Certificate of Coverage Request --Individuals

Certificate of Coverage Request

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
Sample Certificate of Coverage Request Internet Form--Australia.pdf Instruction
Sample Agreement Booklet--Australia.pdf Instruction

Information Collection (IC) Details

IC Title:	Certificate of Coverage Request --Individuals	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 404.1913

Information Collection 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: 30,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 25 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	30,000	-16,000	46,000
Annual IC Time Burden (Hours)	15,000	-8,000	23,000
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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.