Information Collection

Certificate of Coverage Request via Letter - Individuals in Denmark, Netherlands, Norway, & Sweden, and Uruguay

IC 206897 under ICR 202309-0960-007 · 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⚠️ Notice: This information collection may be referencing outdated material.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) - Netherlands.pdf www.socialsecurity.gov/international/Agreement_Pamphlets/netherld.html	Instruction
Sample Agreement Booklet (Internet Version) - Netherlands.pdf www.socialsecurity.gov/international/Agreement_Pamphlets/netherld.html	Instruction
Revised PA Statement.pdf	Other-Revised PA Statement
Revised PA Statement.pdf	Other-Revised PA Statement
Sample Agreement Booklet (Internet Version)-Denmark (revised).pdf	Instruction
Sample Agreement Booklet (Internet Version)-Denmark (revised).pdf	Instruction
Sample Agreement Booklet (Internet Version) - Netherlands (current).pdf Sample Agreement Booklet (Internet Version)- Neverlands (current)	IC Document
Sample Agreement Booklet (Internet Version) - Netherlands (current).pdf Sample Agreement Booklet (Internet Version)- Neverlands (current)	IC Document

IC Title:

Certificate of Coverage Request via Letter - Individuals in Denmark, Netherlands, Norway, & Sweden, and Uruguay

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	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction	Sample Agreement Booklet (Internet Version) - Netherlands.pdf	http://www.socialsecurity.gov/international/Agreement_Pamphlets/netherld.html	Yes	No	Printable Only
Other-Revised PA Statement	Revised PA Statement.pdf		Yes	No	Printable Only
Instruction	Sample Agreement Booklet (Internet Version)-Denmark (revised).pdf		Yes	No	Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 87

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	87	87
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
Sample Agreement Booklet (Internet Version)- Neverlands (current)	Sample Agreement Booklet (Internet Version) - Netherlands (current).pdf	09/28/2023

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