BASIC (04-09)

GN 01750.105 Czech Republic Certified Coverage Record

A. Policy

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

Name of Agency

1.2

Address

2.1

Surname

2.2

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

3.2

Address of institution completing form

3.3

Certification Stamp

3.4

Date

3.5

Signature

The columns on the CZ/USA 205 form are as follows:

  • First column – From period

  • Second column – To period

  • Third column – Qualifying period

  • Fourth column – Amount of benefit

  • Fifth column – Type of benefit

B. Form – Insurance Periods Certificate (CZ /USA 205)

The Insurance Periods Certificate (CZ/USA 205 may be printed from the SSA Totalization Forms section of the Totalization Resource Kit .


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0201750105
GN 01750.105 - Czech Republic Certified Coverage Record - 04/03/2015
Batch run: 04/03/2015
Rev:04/03/2015