej</div>
<div style="left:77px; top:516px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">Address in United States</div>
<div id="63" style="left:78px; top:136px; width:25px; height:25px; display:block; border-style: solid; border-width: 1px; position:absolute; overflow:hidden; background-color:#ffffff;">
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<div style="padding-left: 6px; padding-top: 2px;">X</div>
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<div style="left:48px; top:196px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">3.2 </div>
<div style="left:54px; top:399px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">3.4 Nazwa przedsiębiorstwa, na rzecz którego osoba ubezpieczona będzie wykonywała pracę w Stanach Zjednoczonych</div>
<div style="left:52px; top:496px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">3.5 Adres w Stanach Zjednoczonych</div>
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<img src="data:image/gif;base64, R0lGODdhAQABAOcdAAAAAAEBAQICAgMDAwQEBAUFBQYGBgcHBwgICAkJCQoKCgsLCwwMDA0NDQ4O Dg8PDxAQEBERERISEhMTExQUFBUVFRYWFhcXFxgYGBkZGRoaGhsbGxwcHB0dHR4eHh8fHyAgICEh ISIiIiMjIyQkJCUlJSYmJicnJygoKCkpKSoqKisrKywsLC0tLS4uLi8vLzAwMDExMTIyMjMzMzQ0 NDU1NTY2Njc3Nzg4ODk5OTo6Ojs7Ozw8PD09PT4+Pj8/P0BAQEFBQUJCQkNDQ0REREVFRUZGRkdH R0hISElJSUpKSktLS0xMTE1NTU5OTk9PT1BQUFFRUVJSUlNTU1RUVFVVVVZWVldXV1hYWFlZWVpa WltbW1xcXF1dXV5eXl9fX2BgYGFhYWJiYmNjY2RkZGVlZWZmZmdnZ2hoaGlpaWpqamtra2xsbG1t bW5ubm9vb3BwcHFxcXJycnNzc3R0dHV1dXZ2dnd3d3h4eHl5eXp6ent7e3x8fH19fX5+fn9/f4CA gIGBgYKCgoODg4SEhIWFhYaGhoeHh4iIiImJiYqKiouLi4yMjI2NjY6Ojo+Pj5CQkJGRkZKSkpOT k5SUlJWVlZaWlpeXl5iYmJmZmZqampubm5ycnJ2dnZ6enp+fn6CgoKGhoaKioqOjo6SkpKWlpaam pqenp6ioqKmpqaqqqqurq6ysrK2tra6urq+vr7CwsLGxsbKysrOzs7S0tLW1tba2tre3t7i4uLm5 ubq6uru7u7y8vL29vb6+vr+/v8DAwMHBwcLCwsPDw8TExMXFxcbGxsfHx8jIyMnJycrKysvLy8zM zM3Nzc7Ozs/Pz9DQ0NHR0dLS0tPT09TU1NXV1dbW1tfX19jY2NnZ2dra2tvb29zc3N3d3d7e3t/f 3+Dg4OHh4eLi4uPj4+Tk5OXl5ebm5ufn5+jo6Onp6erq6uvr6+zs7O3t7e7u7u/v7/Dw8PHx8fLy 8vPz8/T09PX19fb29vf39/j4+Pn5+fr6+vv7+/z8/P39/f7+/v///ywAAAAAAQABAAAIBAABBAQA Ozs=" alt="img" style="left:784px; top:121px; width:1px; height:499px; display:block; position:absolute"/>
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<img src="data:image/gif;base64, R0lGODdhAQABAOcdAAAAAAEBAQICAgMDAwQEBAUFBQYGBgcHBwgICAkJCQoKCgsLCwwMDA0NDQ4O Dg8PDxAQEBERERISEhMTExQUFBUVFRYWFhcXFxgYGBkZGRoaGhsbGxwcHB0dHR4eHh8fHyAgICEh ISIiIiMjIyQkJCUlJSYmJicnJygoKCkpKSoqKisrKywsLC0tLS4uLi8vLzAwMDExMTIyMjMzMzQ0 NDU1NTY2Njc3Nzg4ODk5OTo6Ojs7Ozw8PD09PT4+Pj8/P0BAQEFBQUJCQkNDQ0REREVFRUZGRkdH R0hISElJSUpKSktLS0xMTE1NTU5OTk9PT1BQUFFRUVJSUlNTU1RUVFVVVVZWVldXV1hYWFlZWVpa WltbW1xcXF1dXV5eXl9fX2BgYGFhYWJiYmNjY2RkZGVlZWZmZmdnZ2hoaGlpaWpqamtra2xsbG1t bW5ubm9vb3BwcHFxcXJycnNzc3R0dHV1dXZ2dnd3d3h4eHl5eXp6ent7e3x8fH19fX5+fn9/f4CA gIGBgYKCgoODg4SEhIWFhYaGhoeHh4iIiImJiYqKiouLi4yMjI2NjY6Ojo+Pj5CQkJGRkZKSkpOT k5SUlJWVlZaWlpeXl5iYmJmZmZqampubm5ycnJ2dnZ6enp+fn6CgoKGhoaKioqOjo6SkpKWlpaam pqenp6ioqKmpqaqqqqurq6ysrK2tra6urq+vr7CwsLGxsbKysrOzs7S0tLW1tba2tre3t7i4uLm5 ubq6uru7u7y8vL29vb6+vr+/v8DAwMHBwcLCwsPDw8TExMXFxcbGxsfHx8jIyMnJycrKysvLy8zM zM3Nzc7Ozs/Pz9DQ0NHR0dLS0tPT09TU1NXV1dbW1tfX19jY2NnZ2dra2tvb29zc3N3d3d7e3t/f 3+Dg4OHh4eLi4uPj4+Tk5OXl5ebm5ufn5+jo6Onp6erq6uvr6+zs7O3t7e7u7u/v7/Dw8PHx8fLy 8vPz8/T09PX19fb29vf39/j4+Pn5+fr6+vv7+/z8/P39/f7+/v///ywAAAAAAQABAAAIBAABBAQA Ozs=" alt="img" style="left:39px; top:120px; width:746px; height:1px; display:block; position:absolute"/>
