OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

Certificate of Coverage Request via Internet - Individuals (Poland)

IC 222535 under ICR 202601-0960-004 · OMB 0960-0554.

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

View Information Collection (IC)

Certificate of Coverage Request via Internet - Individuals (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 Screens Sample - Individual Internet Request for Poland.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 Privacy Act Statement Updated Privacy Act Statement language for Certificate of Coverage.pdf Yes No Printable Only
Other-Revised Mailing Address Screen Mailing Adress Screen - Revised Version.pdf http://www.ssa.gov/international/Agreement Yes Yes Fillable Fileable Signable

Income Security General Retirement and Disability

 

52 0
   
Private Sector Businesses or other for-profits, Farms, Not-for-profit institutions
 
   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 52 0 0 0 0 52
Annual IC Time Burden (Hours) 36 0 0 0 0 36
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.
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