Basic (01-94)

GN 01736.105 Irish Coverage Certification

A. Policy

Form IRL/USA 4 (Agreement between Ireland and the United States of America on Social Security) is the only acceptable form for the certification of Irish coverage. Certifications in any other format should be forwarded to IOTS for a determination as to their acceptability.

B. Description of form IRL/USA 4

  • The upper part of the form contains identifying information i.e. the worker's name, date of birth and Irish and U.S. Social Security numbers.

  • In the main part of the form, the “FROM” and “TO” columns contain periods of Irish coverage shown in the European style, i.e. day/month/ year.

  • The third column contains the number of weeks of coverage within each coverage period.

  • The name, address and signature of the Irish technician who completed the certification as well as the official stamp of the Irish agency appear at the bottom of the form

C. Exhibit

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GN 01736.105 - Irish Coverage Certification - 01/12/1994
Batch run: 10/17/2016