<img src="data:image/gif;base64, R0lGODdhAQABAOcdAAAAAAEBAQICAgMDAwQEBAUFBQYGBgcHBwgICAkJCQoKCgsLCwwMDA0NDQ4O Dg8PDxAQEBERERISEhMTExQUFBUVFRYWFhcXFxgYGBkZGRoaGhsbGxwcHB0dHR4eHh8fHyAgICEh ISIiIiMjIyQkJCUlJSYmJicnJygoKCkpKSoqKisrKywsLC0tLS4uLi8vLzAwMDExMTIyMjMzMzQ0 NDU1NTY2Njc3Nzg4ODk5OTo6Ojs7Ozw8PD09PT4+Pj8/P0BAQEFBQUJCQkNDQ0REREVFRUZGRkdH R0hISElJSUpKSktLS0xMTE1NTU5OTk9PT1BQUFFRUVJSUlNTU1RUVFVVVVZWVldXV1hYWFlZWVpa WltbW1xcXF1dXV5eXl9fX2BgYGFhYWJiYmNjY2RkZGVlZWZmZmdnZ2hoaGlpaWpqamtra2xsbG1t bW5ubm9vb3BwcHFxcXJycnNzc3R0dHV1dXZ2dnd3d3h4eHl5eXp6ent7e3x8fH19fX5+fn9/f4CA gIGBgYKCgoODg4SEhIWFhYaGhoeHh4iIiImJiYqKiouLi4yMjI2NjY6Ojo+Pj5CQkJGRkZKSkpOT k5SUlJWVlZaWlpeXl5iYmJmZmZqampubm5ycnJ2dnZ6enp+fn6CgoKGhoaKioqOjo6SkpKWlpaam pqenp6ioqKmpqaqqqqurq6ysrK2tra6urq+vr7CwsLGxsbKysrOzs7S0tLW1tba2tre3t7i4uLm5 ubq6uru7u7y8vL29vb6+vr+/v8DAwMHBwcLCwsPDw8TExMXFxcbGxsfHx8jIyMnJycrKysvLy8zM zM3Nzc7Ozs/Pz9DQ0NHR0dLS0tPT09TU1NXV1dbW1tfX19jY2NnZ2dra2tvb29zc3N3d3d7e3t/f 3+Dg4OHh4eLi4uPj4+Tk5OXl5ebm5ufn5+jo6Onp6erq6uvr6+zs7O3t7e7u7u/v7/Dw8PHx8fLy 8vPz8/T09PX19fb29vf39/j4+Pn5+fr6+vv7+/z8/P39/f7+/v///ywAAAAAAQABAAAIBAABBAQA Ozs=" alt="img" style="width:746px; height:1px; left:39px; top:619px; display:block; position:absolute"/>
<img src="data:image/gif;base64, R0lGODdhAQABAOcdAAAAAAEBAQICAgMDAwQEBAUFBQYGBgcHBwgICAkJCQoKCgsLCwwMDA0NDQ4O Dg8PDxAQEBERERISEhMTExQUFBUVFRYWFhcXFxgYGBkZGRoaGhsbGxwcHB0dHR4eHh8fHyAgICEh ISIiIiMjIyQkJCUlJSYmJicnJygoKCkpKSoqKisrKywsLC0tLS4uLi8vLzAwMDExMTIyMjMzMzQ0 NDU1NTY2Njc3Nzg4ODk5OTo6Ojs7Ozw8PD09PT4+Pj8/P0BAQEFBQUJCQkNDQ0REREVFRUZGRkdH R0hISElJSUpKSktLS0xMTE1NTU5OTk9PT1BQUFFRUVJSUlNTU1RUVFVVVVZWVldXV1hYWFlZWVpa WltbW1xcXF1dXV5eXl9fX2BgYGFhYWJiYmNjY2RkZGVlZWZmZmdnZ2hoaGlpaWpqamtra2xsbG1t bW5ubm9vb3BwcHFxcXJycnNzc3R0dHV1dXZ2dnd3d3h4eHl5eXp6ent7e3x8fH19fX5+fn9/f4CA gIGBgYKCgoODg4SEhIWFhYaGhoeHh4iIiImJiYqKiouLi4yMjI2NjY6Ojo+Pj5CQkJGRkZKSkpOT k5SUlJWVlZaWlpeXl5iYmJmZmZqampubm5ycnJ2dnZ6enp+fn6CgoKGhoaKioqOjo6SkpKWlpaam pqenp6ioqKmpqaqqqqurq6ysrK2tra6urq+vr7CwsLGxsbKysrOzs7S0tLW1tba2tre3t7i4uLm5 ubq6uru7u7y8vL29vb6+vr+/v8DAwMHBwcLCwsPDw8TExMXFxcbGxsfHx8jIyMnJycrKysvLy8zM zM3Nzc7Ozs/Pz9DQ0NHR0dLS0tPT09TU1NXV1dbW1tfX19jY2NnZ2dra2tvb29zc3N3d3d7e3t/f 3+Dg4OHh4eLi4uPj4+Tk5OXl5ebm5ufn5+jo6Onp6erq6uvr6+zs7O3t7e7u7u/v7/Dw8PHx8fLy 8vPz8/T09PX19fb29vf39/j4+Pn5+fr6+vv7+/z8/P39/f7+/v///ywAAAAAAQABAAAIBAABBAQA Ozs=" alt="img" style="left:39px; top:86px; width:35px; height:1px; display:block; position:absolute"/>
<div id="69" style="left:79px; top:296px; width:25px; height:25px; display:block; border-style: solid; border-width: 1px; position:absolute; overflow:hidden; background-color:#ffffff;">
<xsl:if test="//wnio:TrescDokumentu/wnio:OsobaUbezpieczona/wnio:PrzenosiDzialalnosc ='true'">
<div style="padding-left: 6px; padding-top: 2px;">X</div>
</xsl:if>
</div>
<div id="74" style="left:216px; top:675px; width:25px; height:25px; display:block; border-style: solid; border-width: 1px; position:absolute; overflow:hidden; background-color:#ffffff;">
<xsl:if test="//wnio:TrescDokumentu/wnio:PodleganiePrzepisomPrawaWPolsce/wnio:Artykul/wnio:Art6_1 ='true'">
<div style="padding-left: 6px; padding-top: 2px;">X</div>
</xsl:if>
</div>
<div style="left:111px; top:199px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">prowadzi działalność na terytorium Polski i Stanów Zjednoczonych od</div>
