Transmission of claim/document/information

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

SED API version: 0.15.2 build 3
Model version: 4.1.0

1. Person * [ SC ]

1.1. Person identification * [ CC ]

1.1.1. Family name(s) *

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1.1.2. Forename(s) *

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1.1.3. Date of birth *

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1.1.4. Sex *

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1.1.5. Family name(s) at birth

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1.1.6. Forename(s) at birth

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1.1.7. PIN of the person in each institution [ CC ]

1.1.7.1. Personal Identification Number(s) * [ CC ]

1.1.7.1.1. Country *

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1.1.7.1.2. Personal Identification Number (PIN) *

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1.1.7.1.3. Sector

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1.1.7.1.4. Institution [ CC ]

1.1.7.1.4.1. Institution ID *

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1.1.7.1.4.2. Institution Name *

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1.1.7.1.Personal Identification Number(s)

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

1.1.8.1. Place of birth [ CC ]

1.1.8.1.1. Town *

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1.1.8.1.2. Region

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1.1.8.1.3. Country *

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1.1.8.2. Father's family name at birth

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1.1.8.3. Forename of father

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1.1.8.4. Mother's family name at birth

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1.1.8.5. Forename of mother

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1.2. Additional information on the person [ SC ]

1.2.1. Nationality

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2. Address of the person [ SC ]

2.1. Address of the person [ SC ]

2.1.1. Type of Address

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2.1.2. Address [ CC ]

2.1.2.1. Street

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2.1.2.2. Building Name

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2.1.2.3. Town *

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2.1.2.4. Postal Code

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2.1.2.5. Region

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2.1.2.6. Country *

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2.1.Address of the person

3. Additional information concerning claim/document/information [ SED ]

3.1. Additional information concerning claim/document/information [ SED ]

3.1.1. Claim/document/information concerns

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

3.1.2.1. Other benefits

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3.2. Other correspondence [ SED ]

3.2.1. Other information

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

3.2.2.1. Type of correspondence

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3.3. Transfer of claim/document/information to [ SED ]

3.3.1. Transfer of claim/document/information to

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3.3.2. Institution code

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3.3.3. Institution name

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

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3.5. The person is the claimant

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4. Reasons for transmission [ SED ]

4.1. Reasons

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5. Please find attached the following documents: [ SC ]

5.1. Predefined Documents

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5.2. Other Documents Attached [ SC ]

5.2.1. Other Document [ SC ]

5.2.1.1. Document

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5.2.1.Other Document

6. Additional information [ SC ]

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