BASIC (07-09)

GN 01752.105 Polish Certified Coverage Record

A. Polish - PL/USA6

The form displayed in the exhibit below is the only acceptable form for the certification of the Polish coverage record. Certified coverage record in any other format should be forwarded to the Office of Central Operations Office of Earnings and International Operations, Division of Training and Program Support for approval.

B. Description of the Polish Certified Coverage Record

The Polish certified coverage record is the PL/USA6 form.

The fields are as follows:

1.

INFORMATION CONCERNING the INSURED PERSON

1.1

Surname

1.2

Surname at Birth

1.3

Forenames

1.4

Date of Birth, Place of Birth

1.5

Father’s Forename,

Mother’s Forename

1.6

SEX -

Male

Female

1.7

Address

1.8

Polish ID Number

1.9

Reference Number in Poland

1.10

U.S. Social Security Number

2.

INFORMATION CONCERNING the CLAIMANT

2.1

Surname

2.2

Surname at Birth

2.3

Forenames

2.4

Date of Birth

Place of Birth

2.5

Father’s Forename

Mother’s Forename

2.6

SEX – Male or Female

2.7

Address

2.8

Polish ID Number

2.9

Reference Number in Poland

2.10

U.S. Social Security Number

Page 2

 

3.

CONFIRMATION OF INSURED PERSON’S INSURANCE PERIODS in POLAND

(concerning person from point 1) (section 1)

 

CONTRIBUTORY and NON CONTRIBUTORY PERIODS

From______________  (Year, Month, Day)

               

To ______________ (Year, Month, Day)

 

CONTRIBUTORY PERIODS

Months_______

Days_________

 

NON-CONTRIBUTORY PERIODS

Months_______

Days_________

3.1

CONTRIBUTORY and NON – CONTRIBUTORY PERIODS TAKEN INTO ACCOUNT FOR THE ACQUISION OF ENTITLEMENT OF BENEFITS

Months______          Days_________

3.2

CONTRIBUTORY and NON-CONTRIBUTORY PERIODS TAKEN INTO ACCOUNT FOR THE CALCULATION OF BENEFITS

Months________

Days__________