There are some entries that must be shown on the Czech Republic certified coverage record before it can be used to credit Czech coverage. GN 01750.106B. in this section, describes the entries required for an acceptable Czech Republic certified coverage record.

The required entries are as follows:

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  Show the name of the receiving agency in item 1.1 on Insurance Periods Certificate (CZ/USA 205).

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  Show an entry in item 1.2 reflecting the address of the office that is receiving the coverage record.

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  Show an entry in item 2.1 to reflect the surname of the applicant.

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  Show an entry in item 2.2 to reflect applicant’s first name.

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  Show an entry in item 2.3 to reflect applicant’s date of birth.

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  Show an entry in item 2.4 to reflect the address of the applicant.

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  Show an entry in item 2.5 to reflect the U.S. SSN.

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  Show an entry in item 2.5 to reflect the Czech Republic (Birth Certificate Number)

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  Show an entry in item 3.1 to reflect the agency completing the form.

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  Show an entry in item 3.2 to reflect the agency’s address.

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  Show an entry in item 3.3, 3.4 and 3.5 to reflect that it is properly certified.

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  If any of the required information is missing, contact your DIO Division Program Analyst.