<div style="left:111px; top:218px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">pursues activities on the territory of Poland and United States from</div>
<div id="66" style="left:78px; top:192px; width:25px; height:25px; display:block; border-style: solid; border-width: 1px; position:absolute; overflow:hidden; background-color:#ffffff;">
<xsl:if test="//wnio:TrescDokumentu/wnio:OsobaUbezpieczona/wnio:ProwadziDzialalnoscWPolsceStanach ='true'">
<div style="padding-left: 6px; padding-top: 2px;">X</div>
</xsl:if>
</div>
<div style="left:304px; top:308px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">od</div>
<div style="left:304px; top:332px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">from</div>
<div style="left:477px; top:308px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">do</div>
<div style="left:477px; top:328px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">to</div>
<div style="left:82px; top:628px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">Osoba ubezpieczona podlega przepisom prawa w Polsce</div>
<div style="left:82px; top:643px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">The insured person is subject to the legal regulations of Poland</div>
<div style="left:248px; top:680px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">6.1</div>
<div id="82" style="left:84px; top:794px; width:25px; height:25px; display:block; border-style: solid; border-width: 1px; position:absolute; overflow:hidden; background-color:#ffffff;">
<xsl:if test="//wnio:TrescDokumentu/wnio:PodleganiePrzepisomPrawaWPolsce/wnio:NaPodstawieZgodyZDnia ='true'">
<div style="padding-left: 6px; padding-top: 2px;">X</div>
</xsl:if>
</div>
<div style="left:116px; top:799px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">na podstawie zgody z dnia</div>
<div style="left:518px; top:799px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">znak:</div>
<div style="left:518px; top:815px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">ref N°</div>
<div style="left:117px; top:815px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">on the grounds of consent dated</div>
<div style="left:117px; top:842px; font-size:12px; font-style:italic; font-family:arial; display:block; position:absolute; overflow:hidden;">(w przypadku art. 6.10 Umowy)</div>
<div style="left:115px; top:866px; font-size:12px; font-style:italic; font-family:arial; display:block; position:absolute; overflow:hidden;">(in the case of art. 6.10 of Agreement)</div>
<div id="75" style="left:278px; top:675px; width:25px; height:25px; display:block; border-style: solid; border-width: 1px; position:absolute; overflow:hidden; background-color:#ffffff;">
<xsl:if test="//wnio:TrescDokumentu/wnio:PodleganiePrzepisomPrawaWPolsce/wnio:Artykul/wnio:Art6_2 ='true'">
<div style="padding-left: 6px; padding-top: 2px;">X</div>
</xsl:if>
</div>
<div style="left:310px; top:680px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">6.2</div>
<div id="76" style="left:340px; top:675px; width:25px; height:25px; display:block; border-style: solid; border-width: 1px; position:absolute; overflow:hidden; background-color:#ffffff;">
<xsl:if test="//wnio:TrescDokumentu/wnio:PodleganiePrzepisomPrawaWPolsce/wnio:Artykul/wnio:Art6_4 ='true'">
