Form CHI/USA 5 is the only acceptable form for the certification of Chilean coverage. Certifications in any other format should be forwarded to CPSI for a determination as to their acceptability. The form is designed to certify coverage under both the old and new Chilean systems. The AFP Superintendency (new system) sends the record of Chilean coverage for anyone with coverage under both systems.

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  Part 1 contains identifying information about the worker.

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  Periods of Chilean coverage are certified in Part 2.

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  The “FROM” and “TO” columns contain periods of Chilean coverage.

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  The fourth column contains the number of months of coverage within each coverage period. (The third and fifth columns for the years and days of coverage will not be completed.)

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  The last column shows the system under which the contributions were made.

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  Part 3 contains the name and address of the agency that issued the coverage certification. It also contains the date, the signature of the individual who completed the form and the official stamp of the agency.