Information Collection

Certificate of Coverage Request via Letter - Employers (minus Denmark, Netherlands, Norway, & Sweden)

IC 206899 under ICR 201905-0960-002 · 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⚠️ Notice: This information collection may be referencing outdated material.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 - Australia.pdf www.ssa.gov/international/Agreement_Pamphlets/austrlia.html	Instruction
Revised PA Statement.pdf	Other-Revised PA Statement

IC Title:

Certificate of Coverage Request via Letter - Employers (minus Denmark, Netherlands, Norway, & Sweden)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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 - Australia.pdf	http://www.ssa.gov/international/Agreement_Pamphlets/austrlia.html	Yes	No	Printable Only
Other-Revised PA Statement			Revised PA Statement.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: 26,047

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

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

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	26,047	16	26,031
Annual IC Time Burden (Hours)	17,365	11	17,354
Annual IC Cost Burden (Dollars)	0	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.