Information Collection

Certificate of Coverage Request via Letter - Individuals (Poland)

IC 222534 under ICR 202210-0960-001 · 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⚠️ Notice: This information collection may be referencing outdated material.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
Sample Agreement Booklet (Internet Version) - Poland.pdf	Instruction
Revised PA Statement.pdf	Other-Revised PA Statement
Revised PA Statement.pdf	Other-Revised PA Statement

IC Title:

Certificate of Coverage Request via Letter - Individuals (Poland)

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 (Internet Version) - Poland.pdf		Yes	Yes	Paper Only
Other-Revised PA Statement			Revised PA Statement.pdf		Yes	Yes	Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 31

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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	31	15	16
Annual IC Time Burden (Hours)	21	10	11
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.