Form J/USA 5 is the only acceptable form for the certification of Japanese coverage.
Certifications in any other format should be forwarded to the Division of Training
and Program Support (DTPS) for a determination as to their acceptability.
Japanese Basic Pension Number or Number on Pension Handbook
U.S. Social Security Number
Japanese reference number (for Japanese agency use only)
Date of Certification (Year/Month/Day format)
Signature of Japanese agency
Identifying information about the claimant is shown in both Roman and Katakana letters.
The following columns will be present in item 2:
Type of period of coverage (An explanation of the types of coverage is footnoted at
the bottom of the certification)
Date of enrollment (Year/Month/Day format)
Date of withdrawal (Year/Month/Day format)
Number of months covered
Total number of months (for all periods of coverage)