The Polish certified coverage record is the PL/USA6 form.
The fields are as follows:
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1.
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INFORMATION CONCERNING the INSURED PERSON
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1.1
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Surname
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1.2
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Surname at Birth
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1.3
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Forenames
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1.4
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Date of Birth, Place of Birth
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1.5
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Father’s Forename,
Mother’s Forename
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1.6
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SEX -
Male
Female
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1.7
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Address
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1.8
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Polish ID Number
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1.9
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Reference Number in Poland
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1.10
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U.S. Social Security Number
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2.
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INFORMATION CONCERNING the CLAIMANT
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2.1
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Surname
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2.2
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Surname at Birth
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2.3
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Forenames
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2.4
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Date of Birth
Place of Birth
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2.5
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Father’s Forename
Mother’s Forename
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2.6
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SEX – Male or Female
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2.7
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Address
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2.8
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Polish ID Number
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2.9
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Reference Number in Poland
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2.10
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U.S. Social Security Number
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Page 2
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3.
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CONFIRMATION OF INSURED PERSON’S INSURANCE PERIODS in POLAND
(concerning person from point 1) (section 1)
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CONTRIBUTORY and NON CONTRIBUTORY PERIODS
From______________ (Year, Month, Day)
To ______________ (Year, Month, Day)
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CONTRIBUTORY PERIODS
Months_______
Days_________
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NON-CONTRIBUTORY PERIODS
Months_______
Days_________
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3.1
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CONTRIBUTORY and NON – CONTRIBUTORY PERIODS TAKEN INTO ACCOUNT FOR THE ACQUISION OF
ENTITLEMENT OF BENEFITS
Months______ Days_________
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3.2
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CONTRIBUTORY and NON-CONTRIBUTORY PERIODS TAKEN INTO ACCOUNT FOR THE CALCULATION OF
BENEFITS
Months________
Days__________
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4.1
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Stamp
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4.2
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Date
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4.3
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Signature
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The columns on the PL/USA 6 form page 2 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 - Contributory Periods - Months
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Fourth column - Contributory Periods - Days
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Fifth column - Non Contributory Periods - Months
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Sixth column - Non Contributory Periods - Days