Information Collection

Certificate of Coverage Request--Private Sector

IC 182116 under ICR 200709-0960-013 · OMB 0960-0554.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0554 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Sample Certificate of Coverage Request Internet Form--Australia.pdf	Instruction
Sample Agreement Booklet--Australia.pdf	Instruction

IC Title:

Certificate of Coverage Request--Private Sector

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 404.1913

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			Sample Certificate of Coverage Request Internet Form--Australia.pdf		Yes	Yes	Fillable Fileable Signable
Instruction			Sample Agreement Booklet--Australia.pdf		Yes	No	Printable Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 20,000

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 25 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	20,000	20,000
Annual IC Time Burden (Hours)	10,000	10,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.