The form displayed in the exhibit in GN 01750.105C in this section is the only acceptable form for the certification of the Czech Republic
coverage record. Forward certified coverage record in any other format to the Center
for Program Support for approval. Description of the Czech Republic certified coverage
record
The Czech Republic certified coverage record is the Insurance Periods Certificate
(CZ/USA 205).
The fields are as follows:
|
1.1
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Name of Agency
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|
1.2
|
Address
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|
2.1
|
Surname
|
|
2.2
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Forename (maiden name)
|
|
2.3
|
Date of birth / Place of birth
|
|
2.4
|
Address
|
|
2.5
|
Insurance Number (SSN and Czech Birth Number)
|
|
3.1
|
Name of institution completing form
|
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3.2
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Address of institution completing form
|
|
3.3
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Certification Stamp
|
|
3.4
|
Date
|
|
3.5
|
Signature
|
The columns on the CZ/USA 205 form are as follows:
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•
First column – From period
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•
Second column – To period
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•
Third column – Qualifying period
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•
Fourth column – Amount of benefit
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•
Fifth column – Type of benefit