Certificate of Coverage Request via Letter - Individuals (Poland)

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⚠️ Notice: This information collection may be referencing outdated material.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
Sample Agreement Booklet (Internet Version) - Poland.pdf Instruction
Sample Agreement Booklet (Internet Version) - Poland.pdf Instruction
Revised PA Statement.pdf Other-Revised PA Statement
Revised PA Statement.pdf Other-Revised PA Statement

Information Collection (IC) Details

IC Title:	Certificate of Coverage Request via Letter - Individuals (Poland)	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
Instruction			Sample Agreement Booklet (Internet Version) - Poland.pdf		Yes	Yes	Paper Only
Other-Revised PA Statement			Revised PA Statement.pdf		Yes	Yes	Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 31	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Farms, Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	31	15	16
Annual IC Time Burden (Hours)	21	10	11
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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