Form KOR-USA 2 (Liaison Form) is the only acceptable form for the certification of Korean coverage. Certifications in any other format should be forwarded to CPSI for a determination as to their acceptability.

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  Periods of Korean coverage are certified in item C.2.

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  The “FROM” and “TO” columns contain periods of Korean coverage shown in the American style; i.e., month/year.

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

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  The signature of the Korean technician who completed the form as well as the official stamp of the NPC are entered at the bottom of the form.

Exhibit of Form KOR-USA 2, GN 01742.235B.