Certificate of Coverage Request --Individuals 20 CFR 404.1913

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⚠️ Notice: This information collection may be referencing outdated material.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 Certificate of Coverage Request Internet Form Australia Final.pdf Instruction
Sample Agreement Booklet Australia Final.pdf Instruction

Information Collection (IC) Details

IC Title:	Certificate of Coverage Request --Individuals 20 CFR 404.1913	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

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 Certificate of Coverage Request Internet Form Australia Final.pdf		Yes	Yes	Fillable Fileable Signable
Instruction			Sample Agreement Booklet Australia Final.pdf		Yes	No	Printable Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 40,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 30 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	40,000	10,000	30,000
Annual IC Time Burden (Hours)	20,000	5,000	15,000
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.