F021 - Application for additional benefits
Articles 69, 81 of Regulation (EC) No 883/2004; Article 61 of Regulation (EC) No 987/2009
SED API version: 0.16.2 build 2
Model version: 4.2.0
Receipt of application for additional or special family benefit for orphans
Date of receipt of the application
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Type of claim
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Information on application
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Points for which more information is needed
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Deceased person
*
Person Identification
*
Family name(s)
*
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Forename(s)
*
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Date of birth
*
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Sex
*
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Family name(s) at birth
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Forename(s) at birth
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PIN of the person in each institution
Personal Identification Number(s)
*
Country
*
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Personal Identification Number (PIN)
*
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Sector
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{{metaSection.sector.$$warning}}
Institution
Institution ID
*
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{{metaSection.institutionID.$$warning}}
Institution Name
*
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If PIN not provided for every institution, please provide
Place of birth
Town
*
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Region
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Country
*
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Father's family name at birth
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Forename of father
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Mother's family name at birth
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{{metaSection.motherFamilyNameAtBirth.$$warning}}
Forename of mother
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Additional information about nationality
Nationalities
Nationality
*
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Since
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Details of Death
Place of Death
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Date of Death
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Person's latest addresses
Address of the Person
Type of address
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Address
Street
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{{metaSection.street.$$warning}}
Building Name
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Town
*
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Postal Code
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Region
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Country
*
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Coverage by social security scheme
Periods Covered by security scheme in sending Member State
Period
Start Date
*
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End Date
*
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Periods Not covered
Period Not Covered
Start Date
*
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End Date
*
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{{metaSection.endDate.$$warning}}
Periods of Entitlement
Entitlement to Family Benefits, if yes
If no entitlement, choose one reason
Period Entitlement Family Benefits
Period of Entitlement to family benefit
Start Date
*
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End Date
*
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Reason
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Other reason
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Additional information
Additional information
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Information on spouse or partner
Is the person the claimant?
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Person Identification
*
Family name(s)
*
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Forename(s)
*
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Date of birth
*
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Sex
*
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Family name(s) at birth
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Forename(s) at birth
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PIN of the person in each institution
Personal Identification Number(s)
*
Country
*
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Personal Identification Number (PIN)
*
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Sector
{{$select.selected[ 'name']}}
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{{metaSection.sector.$$warning}}
Institution
Institution ID
*
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{{metaSection.institutionID.$$warning}}
Institution Name
*
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{{metaSection.institutionName.$$warning}}
If PIN not provided for every institution, please provide
Place of birth
Town
*
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Region
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{{metaSection.region.$$warning}}
Country
*
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Father's family name at birth
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{{metaSection.fatherFamilyNameAtBirth.$$warning}}
Forename of father
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{{metaSection.forenameFather.$$warning}}
Mother's family name at birth
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{{metaSection.motherFamilyNameAtBirth.$$warning}}
Forename of mother
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{{metaSection.forenameMother.$$warning}}
Additional information about nationality
Nationalities
Nationality
*
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{{metaSection.nationality.$$error}}
{{metaSection.nationality.$$warning}}
Since
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Addresses of the person
Address of the Person
Type of address
{{option.name}}
{{metaSection.typeAddress.$$error}}
{{metaSection.typeAddress.$$warning}}
Address
Street
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{{metaSection.street.$$warning}}
Building Name
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Town
*
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{{metaSection.town.$$warning}}
Postal Code
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Region
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{{metaSection.region.$$warning}}
Country
*
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{{metaSection.country.$$warning}}
Contact Details
Telephone Numbers
Telephone Number
Type
{{option.name}}
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{{metaSection.type.$$warning}}
Number
*
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{{metaSection.number.$$warning}}
Email Addresses
Email Address
Email Address
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{{metaSection.email.$$warning}}
Coverage by social security scheme
Periods Covered by security scheme in sending Member State
Period
Start Date
*
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End Date
*
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Periods Not covered
Period Not Covered
Start Date
*
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{{metaSection.startDate.$$warning}}
End Date
*
{{metaSection.endDate.$$error}}
{{metaSection.endDate.$$warning}}
Periods of Entitlement
Entitlement to Family Benefits, if yes
If no entitlement, choose one reason
Period Entitlement Family Benefits
Period of Entitlement to family benefit
Start Date
*
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{{metaSection.startDate.$$warning}}
End Date
*
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{{metaSection.endDate.$$warning}}
Reason
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Other reason
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Family relationship of deceased person to the spouse, partner or other person
Relationships
Family relationship
Family Relationship
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{{metaSection.familyRelationship.$$error}}
{{metaSection.familyRelationship.$$warning}}
Other
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Period
Fixed period
*
Open period
*
Start date
*
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End date
*
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{{metaSection.endDate.$$warning}}
Type of Open Period
*
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Start date
*
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Other relationship
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Name of person
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Date of relationship
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Was the claimant a member of the same household as the person in question
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{{metaSection.wasClaimantAMemberSameHouseholdPersonInQuestionIndicator.$$warning}}
Information on other person
Is the person the claimant?
