Certificate of Coverage Request

OMB 0960-0554

OMB 0960-0554

To obtain a certificate of coverage, SSA requires the worker or employer to write to SSA and provide personally identifiable information and details of employment. The information required to issue a certificate differs depending on the agreement negotiated with a particular country. As a result, SSA created 30 forms for each agreement corresponding to the 30 countries with which we have agreements. The forms require respondents to provide personally identifiable information about the worker; the employer; and residential locations for the worker and employer. Some of the questions include the applicant’s name, U.S. Social Security number, date of birth, country of birth, country of citizenship, country of permanent residence, date of hire, country of hire, beginning and ending date of work assignment in the foreign country, the employer, and residential location in the U.S. and abroad. The respondents are U.S. citizens and residents who wish to work in a foreign country, and their employers.

The latest form for Certificate of Coverage Request expires 2022-12-31 and can be found here.

Latest Forms, Documents, and Supporting Material
Document
Name
Justification for No Material/Nonsubstantive Change
Supporting Statement A
All Historical Document Collections
Approved without change
No material or nonsubstantive change to a currently approved collection 2023-10-06
Approved without change
Revision of a currently approved collection 2022-12-14
Approved without change
Revision of a currently approved collection 2019-09-20
Approved without change
No material or nonsubstantive change to a currently approved collection 2018-09-12
Approved without change
Revision of a currently approved collection 2016-09-30
Approved without change
No material or nonsubstantive change to a currently approved collection 2015-12-30
Approved without change
No material or nonsubstantive change to a currently approved collection 2014-02-05
Approved with change
Revision of a currently approved collection 2013-08-16
Approved without change
Revision of a currently approved collection 2010-08-27
Approved without change
Extension without change of a currently approved collection 2007-11-23
Approved without change
Extension without change of a currently approved collection 2004-09-17
Approved without change
Extension without change of a currently approved collection 2001-08-14
Approved without change
No material or nonsubstantive change to a currently approved collection 1999-09-23
Approved without change
Extension without change of a currently approved collection 1998-08-06
Approved without change
New collection (Request for a new OMB Control Number) 1995-06-30
OMB Details

Certificate of Coverage Request via Letter - Individuals (minus Denmark, Netherlands, Norway, & Sweden)

Federal Enterprise Architecture: Income Security - General Retirement and Disability


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