Information Collection

Certificate of Coverage Request via Letter - Employers in Denmark, Iceland, Netherlands, Norway, and Sweden

IC 206902 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	Other-Certificate of Coverage Countr
Revised PA Statement.pdf	Other-Revised PA Statement
Totalization Agreements Unified Webpage Screen Shot.docx www.ssa.gov/international/totalization_agreements.html	Other-Totalization Agreements
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

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
Other-Certificate of Coverage Country Agreement	http://www.socialsecurity.gov/international/Agreement_Pamphlets/netherld.html	Yes	No	Printable Only
Other-Revised PA Statement		Yes	No	Printable Only
Other-Totalization Agreements	http://www.ssa.gov/international/totalization_agreements.html	Yes	No	Printable Only
Other-Revised Employer Mailing Address Screen	http://www.ssa.gov/international/Agreement	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: 4

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: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	4	-164	168
Annual IC Time Burden (Hours)	3	-120	123
Annual IC Cost Burden (Dollars)	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.

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