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: 0.14.2 PREVIEW build 3
Model version: 4.0.16

1. Local Case Numbers

1.1. Local Case Number

1.1.1. Country *

1.1.2. Case number *

1.1.3. Institution

1.1.3.1. Institution ID *

1.1.3.2. Institution Name *

1.1.Local Case Number

2. Persons *

2.1. Person *

2.1.1. Person Identification *

2.1.1.1. Family name(s) *

2.1.1.2. Forename(s) *

2.1.1.3. Date of birth *

2.1.1.4. Sex *

2.1.1.5. Family name(s) at birth

2.1.1.6. Forename(s) at birth

2.1.1.7. PIN of the person in each institution

2.1.1.7.1. Personal Identification Number(s) *

2.1.1.7.1.1. Country *

2.1.1.7.1.2. Personal Identification Number (PIN) *

2.1.1.7.1.3. Sector

2.1.1.7.1.4. Institution

2.1.1.7.1.4.1. Institution ID *

2.1.1.7.1.4.2. Institution Name *

2.1.1.7.1.Personal Identification Number(s)

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

2.1.1.8.1. Place of birth

2.1.1.8.1.1. Town *

2.1.1.8.1.2. Region

2.1.1.8.1.3. Country *

2.1.1.8.2. Father's family name at birth

2.1.1.8.3. Forename of father

2.1.1.8.4. Mother's family name at birth

2.1.1.8.5. Forename of mother

2.1.2. Additional information about a person *

2.1.2.1. Status of the person *

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

2.1.2.2.1. Other status of the person

2.1.2.3. Nationality

2.1.2.4. Previous family name(s)

2.1.2.4.1. Previous family name(s)

2.1.2.4.1.1. Previous family name(s)

2.1.2.4.1.Previous family name(s)

2.1.2.5. Previous forenames

2.1.2.5.1. Previous forename

2.1.2.5.1.1. Previous forename

2.1.2.5.1.Previous forename

2.1.2.6. Current family status

2.1.2.7. Date of death

2.1.3. Person's last known addresses

2.1.3.1. Person's last known address details *

2.1.3.1.1. Type of address *

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

2.1.3.1.2.1. Specify "Other" Type

2.1.3.1.3. Address detail *

2.1.3.1.3.1. Street

2.1.3.1.3.2. Building Name

2.1.3.1.3.3. Town *

2.1.3.1.3.4. Postal Code

2.1.3.1.3.5. Region

2.1.3.1.3.6. Country *

2.1.3.1.Person's last known address details

2.1.Person

3. Decision on competent institution *

3.1. Date competence determined

3.2. Date by which this request must be made *

4. Provisionally paid benefit *

4.1. Type of benefit *

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

4.2.1. Type of other benefits

5. Provisional payment period *

5.1. Start Date *

5.2. End Date *

6. Provisional payment total amount *

6.1. Amount *

6.2. Currency *

7. Bank details *

7.1. SEPA Bank details *

7.1.1. IBAN *

7.1.2. BIC-SWIFT

7.2. Account holder name *

7.3. Payment reference *

7.4. Receiving bank address

7.4.1. Street

7.4.2. Building Name

7.4.3. Town *

7.4.4. Postal Code

7.4.5. Region

7.4.6. Country *

8. Additional information

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