Information Collection

Certificate of Coverage Request Internet- Employers (Poland)

IC 222537 under ICR 201607-0960-003 · 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⚠️ Notice: This information collection may be referencing outdated material.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 Agreement Booklet (Internet Version) - Poland.pdf	Instruction

IC Title:

Certificate of Coverage Request Internet- Employers (Poland)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

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 Agreement Booklet (Internet Version) - Poland.pdf		Yes	Yes	Printable Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 93

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Farms, Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	93	93
Annual IC Time Burden (Hours)	64	64
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.