Certificate of Coverage Request via Internet - Individuals (minus Denmark, Netherlands, Norway, & Sweden)

Certificate of Coverage Request

Documents and Forms

Document Name Document Type
Screen Shot Template for Most Countries (revised).pdf www.ssa.gov/international/totalization_agreements.html Other-Internet Application
Screen Shot Template for Most Countries (revised).pdf www.ssa.gov/international/totalization_agreements.html Other-Internet Application
Totalization Agreements Unified Webpage Screen Shot.docx Other- Totalization Agreements Unifi
Totalization Agreements Unified Webpage Screen Shot.docx Other- Totalization Agreements Unifi
Screen Shot Template for Most Countries (current).pdf Screen Shot Template for Most Countries (current) IC Document
Screen Shot Template for Most Countries (current).pdf Screen Shot Template for Most Countries (current) IC Document

Information Collection (IC) Details

IC Title:	Certificate of Coverage Request via Internet - Individuals (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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Internet Application			Screen Shot Template for Most Countries (revised).pdf	http://www.ssa.gov/international/totalization_agreements.html	Yes	Yes	Fillable Fileable Signable
Other- Totalization Agreements Unified Webpage Screen Shot			Totalization Agreements Unified Webpage Screen Shot.docx		Yes	Yes	Fillable Fileable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 3,253	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	3,253	3,253
Annual IC Time Burden (Hours)	2,169	2,169
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Screen Shot Template for Most Countries (current)	Screen Shot Template for Most Countries (current).pdf	09/28/2023

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