Information Collection Request

Certificate of Coverage Request

ICR 202601-0960-004 · OMB 0960-0554 · Active

Forms and Documents
DocumentTypeStatusAvailability
Addendum - 0554 (Final).docx Supplementary Document Uploaded 2026-02-24 Available
Supporting Statement - 0554 (Final).docx Supporting Statement A Uploaded 2026-02-24 Available
IC Document Collections
IC IDCollectionTypeStatusForm
9477 Certificate of Coverage Request via Letter - Individuals (minus Denmark, Iceland, Netherlands, Norway, Slovenia, Sweden, Uruguay, France, Japan, Belgium, and Poland) Instruction Modified
279197 Certificate of Coverage Request via Internet - Employers in Belgium Other-Certificate of Coverage Country Agreement New
279196 Certificate of Coverage Request via Letter - Employers in Belgium Other-Certificate of Coverage Country Agreement New
279195 Certificate of Coverage Request via Internet - Employers in France and Japan Other-Certificate of Coverage Country Agreement New
279194 Certificate of Coverage Request via Letter - Employers in France and Japan Other-Certificate of Coverage Country Agreement New
279193 Certificate of Coverage Request via Internet - Employers in Germany, Italy, Spain, Uruguay Other-Certificate of Coverage Country Agreement New
279192 Certificate of Coverage Request via Letter - Employers in Germany, Italy, Spain, Uruguay Other-Certificate of Coverage Country Agreement New
279187 Certificate of Coverage Request via Internet - Individuals in Belgium Other-Certificate of Coverage Country Agreement New
279186 Certificate of Coverage Request via Letter - Individuals in Belgium Other-Certificate of Coverage Country Agreement New
279126 Certificate of Coverage Request via Internet - Individuals in France and Japan Other-Internet Screens New
279124 Certificate of Coverage Request via Letter - Individuals in France and Japan Other-Internet Screens New
279122 Certificate of Coverage Request via Internet - Individuals in Germany, Italy, Spain, Uruguay Other-Internet Screens New
279121 Certificate of Coverage Request via Letter - Individuals in Germany, Italy, Spain, Uruguay Other-Internet Screens New
222537 Certificate of Coverage Request via Internet - Employers (Poland) Other-Certificate of Coverage Country Agreement Modified
222536 Certificate of Coverage Request via Letter - Employers (Poland) Other-Certificate of Coverage Country Agreement Modified
222535 Certificate of Coverage Request via Internet - Individuals (Poland) Other-Internet Screens Modified
222534 Certificate of Coverage Request via Letter - Individuals (Poland) Other-Certificate of Coverage Country Agreement Modified
206903 Certificate of Coverage Request via Internet - Employers in Denmark, Iceland, Netherlands, Norway, and Sweden Other-Internet Application Modified
206902 Certificate of Coverage Request via Letter - Employers in Denmark, Iceland, Netherlands, Norway, and Sweden Other-Certificate of Coverage Country Agreement Modified
206901 Certificate of Coverage Request via Internet - Employers (minus Denmark, Iceland, Netherlands, Norway, Sweden, Germany, Italy, Spain, Uruguay, France, Japan, Belgium, and Poland) Other-Internet Application Modified
206899 Certificate of Coverage Request via Letter - Employers (minus Denmark, Iceland, Netherlands, Norway, Sweden, Germany, Italy, Spain, Uruguay, France, Japan, Belgium, and Poland) Other-Certificate of Coverage Country Agreement Modified
206898 Certificate of Coverage Request via Internet - Individuals in Denmark, Iceland, Netherlands, Norway, Slovenia, Sweden & Uruguay Other-Internet Application Modified
206897 Certificate of Coverage Request via Letter - Individuals in Denmark, Iceland, Netherlands, Norway, & Sweden) Instruction Modified
182116 Certificate of Coverage Request via Internet - Individuals (minus Denmark, Iceland, Netherlands, Norway, Slovenia, Sweden, Uruguay, France, Japan, Belgium, and Poland) Other-Internet Application Modified
ICR Details
0960-0554 202601-0960-004
Active 202309-0960-007
SSA
Certificate of Coverage Request
Revision of a currently approved collection   No
Regular
Approved without change 04/10/2026
Retrieve Notice of Action (NOA) 02/24/2026
  Inventory as of this Action Requested Previously Approved
04/30/2029 36 Months From Approved 04/30/2026
20,770 0 32,722
14,100 0 21,975
0 0 0

