Information Collection

Certificate of Coverage Request via Internet - Individuals (Poland)

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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Sample - Individual Internet Request for Poland.pdf www.ssa.gov/international/Agreement	Other-Internet Screens
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
Mailing Adress Screen - Revised Version.pdf www.ssa.gov/international/Agreement	Other-Revised Mailing Address Screen
Mailing Address Screen - Current Version.pdf Current 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-Internet Screens	http://www.ssa.gov/international/Agreement	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 Mailing Address Screen	http://www.ssa.gov/international/Agreement	Yes	Yes	Fillable Fileable Signable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 52

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	Previously Approved
Annual Number of Responses for this IC	52	52
Annual IC Time Burden (Hours)	36	36
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Current 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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