Certificate of Coverage Request via Internet - Individuals (Poland)

Certificate of Coverage Request

Documents and Forms

Document Name Document Type
Screen Shot for Poland.pdf Other-Internet Screens
Screen Shot for Poland.pdf Other-Internet Screens
Totalization Agreements Unified Webpage Screen Shot.docx Other- Totalization Agreements Unifi
Totalization Agreements Unified Webpage Screen Shot.docx Other- Totalization Agreements Unifi

Information Collection (IC) Details

IC Title:	Certificate of Coverage Request via Internet - 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
Other-Internet Screens			Screen Shot for Poland.pdf		Yes	Yes	Fillable Fileable Signable
Other- Totalization Agreements Unified Webpage Screen Shot			Totalization Agreements Unified Webpage Screen Shot.docx		Yes	Yes	Fillable Fileable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 52	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	Previously Approved
Annual Number of Responses for this IC	52	52
Annual IC Time Burden (Hours)	36	36
Annual IC Cost Burden (Dollars)	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.