Information Collection

Certificate of Coverage Request via Internet - Individuals (minus Denmark, Iceland, Netherlands, Norway, Slovenia, Sweden, Uruguay, France, Japan, Belgium, and Poland)

IC 182116 under ICR 202601-0960-004 · OMB 0960-0554.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Sample - Individual General Internet Request.pdf www.ssa.gov/international/Agreement	Other-Internet Application
Totalization Agreements Unified Webpage Screen Shot.docx	Other- Totalization Agreements Unifi
Mailing Adress Screen - Revised Version.pdf www.ssa.gov/international/Agreement	Other-Revised Mailing Address Screen
Updated Privacy Act Statement language for Certificate of Coverage.pdf	Other-Revised Privacy Act Statement
Mailing Address Screen - Current Version.pdf Current Mailing Address Screen	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Certificate of Coverage Request via Internet - Individuals (minus Denmark, Iceland, Netherlands, Norway, Slovenia, Sweden, Uruguay, France, Japan, Belgium, and 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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Internet Application	http://www.ssa.gov/international/Agreement	Yes	Yes	Fillable Fileable Signable
Other- Totalization Agreements Unified Webpage Screen Shot		Yes	Yes	Fillable Fileable
Other-Revised Mailing Address Screen	http://www.ssa.gov/international/Agreement	Yes	Yes	Fillable Fileable Signable
Other-Revised Privacy Act Statement		Yes	No	Printable Only

Federal Enterprise Architecture Business Reference Module

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 995

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	995	-2,087	-171	3,253
Annual IC Time Burden (Hours)	663	-1,492	-14	2,169
Annual IC Cost Burden (Dollars)	0	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Current Mailing Address Screen		02/24/2026

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

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