Transmission of claim/document/information

H065 - Transmission of claim/document/information
Article 2 (3) (4) of Regulation (EC) No 987/2009

SED API version: 0.15.3 build preview 1
Model version: 4.1.0

1. Person *

1.1. Person identification *

1.1.1. Family name(s) *

1.1.2. Forename(s) *

1.1.3. Date of birth *

1.1.4. Sex *

1.1.5. Family name(s) at birth

1.1.6. Forename(s) at birth

1.1.7. PIN of the person in each institution

1.1.7.1. Personal Identification Number(s) *

1.1.7.1.1. Country *

1.1.7.1.2. Personal Identification Number (PIN) *

1.1.7.1.3. Sector

1.1.7.1.4. Institution

1.1.7.1.4.1. Institution ID *

1.1.7.1.4.2. Institution Name *

1.1.7.1.Personal Identification Number(s)

1.1.8. If PIN not provided for every institution, please provide

1.1.8.1. Place of birth

1.1.8.1.1. Town *

1.1.8.1.2. Region

1.1.8.1.3. Country *

1.1.8.2. Father's family name at birth

1.1.8.3. Forename of father

1.1.8.4. Mother's family name at birth

1.1.8.5. Forename of mother

1.2. Additional information on the person

1.2.1. Nationality

2. Address of the person

2.1. Address of the person

2.1.1. Type of Address

2.1.2. Address

2.1.2.1. Street

2.1.2.2. Building Name

2.1.2.3. Town *

2.1.2.4. Postal Code

2.1.2.5. Region

2.1.2.6. Country *

2.1.Address of the person

3. Additional information concerning claim/document/information

3.1. Additional information concerning claim/document/information

3.1.1. Claim/document/information concerns

3.1.2. Please fill in the following if "Claim/document/information" = "Other benefit" :

3.1.2.1. Other benefits

3.2. Other correspondence

3.2.1. Other information

3.2.2. Please fill in the following if "Other correspondence " = "Other" :

3.2.2.1. Type of correspondence

3.3. Transfer of claim/document/information to

3.3.1. Transfer of claim/document/information to

3.3.2. Institution code

3.3.3. Institution name

3.4. Date of receipt of the claim/document/information *

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3.5. The person is the claimant

4. Reasons for transmission

4.1. Reasons

5. Please find attached the following documents:

5.1. Predefined Documents

5.2. Other Documents Attached

5.2.1. Other Document

5.2.1.1. Document

5.2.1.Other Document

6. Additional information

6.1. Additional information

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H065 - Transmission of claim/document/information Article 2 (3) (4) of Regulation (EC) No 987/2009

H065 - Transmission of claim/document/information
Article 2 (3) (4) of Regulation (EC) No 987/2009