Information Collection

Certificate of Coverage Request via Internet - Employers (minus Denmark, Iceland, Netherlands, Norway, Sweden, Germany, Italy, Spain, Uruguay, France, Japan, Belgium, and Poland)

IC 206901 under ICR 202601-0960-004 · OMB 0960-0554.

Documents and Forms

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

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Certificate of Coverage Request via Internet - Employers (minus Denmark, Iceland, Netherlands, Norway, Sweden, Germany, Italy, Spain, 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_Pamphlets/austrlia.html	Yes	Yes	Fillable Fileable Signable
Other- Totalization Agreements Unified Webpage Screen Shot		Yes	Yes	Fillable Fileable
Other-Revised Privacy Act Statement		Yes	No	Printable Only
Other-Revised Employer Mailing Address Screen	http://www.ssa.gov/international/Agreement	Yes	Yes	Fillable Fileable Signable

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: 7,664

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Farms, Not-for-profit institutions

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	7,664	-8,108	-9,393	25,165
Annual IC Time Burden (Hours)	5,109	-5,541	-6,127	16,777
Annual IC Cost Burden (Dollars)	0	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Current Employer Mailing Address 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].