Complete the Certification of Data part of the form only when transmitting a claim
for Japanese benefits in response to the Japanese agency’s request for specific information.
If the requested information is not available, indicate “unknown.” If the requested
information is known but is not verified in SSA records, enter the information but
do not check the “Verified” block.
a. Item A – name and date of birth
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•
Enter the names of all claimants and in survivor cases, the name of the deceased worker.
Enter the first and last names and, if applicable, the maiden name.
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•
Enter the date of birth for all claimants and, if applicable, for the deceased worker.
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•
Check the “Verified” block if the date of birth has been used to award U.S. benefits,
or the date is shown on the MBR as proven.
b. Item B – worker/contributor's date of death
Enter the deceased worker's date of death in survivor claims. Check “Verified” if
the date has been used to award U.S. benefits or the date is shown on the MBR as proven.
c. Item C – date of marriage
Enter the date of marriage if a spouse or widow(er) is claiming benefits. Check “Verified”
if the data has been used to award U.S. benefits or the date is shown on the MBR as proven.
d. Item D – date of divorce
Enter the date of divorce if a divorced spouse or widow(er) is claiming benefits.
Check “Verified” if the data has been used to award U.S. benefits or the date is shown on the MBR as proven.
e. Item E – country of birth
Enter the country of birth for the worker. Check “Verified” if the data has been used
to award U.S. benefits or the date is shown on the MBR as proven.
Enter the country of citizenship of the worker. Check “Verified” if the data has been
used to award U.S. benefits or the date is shown on the MBR as proven.