OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

Certificate of Coverage Request via Letter - Individuals (minus Denmark, Iceland, Netherlands, Norway, Slovenia, Sweden, Uruguay, France, Japan, Belgium, and Poland)

IC 9477 under ICR 202601-0960-004 · OMB 0960-0554.

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

View Information Collection (IC)

Certificate of Coverage Request via Letter - Individuals (minus Denmark, Iceland, Netherlands, Norway, Slovenia, Sweden, Uruguay, France, Japan, Belgium, and 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
Instruction Sample Agreement Booklet (Internet Version) - Netherlands.pdf http://www.socialsecurity.gov/international/Agreement_Pamphlets/netherld.html Yes No Printable Only
Other-Revised Privacy Act Statement Updated Privacy Act Statement language for Certificate of Coverage.pdf Yes No Printable Only
Other-Totalization Agreements Totalization Agreements Unified Webpage Screen Shot.docx http://www.ssa.gov/international/totalization_agreements.html Yes No Printable Only
Other-Revised Mailing Address Screen Mailing Adress Screen - Revised Version.pdf http://www.socialsecurity.gov/international/Agreement_Pamphlets/netherld.html Yes No Printable Only

Income Security General Retirement and Disability

 

43 0
   
Individuals or Households
 
   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 43 0 -23 -445 0 511
Annual IC Time Burden (Hours) 29 0 -130 -182 0 341
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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