The required entries are as follows:
SECTION 1. Information concerning insured person
The entire section 1.1 through 1.10 which is information concerning the insured person
must be completed. The required entries are the surname, surname at birth, forenames,
date of birth, place of birth, father’s forename, mother’s forename, sex, address,
Polish ID number, reference number (if given) and US social security number.
SECTION 2. Information concerning the claimant
Sections 2.1 through 2.10 must be completed. The required entries are claimant’s surname,
claimant’s surname at birth, claimant’s forenames, claimant’s date of birth, claimant’s
place of birth, claimant’s father’s forename, claimant’s mother’s forename, claimant’s
sex, claimant’s address, claimant’s Polish ID number, claimant’s reference number
(if available) and claimant’s US social security number.
SECTION 3. Confirmation of insured person’s insurance period in Poland (concerning person from
Section 1 only)
This section must show the contributory and any non-contributory periods of employment.
Column 1 indicates the start date using year/month/day.
Column 2 indicates the stop date using year/month/day.
Column 3 is for the number of months of contributory periods listed in column 1 and
2.
Column 4 is for the number of days of contributory periods listed in column 1 and
2.
Column 5 is for the number months of non-contributory periods listed in column 1 and
2.
Column 6 is for the number of days of non-contributory periods listed in column 1
and 2.
3.1 Contributory and non-contributory periods taken into account for the acquisition
of entitlement of benefits.
This entry requires months and days for contributory and non-contributory periods
for acquisition of entitlement of benefits.
3.2 Contributory and non-contributory periods taken into account for the calculation
of benefits.
This entry requires months and days for contributory and non-contributory periods
for calculation of benefits.
SECTION 4. STAMP, DATE AND SIGNATURE
Polish stamp, date and signature are required entries.
If any of the required information is missing, contact your Office of International
Operations (OIO) Division Program Analyst.