<div style="padding-left: 6px; padding-top: 2px;">X</div>
</xsl:if>
</div>
<div style="left:372px; top:680px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">6.4</div>
<div id="77" style="left:409px; top:675px; width:25px; height:25px; display:block; border-style: solid; border-width: 1px; position:absolute; overflow:hidden; background-color:#ffffff;">
<xsl:if test="//wnio:TrescDokumentu/wnio:PodleganiePrzepisomPrawaWPolsce/wnio:Artykul/wnio:Art6_6 ='true'">
<div style="padding-left: 6px; padding-top: 2px;">X</div>
</xsl:if>
</div>
<div style="left:441px; top:680px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">6.6</div>
<div id="78" style="left:472px; top:675px; width:25px; height:25px; display:block; border-style: solid; border-width: 1px; position:absolute; overflow:hidden; background-color:#ffffff;">
<xsl:if test="//wnio:TrescDokumentu/wnio:PodleganiePrzepisomPrawaWPolsce/wnio:Artykul/wnio:Art6_8 ='true'">
<div style="padding-left: 6px; padding-top: 2px;">X</div>
</xsl:if>
</div>
<div style="left:504px; top:680px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">6.8</div>
<div id="79" style="left:534px; top:675px; width:25px; height:25px; display:block; border-style: solid; border-width: 1px; position:absolute; overflow:hidden; background-color:#ffffff;">
<xsl:if test="//wnio:TrescDokumentu/wnio:PodleganiePrzepisomPrawaWPolsce/wnio:Artykul/wnio:Art6_10 ='true'">
<div style="padding-left: 6px; padding-top: 2px;">X</div>
</xsl:if>
</div>
<div style="left:566px; top:680px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">6.10 Umowy</div>
<div style="left:56px; top:730px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">4.2 od</div>
<div style="left:56px; top:790px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">4.3</div>
<div style="left:83px; top:748px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">from</div>
<div style="left:339px; top:750px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">to</div>
<div style="left:335px; top:732px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">do</div>
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<div style="left:53px; top:641px; width:27px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">4.</div>
<div style="left:55px; top:674px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">4.1 na mocy artykułu:</div>
<div style="left:76px; top:690px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">on the strength of article</div>
<div id="84" style="width:198px; left:578px; top:799px; height:25px; display:block; border-style: solid; border-width: 1px; position:absolute; overflow:hidden; background-color:#ffffff;">
<div style="padding-left:5px; padding-top:3px;">
<xsl:value-of select="//wnio:TrescDokumentu/wnio:PodleganiePrzepisomPrawaWPolsce/wnio:Znak"/>
</div>
</div>
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<div id="86" style="left:143px; top:1012px; width:632px; height:25px; display:block; border-style: solid; border-width: 1px; position:absolute; overflow:hidden; background-color:#ffffff;">
<div style="padding-left:5px; padding-top:3px;">
<xsl:value-of select="//wnio:TrescDokumentu/wnio:InstytucjaWlasciwaWPolsce/wnio:Adres"/>
</div>
</div>
<div id="85" style="left:124px; top:958px; width:649px; height:25px; display:block; border-style: solid; border-width: 1px; position:absolute; overflow:hidden; background-color:#ffffff;">
