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Information Collection

Request For A Certificate Of Coverage

IC 115390 under ICR 198311-0960-002 · OMB 0960-0357.

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REQUEST FOR A CERTIFICATE OF COVERAGE
 
No Migrated
 
Required to Obtain or Retain Benefits
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form SSA-4569 No No


    

2,500 0
   
Individuals or Households
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 2,500 0 2,500 0 0 0
Annual IC Time Burden (Hours) 417 0 417 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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