BASIC (10-05)

GN 01746.105 Japanese Coverage Certification

A. Policy - Form J/USA 5 Certificate for Periods of Coverage

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.

B. Description – Form J/USA 5

1. Information at Top of Form

  • 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

2. Claimant-Item 1

Identifying information about the claimant is shown in both Roman and Katakana letters.

3. Verified Periods of Coverage-Item 2

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

  • Remarks

  • Total number of months (for all periods of coverage)

C. Exhibit - Form J/USA5 - Certificate for Periods of Coverage

G-J-USA_5-1

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G-J-USA_5-2

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To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0201746105
GN 01746.105 - Japanese Coverage Certification - 05/17/2017
Batch run: 05/17/2017
Rev:05/17/2017