To obtain a certificate of coverage, SSA requires the worker or employer to write to SSA and provide personally identifiable information and details of employment. The information required to issue a certificate differs depending on the agreement negotiated with a particular country. As a result, SSA created 30 forms for each agreement corresponding to the 30 countries with which we have agreements. The forms require respondents to provide personally identifiable information about the worker; the employer; and residential locations for the worker and employer. Some of the questions include the applicant’s name, U.S. Social Security number, date of birth, country of birth, country of citizenship, country of permanent residence, date of hire, country of hire, beginning and ending date of work assignment in the foreign country, the employer, and residential location in the U.S. and abroad. The respondents are U.S. citizens and residents who wish to work in a foreign country, and their employers.

US Code: 42 USC 433 Name of Law: Social Security Act
  
None

Not associated with rulemaking

  90 FR 42294 08/29/2025
90 FR 58678 12/17/2025
No

24
IC Title Form No. Form Name
Certificate of Coverage Request via Internet - Employers (Poland)
Certificate of Coverage Request via Internet - Individuals (minus Denmark, Iceland, Netherlands, Norway, Slovenia, Sweden, Uruguay, France, Japan, Belgium, and Poland)
Certificate of Coverage Request via Internet - Employers (minus Denmark, Iceland, Netherlands, Norway, Sweden, Germany, Italy, Spain, Uruguay, France, Japan, Belgium, and Poland)
Certificate of Coverage Request via Internet - Employers in Belgium
Certificate of Coverage Request via Internet - Employers in Denmark, Iceland, Netherlands, Norway, and Sweden
Certificate of Coverage Request via Internet - Employers in France and Japan
Certificate of Coverage Request via Internet - Employers in Germany, Italy, Spain, Uruguay
Certificate of Coverage Request via Internet - Individuals (Poland)
Certificate of Coverage Request via Internet - Individuals in Belgium
Certificate of Coverage Request via Internet - Individuals in Denmark, Iceland, Netherlands, Norway, Slovenia, Sweden & Uruguay
Certificate of Coverage Request via Internet - Individuals in France and Japan
Certificate of Coverage Request via Internet - Individuals in Germany, Italy, Spain, Uruguay
Certificate of Coverage Request via Letter - Employers (Poland)
Certificate of Coverage Request via Letter - Employers (minus Denmark, Iceland, Netherlands, Norway, Sweden, Germany, Italy, Spain, Uruguay, France, Japan, Belgium, and Poland)
Certificate of Coverage Request via Letter - Employers in Belgium
Certificate of Coverage Request via Letter - Employers in Denmark, Iceland, Netherlands, Norway, and Sweden
Certificate of Coverage Request via Letter - Employers in France and Japan
Certificate of Coverage Request via Letter - Employers in Germany, Italy, Spain, Uruguay
Certificate of Coverage Request via Letter - Individuals (Poland)
Certificate of Coverage Request via Letter - Individuals (minus Denmark, Iceland, Netherlands, Norway, Slovenia, Sweden, Uruguay, France, Japan, Belgium, and Poland)
Certificate of Coverage Request via Letter - Individuals in Belgium
Certificate of Coverage Request via Letter - Individuals in Denmark, Iceland, Netherlands, Norway, & Sweden)
Certificate of Coverage Request via Letter - Individuals in France and Japan
Certificate of Coverage Request via Letter - Individuals in Germany, Italy, Spain, Uruguay

  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 20,770 32,722 0 -86 -11,866 0
Annual Time Burden (Hours) 14,100 21,975 0 -259 -7,616 0
Annual Cost Burden (Dollars) 0 0 0 -3,985 3,985 0
Yes
Miscellaneous Actions
Yes
Miscellaneous Actions
When we last cleared this IC in 2023, the burden was 21,975 hours. However, we are currently reporting a burden of 14,100 hours. This change stems a decrease in the number of responses from 32,722 to 20,770, due to a decrease in respondents traveling and working in other countries. Although the number of responses changed, SSA did not take any action to cause this change. These figures represent current Management Information data. In addition, we have also added new Certificates of Coverage agreements with the seven countries that recently required us to include additional information (Germany, Italy, Spain, Uruguay, France, Japan, and Belgium). These new forms minorly increase the burden for the respondents from those countries. Therefore, we have increased the burden accordingly. The chart in #12 above shows the additional burden information.

$156,133
No
    Yes
    Yes
No
No
No
No
Faye Lipsky 410 965-8783 [email protected]

  No

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
02/24/2026