{{option.name}}
{{metaSection.isPersonClaimantIndicator.$$error}}
{{metaSection.isPersonClaimantIndicator.$$warning}}
Person Identification
*
Family name(s)
*
{{metaSection.familyName.$$error}}
{{metaSection.familyName.$$warning}}
Forename(s)
*
{{metaSection.forename.$$error}}
{{metaSection.forename.$$warning}}
Date of birth
*
{{metaSection.dateBirth.$$error}}
{{metaSection.dateBirth.$$warning}}
Sex
*
{{option.name}}
{{metaSection.sex.$$error}}
{{metaSection.sex.$$warning}}
Family name(s) at birth
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{{metaSection.familyNameAtBirth.$$warning}}
Forename(s) at birth
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{{metaSection.forenameAtBirth.$$warning}}
PIN of the person in each institution
Personal Identification Number(s)
*
Country
*
{{$select.selected[ 'name']}}
{{metaSection.country.$$error}}
{{metaSection.country.$$warning}}
Personal Identification Number (PIN)
*
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{{metaSection.personalIdentificationNumber.$$warning}}
Sector
{{$select.selected[ 'name']}}
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{{metaSection.sector.$$warning}}
Institution
Institution ID
*
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{{metaSection.institutionID.$$warning}}
Institution Name
*
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{{metaSection.institutionName.$$warning}}
If PIN not provided for every institution, please provide
Place of birth
Town
*
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{{metaSection.town.$$warning}}
Region
{{metaSection.region.$$error}}
{{metaSection.region.$$warning}}
Country
*
{{$select.selected[ 'name']}}
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{{metaSection.country.$$warning}}
Father's family name at birth
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{{metaSection.fatherFamilyNameAtBirth.$$warning}}
Forename of father
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{{metaSection.forenameFather.$$warning}}
Mother's family name at birth
{{metaSection.motherFamilyNameAtBirth.$$error}}
{{metaSection.motherFamilyNameAtBirth.$$warning}}
Forename of mother
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{{metaSection.forenameMother.$$warning}}
Additional information about nationality
Nationalities
Nationality
*
{{$select.selected[ 'name']}}
{{metaSection.nationality.$$error}}
{{metaSection.nationality.$$warning}}
Since
{{metaSection.since.$$error}}
{{metaSection.since.$$warning}}
Addresses of the person
Address of the Person
Type of address
{{option.name}}
{{metaSection.typeAddress.$$error}}
{{metaSection.typeAddress.$$warning}}
Address
Street
{{metaSection.street.$$error}}
{{metaSection.street.$$warning}}
Building Name
{{metaSection.buildingName.$$error}}
{{metaSection.buildingName.$$warning}}
Town
*
{{metaSection.town.$$error}}
{{metaSection.town.$$warning}}
Postal Code
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{{metaSection.postalCode.$$warning}}
Region
{{metaSection.region.$$error}}
{{metaSection.region.$$warning}}
Country
*
{{$select.selected[ 'name']}}
{{metaSection.country.$$error}}
{{metaSection.country.$$warning}}
Contact Details
Telephone Numbers
Telephone Number
Type
{{option.name}}
{{metaSection.type.$$error}}
{{metaSection.type.$$warning}}
Number
*
{{metaSection.number.$$error}}
{{metaSection.number.$$warning}}
Email Addresses
Email Address
Email Address
{{metaSection.email.$$error}}
{{metaSection.email.$$warning}}
Coverage by social security scheme
Periods Covered by security scheme in sending Member State
Period
Start Date
*
{{metaSection.startDate.$$error}}
{{metaSection.startDate.$$warning}}
End Date
*
{{metaSection.endDate.$$error}}
{{metaSection.endDate.$$warning}}
Periods Not covered
Period Not Covered
Start Date
*
{{metaSection.startDate.$$error}}
{{metaSection.startDate.$$warning}}
End Date
*
{{metaSection.endDate.$$error}}
{{metaSection.endDate.$$warning}}
Periods of Entitlement
Entitlement to Family Benefits, if yes
If no entitlement, choose one reason
Period Entitlement Family Benefits
Period of Entitlement to family benefit
Start Date
*