<div style="padding-left:5px; padding-top:3px;">
<xsl:value-of select="//wnio:TrescDokumentu/wnio:InstytucjaWlasciwaWPolsce/wnio:Nazwa"/>
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</div>
<div style="left:82px; top:917px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">Instytucja właściwa w Polsce</div>
<div style="left:82px; top:932px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">Competent institution in Poland</div>
<div style="left:76px; top:1037px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">Address</div>
<div style="left:61px; top:1024px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">5.2 Adres:</div>
<div style="left:82px; top:1112px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">Stamp</div>
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<div style="left:53px; top:930px; width:27px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">5.</div>
<div style="left:55px; top:963px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">5.1 Nazwa:</div>
<div style="left:76px; top:979px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">Name</div>
<div style="left:60px; top:1096px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">5.3 Pieczęć</div>
<div style="left:473px; top:1130px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">Date</div>
<div style="left:451px; top:1114px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">5.4 Data</div>
<div style="left:472px; top:1167px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">Signature</div>
<div style="left:450px; top:1151px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">5.5 Podpis</div>
<div style="width:208px; font-size:14px; font-weight:normal; font-family:verdana; text-align:center; left:545px; top:1159px; display:block; position:absolute; overflow:hidden;">......................................</div>
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<div style="left:85px; top:112px; width:757px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">Właściwa terenowa jednostka Zakładu Ubezpieczeń Społecznych wystawia formularz na wniosek pracodawcy lub osoby pracującej na własny rachunek. Rolnikom, na ich wniosek formularz wystawia Centrala Kasy Rolniczego Ubezpieczenia Społecznego. Formularz potwierdza okres, w którym pracownik lub osoba pracująca na własny rachunek w dalszym ciągu podlega polskim przepisom prawnym. Kopię tego formularza jednostka terenowa Zakładu Ubezpieczeń Społecznych lub Centrala Kasy Rolniczego Ubezpieczenia Społecznego wysyła do Social Security Administration, a drugą kopię pozostawia się zainteresowanemu jako dowód, że w stosunku do niego nie są stosowane amerykańskie przepisy prawne o obowiązkowym ubezpieczeniu.</div>
<div style="left:83px; top:303px; width:759px; font-size:12px; font-weight:bold; font-family:arial; display:block; position:absolute; overflow:hidden;">W przypadku, o którym mowa w art. 6.10 Umowy właściwa terenowa jednostka Zakładu Ubezpieczeń Społecznych wystawia formularz, po uzyskaniu pisemnej zgody otrzymanej od instytucji amerykańskiej.</div>
<div style="left:40px; top:112px; font-size:12px; font-weight:bold; font-family:arial; display:block; position:absolute; overflow:hidden;">(1)</div>
