The Polish certified coverage record is the PL/USA6 form.
The fields are as follows:
1.
|
INFORMATION CONCERNING the INSURED PERSON
|
1.1
|
Surname
|
1.2
|
Surname at Birth
|
1.3
|
Forenames
|
1.4
|
Date of Birth, Place of Birth
|
1.5
|
Father’s Forename,
Mother’s Forename
|
1.6
|
SEX -
Male
Female
|
1.7
|
Address
|
1.8
|
Polish ID Number
|
1.9
|
Reference Number in Poland
|
1.10
|
U.S. Social Security Number
|
2.
|
INFORMATION CONCERNING the CLAIMANT
|
2.1
|
Surname
|
2.2
|
Surname at Birth
|
2.3
|
Forenames
|
2.4
|
Date of Birth
Place of Birth
|
2.5
|
Father’s Forename
Mother’s Forename
|
2.6
|
SEX – Male or Female
|
2.7
|
Address
|
2.8
|
Polish ID Number
|
2.9
|
Reference Number in Poland
|
2.10
|
U.S. Social Security Number
|
Page 2
|
|
3.
|
CONFIRMATION OF INSURED PERSON’S INSURANCE PERIODS in POLAND
(concerning person from point 1) (section 1)
|
|
CONTRIBUTORY and NON CONTRIBUTORY PERIODS
From______________ (Year, Month, Day)
To ______________ (Year, Month, Day)
|
|
CONTRIBUTORY PERIODS
Months_______
Days_________
|
|
NON-CONTRIBUTORY PERIODS
Months_______
Days_________
|
3.1
|
CONTRIBUTORY and NON – CONTRIBUTORY PERIODS TAKEN INTO ACCOUNT FOR THE ACQUISION OF
ENTITLEMENT OF BENEFITS
Months______ Days_________
|
3.2
|
CONTRIBUTORY and NON-CONTRIBUTORY PERIODS TAKEN INTO ACCOUNT FOR THE CALCULATION OF
BENEFITS
Months________
Days__________
|
4.1
|
Stamp
|
4.2
|
Date
|
4.3
|
Signature
|
The columns on the PL/USA 6 form page 2 are as follows:
-
•
First column - From period
-
•
Second column - To period
-
•
Third column - Contributory Periods - Months
-
•
Fourth column - Contributory Periods - Days
-
•
Fifth column - Non Contributory Periods - Months
-
•
Sixth column - Non Contributory Periods - Days