Information Collection

Certificate of Coverage Request via Letter - Individuals in Denmark, Iceland, Netherlands, Norway, & Sweden)

IC 206897 under ICR 202601-0960-004 · OMB 0960-0554.

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
Totalization Agreements Unified Webpage Screen Shot.docx www.ssa.gov/international/totalization_agreements.html	Other-Totalization Agreements
Updated Privacy Act Statement language for Certificate of Coverage.pdf	Other-Revised Privacy Act Statement
Mailing Adress Screen - Revised Version.pdf www.socialsecurity.gov/international/Agreement_Pamphlets/netherld.html	Other-Revised Mailing Address Screen
Mailing Address Screen - Current Version.pdf Current Mailing Adress Screen	IC Document

IC Title:

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
Instruction	http://www.socialsecurity.gov/international/Agreement_Pamphlets/netherld.html	Yes	No	Printable Only
Other-Totalization Agreements	http://www.ssa.gov/international/totalization_agreements.html	Yes	No	Printable Only
Other-Revised Privacy Act Statement		Yes	No	Printable Only
Other-Revised Mailing Address Screen	http://www.socialsecurity.gov/international/Agreement_Pamphlets/netherld.html	Yes	No	Printable Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1

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	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	1	-86	87
Annual IC Time Burden (Hours)	1	-63	64
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Current Mailing Adress Screen		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].