<div style="left:85px; top:384px; width:736px; font-size:12px; font-weight:bold; font-family:arial; display:block; position:absolute; overflow:hidden;">Ulica, numer domu, numer mieszkania, kod pocztowy, miejscowość, gmina/powiat/województwo.</div>
<div style="left:40px; top:384px; font-size:12px; font-weight:bold; font-family:arial; display:block; position:absolute; overflow:hidden;">(2)</div>
<div style="left:85px; top:215px; width:757px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">The competent local branch of Social Insurance Institution issues this form on request of the employer or self--employed person. For farmers, on their request, the form issues the Headquarters of Agricultural Social Insurance. This form confirms the period over which an employee or a self-employed person has been now subject to jurisdiction of Poland. A copy of this form is to be sent by local branch of Social Insurance Institution or Headquarters of Agricultural Social Insurance to Social Security Administration and a second copy is to be keptby the applicant as a proof that the legal regulations applicable to mandatory insurance in United States are not applied in relation to him/her.</div>
<div style="left:83px; top:342px; width:757px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">In cases mentioned in art. 6.10 of the Agreement the competent local branch of Social Insurance Institutionissues this form after having obtained written consent from competent authorities or an institution of the other Country appointed by them.</div>
<div style="left:85px; top:404px; width:757px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">Street name and number, apartment number, postal code, town/village, commune, district, province.</div>
<div style="left:85px; top:435px; width:757px; font-size:12px; font-weight:bold; font-family:arial; display:block; position:absolute; overflow:hidden;">PESEL i NIP, a w razie gdy ubezpieczonemu nie nadano tych numerów lub jednego z nich – seria i numer dowodu osobistego lub paszportu.</div>
<div style="left:40px; top:435px; font-size:12px; font-weight:bold; font-family:arial; display:block; position:absolute; overflow:hidden;">(3)</div>
<div style="left:85px; top:473px; width:757px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">PESEL and NIP, and in cases the insured has not been assigned one or both of these numbers – series and number of the Country ID or Passport.</div>
<div style="left:365px; top:545px; width:148px; font-size:12px; font-weight:bold; font-family:arial; display:block; position:absolute; overflow:hidden;">INSTYTUCJE WŁAŚCIWE</div>
<div style="left:90px; top:597px; width:736px; font-size:12px; font-weight:bold; font-family:arial; display:block; position:absolute; overflow:hidden;">dla celów realizacji Umowy</div>
<div style="left:206px; top:597px; width:146px; font-size:12px; font-weight:bold; font-style:italic; font-family:arial; display:block; position:absolute; overflow:hidden;">art. 6.1, 6.2, 6.4, 6.6, 6.8</div>
<div style="left:90px; top:617px; width:559px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">for the purpose of implementation of of the Agreement</div>
<div style="left:295px; top:617px; font-size:12px; font-style:italic; width:144px; font-family:arial; display:block; position:absolute; overflow:hidden;">art. 6.1, 6.2, 6.4, 6.6, 6.8</div>
