Request for reimbursement of provisionally paid benefits

R008 - Request for reimbursement of provisionally paid benefits
Article 73(1) of Regulation (EC) No 987/2009

SED API version: 0.15.2 build 3
Model version: 4.1.0

1. Local Case Numbers [ CC ]

1.1. Local Case Number [ CC ]

1.1.1. Country *

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1.1.2. Case number *

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1.1.3. Institution [ CC ]

1.1.3.1. Institution ID *

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1.1.3.2. Institution Name *

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1.1.Local Case Number

2. Persons * [ SC ]

2.1. Person * [ SC ]

2.1.1. Person Identification * [ CC ]

2.1.1.1. Family name(s) *

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2.1.1.2. Forename(s) *

[ BDT ] {{metaSection.forename.$$error}} {{metaSection.forename.$$warning}}

2.1.1.3. Date of birth *

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2.1.1.4. Sex *

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2.1.1.5. Family name(s) at birth

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2.1.1.6. Forename(s) at birth

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

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

2.1.1.7.1.1. Country *

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2.1.1.7.1.2. Personal Identification Number (PIN) *

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2.1.1.7.1.3. Sector

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2.1.1.7.1.4. Institution [ CC ]

2.1.1.7.1.4.1. Institution ID *

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2.1.1.7.1.4.2. Institution Name *

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2.1.1.7.1.Personal Identification Number(s)

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

2.1.1.8.1. Place of birth [ CC ]

2.1.1.8.1.1. Town *

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2.1.1.8.1.2. Region

[ CDT ] {{metaSection.region.$$error}} {{metaSection.region.$$warning}}

2.1.1.8.1.3. Country *

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2.1.1.8.2. Father's family name at birth

[ BDT ] {{metaSection.fatherFamilyNameAtBirth.$$error}} {{metaSection.fatherFamilyNameAtBirth.$$warning}}

2.1.1.8.3. Forename of father

[ BDT ] {{metaSection.forenameFather.$$error}} {{metaSection.forenameFather.$$warning}}

2.1.1.8.4. Mother's family name at birth

[ BDT ] {{metaSection.motherFamilyNameAtBirth.$$error}} {{metaSection.motherFamilyNameAtBirth.$$warning}}

2.1.1.8.5. Forename of mother

[ BDT ] {{metaSection.forenameMother.$$error}} {{metaSection.forenameMother.$$warning}}

2.1.2. Additional information about a person * [ SC ]

2.1.2.1. Status of the person *

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2.1.2.2. Please fill in the following if "Status of the person" = "Other" : [ SC ]

2.1.2.2.1. Other status of the person

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2.1.2.3. Nationality

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2.1.2.4. Previous family name(s) [ SC ]

2.1.2.4.1. Previous family name(s) [ SC ]

2.1.2.4.1.1. Previous family name(s)

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2.1.2.4.1.Previous family name(s)

2.1.2.5. Previous forenames [ SC ]

2.1.2.5.1. Previous forename [ SC ]

2.1.2.5.1.1. Previous forename

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2.1.2.5.1.Previous forename

2.1.2.6. Current family status

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2.1.2.7. Date of death

[ BDT ] {{metaSection.dateDeath.$$error}} {{metaSection.dateDeath.$$warning}}

2.1.3. Person's last known addresses [ SC ]

2.1.3.1. Person's last known address details * [ SC ]

2.1.3.1.1. Type of address *

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2.1.3.1.2. Please fill in the following if "Type of address" = "Other" : [ SC ]

2.1.3.1.2.1. Specify "Other" Type

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2.1.3.1.3. Address detail * [ CC ]

2.1.3.1.3.1. Street

[ CDT ] {{metaSection.street.$$error}} {{metaSection.street.$$warning}}

2.1.3.1.3.2. Building Name

[ CDT ] {{metaSection.buildingName.$$error}} {{metaSection.buildingName.$$warning}}

2.1.3.1.3.3. Town *

[ CDT ] {{metaSection.town.$$error}} {{metaSection.town.$$warning}}

2.1.3.1.3.4. Postal Code

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2.1.3.1.3.5. Region

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2.1.3.1.3.6. Country *

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2.1.3.1.Person's last known address details

2.1.Person

3. Decision on competent institution * [ SED ]

3.1. Date competence determined

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3.2. Date by which this request must be made *

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4. Provisionally paid benefit * [ SC ]

4.1. Type of benefit *

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4.2. Please fill in the following if "Type of benefit" = "Other benefit" : [ SC ]

4.2.1. Type of other benefits

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5. Provisional payment period * [ CC ]

5.1. Start Date *

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5.2. End Date *

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6. Provisional payment total amount * [ CC ]

6.1. Amount *

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6.2. Currency *

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7. Bank details * [ SC ]

7.1. SEPA Bank details * [ CC ]

7.1.1. IBAN *

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7.1.2. BIC-SWIFT

[ BDT ] {{metaSection.BICSWIFT.$$error}} {{metaSection.BICSWIFT.$$warning}}

7.2. Account holder name *

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7.3. Payment reference *

[ CDT ] {{metaSection.paymentReference.$$error}} {{metaSection.paymentReference.$$warning}}

7.4. Receiving bank address [ CC ]

7.4.1. Street

[ CDT ] {{metaSection.street.$$error}} {{metaSection.street.$$warning}}

7.4.2. Building Name

[ CDT ] {{metaSection.buildingName.$$error}} {{metaSection.buildingName.$$warning}}

7.4.3. Town *

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7.4.4. Postal Code

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7.4.5. Region

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7.4.6. Country *

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8. Additional information [ SC ]

8.1. Additional information

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R008 - Request for reimbursement of provisionally paid benefits Article 73(1) of Regulation (EC) No 987/2009

R008 - Request for reimbursement of provisionally paid benefits
Article 73(1) of Regulation (EC) No 987/2009