Certificate of Coverage Request via Internet - Employers (minus Denmark, Netherlands, Norway, & Sweden and Urugay)

Certificate of Coverage Request

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0554 can be found here:

Documents and Forms

Document Name Document Type
Screen Shot Template for Most Countries.pdf www.ssa.gov/international/totalization_agreements.html Other-Internet Application
Screen Shot Template for Most Countries.pdf www.ssa.gov/international/totalization_agreements.html Other-Internet Application
Certificate of Coverage Internet Request - Australia.pdf Certificate of Coverage IC Document
Certificate of Coverage Internet Request - Australia.pdf Certificate of Coverage IC Document

Information Collection (IC) Details

IC Title:	Certificate of Coverage Request via Internet - Employers (minus Denmark, Netherlands, Norway, & Sweden and Urugay)	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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Internet Application			Screen Shot Template for Most Countries.pdf	http://www.ssa.gov/international/totalization_agreements.html	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: 25,165	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 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	25,165	-13,931	39,096
Annual IC Time Burden (Hours)	16,777	-9,287	26,064
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Certificate of Coverage	Certificate of Coverage Internet Request - Australia.pdf	09/21/2016

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.