<div style="left:91px; top:653px; width:736px; font-size:12px; font-weight:bold; font-family:arial; display:block; position:absolute; overflow:hidden;">Terenowe jednostki Zakładu Ubezpieczeń Społecznych właściwe dla siedziby pracodawcy lub firmy prowadzonej przez osobę pracującą na własny rachunek.</div>
<div style="left:92px; top:688px; width:753px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">Local branches of Social Insurance Institution with competence over the area where the headquarters of the employeror the fi rm run by the self-employed person.</div>
<div style="left:91px; top:742px; width:177px; font-size:12px; font-weight:bold; font-family:arial; display:block; position:absolute; overflow:hidden;">dla celów realizacji</div>
<div style="left:207px; top:742px; width:80px; font-size:12px; font-weight:bold; font-style:italic; font-family:arial; display:block; position:absolute; overflow:hidden;">art. 6.1, 6.4</div>
<div style="left:93px; top:763px; width:757px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">for the purpose of implementation of of the Agreement – applying legal regulations on agricultural social insurance.</div>
<div style="left:298px; top:763px; width:80px; font-size:12px; font-style:italic; font-family:arial; display:block; position:absolute; overflow:hidden;">art. 6.1, 6.4</div>
<div style="left:277px; top:742px; width:436px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">Umowy – przy zastosowaniu przepisów o ubezpieczeniu społecznym rolników.</div>
<div style="left:88px; top:795px; width:379px; font-size:12px; font-weight:bold; font-family:arial; display:block; position:absolute; overflow:hidden;">Centrala Kasy Rolniczego Ubezpieczenia Społecznego</div>
<div style="left:88px; top:815px; width:757px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">Headquarters of Agricultural Social Insurance</div>
<div style="left:88px; top:853px; width:264px; font-size:12px; font-weight:bold; font-family:arial; display:block; position:absolute; overflow:hidden;">dla celów realizacji Umowy</div>
<div style="left:202px; top:853px; width:68px; font-size:12px; font-weight:bold; font-style:italic; font-family:arial; display:block; position:absolute; overflow:hidden;">art. 6.10</div>
<div style="left:88px; top:873px; width:379px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">for the purpose of implementation of of the Agreement</div>
<div style="left:295px; top:873px; width:64px; font-size:12px; font-style:italic; font-family:arial; display:block; position:absolute; overflow:hidden;">art. 6.10</div>
<div style="left:88px; top:900px; width:736px; font-size:12px; font-weight:bold; font-family:arial; display:block; position:absolute; overflow:hidden;">Centrala Zakładu Ubezpieczeń Społecznych</div>
<div style="left:88px; top:920px; width:757px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">Headquarters of Social Insurance Institution</div>
<div style="left:349px; top:568px; width:175px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">COMPETENT INSTITUTIONS</div>
<div style="left:389px; top:47px; width:88px; font-family:arial; font-size:12px; display:block; position:absolute; overflow:hidden;">COMMENTS</div>
<div style="left:389px; top:30px; width:88px; font-size:12px; font-weight:bold; font-family:arial; display:block; position:absolute; overflow:hidden;"> UWAGI</div>
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