OMB.report

Federal forms, ICRs, and supporting documents

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
Document Name
Document Type
Other-Internet Application
Other- Totalization Agreements Unifi
Other-Revised Mailing Address Screen
Other-Revised Privacy Act Statement
IC Document
Information Collection (IC) Details

View Information Collection (IC)

Certificate of Coverage Request via Internet - Individuals (minus Denmark, Iceland, Netherlands, Norway, Slovenia, Sweden, Uruguay, France, Japan, Belgium, and Poland)
 
No Modified
 
Required to Obtain or Retain Benefits
 
20 CFR 404.1913

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Other-Internet Application Sample - Individual General Internet Request.pdf http://www.ssa.gov/international/Agreement Yes Yes Fillable Fileable Signable
Other- Totalization Agreements Unified Webpage Screen Shot Totalization Agreements Unified Webpage Screen Shot.docx Yes Yes Fillable Fileable
Other-Revised Mailing Address Screen Mailing Adress Screen - Revised Version.pdf http://www.ssa.gov/international/Agreement Yes Yes Fillable Fileable Signable
Other-Revised Privacy Act Statement Updated Privacy Act Statement language for Certificate of Coverage.pdf Yes No Printable Only

Income Security General Retirement and Disability

 

995 0
   
Individuals or Households
 
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 995 0 -2,087 -171 0 3,253
Annual IC Time Burden (Hours) 663 0 -1,492 -14 0 2,169
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Current Mailing Address Screen Mailing Address Screen - Current Version.pdf 02/24/2026
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
Something went wrong when downloading this file. If you have any questions, please send an email to [email protected].