Information Collection

Certificate of Coverage Request via Internet - Employers (Poland)

IC 222537 under ICR 202601-0960-004 · OMB 0960-0554.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Sample - Employer Internet Request for Poland.pdf www.ssa.gov/international/Agreement	Other-Certificate of Coverage Countr
Totalization Agreements Unified Webpage Screen Shot.docx www.ssa.gov/international/totalization_agreements.html	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

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.ssa.gov/international/Agreement	Yes	Yes	Fillable Fileable Signable
Other- Totalization Agreements Unified Webpage Screen Shot	http://www.ssa.gov/international/totalization_agreements.html	Yes	Yes	Fillable Fileable Signable
Other-Revised Privacy Act Statement		Yes	Yes	Printable Only
Other-Revised Employer 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: 210

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	210	-33	243
Annual IC Time Burden (Hours)	144	-22	166
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.

Something went wrong when downloading this file. If you have any questions, please send an email to [email protected].