{{metaSection.startDate.$$error}}
{{metaSection.startDate.$$warning}}
End Date
*
{{metaSection.endDate.$$error}}
{{metaSection.endDate.$$warning}}
Reason
{{option.name}}
{{metaSection.reason.$$error}}
{{metaSection.reason.$$warning}}
Other reason
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{{metaSection.otherReason.$$warning}}
Family relationship of deceased person to the spouse, partner or other person
Relationships
Family relationship
Family Relationship
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{{metaSection.familyRelationship.$$error}}
{{metaSection.familyRelationship.$$warning}}
Other
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{{metaSection.other.$$warning}}
Period
Fixed period
*
Open period
*
Start date
*
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{{metaSection.startDate.$$warning}}
End date
*
{{metaSection.endDate.$$error}}
{{metaSection.endDate.$$warning}}
Type of Open Period
*
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{{metaSection.typeOpenPeriod.$$warning}}
Start date
*
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{{metaSection.startDate.$$warning}}
Other relationship
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{{metaSection.otherRelationship.$$warning}}
Name of person
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{{metaSection.namePerson.$$warning}}
Date of relationship
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{{metaSection.dateRelationship.$$warning}}
Was the claimant a member of the same household as the person in question
{{option.name}}
{{metaSection.wasClaimantAMemberSameHouseholdPersonInQuestionIndicator.$$error}}
{{metaSection.wasClaimantAMemberSameHouseholdPersonInQuestionIndicator.$$warning}}
Claiming authority
Reason for authority claim
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{{metaSection.reasonForAuthorityClaim.$$warning}}
Claiming authority
Institution ID
*
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{{metaSection.institutionID.$$warning}}
Institution Name
*
{{metaSection.institutionName.$$error}}
{{metaSection.institutionName.$$warning}}
Bank details
SEPA account
*
Non-SEPA account
*
IBAN
*
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{{metaSection.IBAN.$$warning}}
BIC-SWIFT
{{metaSection.BICSWIFT.$$error}}
{{metaSection.BICSWIFT.$$warning}}
Account number
*
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{{metaSection.accountNumber.$$warning}}
BIC-SWIFT
*
{{metaSection.BICSWIFT.$$error}}
{{metaSection.BICSWIFT.$$warning}}
Bank Name
*
{{metaSection.bankName.$$error}}
{{metaSection.bankName.$$warning}}
Bank Address
*
Street
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{{metaSection.street.$$warning}}
Building Name
{{metaSection.buildingName.$$error}}
{{metaSection.buildingName.$$warning}}
Town
*
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{{metaSection.town.$$warning}}
Postal Code
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Region
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Country
*
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Information on child(ren)
Is the child the claimant?
{{option.name}}
{{metaSection.isChildClaimantIndicator.$$error}}
{{metaSection.isChildClaimantIndicator.$$warning}}
Child
Child Details
*
Family name(s)
*
{{metaSection.familyName.$$error}}
{{metaSection.familyName.$$warning}}
Forename(s)
*
{{metaSection.forename.$$error}}
{{metaSection.forename.$$warning}}
Date of birth
*
{{metaSection.dateBirth.$$error}}
{{metaSection.dateBirth.$$warning}}
Sex
*
{{option.name}}
{{metaSection.sex.$$error}}
{{metaSection.sex.$$warning}}
Family name(s) at birth
{{metaSection.familyNameAtBirth.$$error}}
{{metaSection.familyNameAtBirth.$$warning}}
Forename(s) at birth
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{{metaSection.forenameAtBirth.$$warning}}
PIN of the person in each institution
Personal Identification Number(s)
*
Country
*
{{$select.selected[ 'name']}}
{{metaSection.country.$$error}}
{{metaSection.country.$$warning}}
Personal Identification Number (PIN)
*
{{metaSection.personalIdentificationNumber.$$error}}
{{metaSection.personalIdentificationNumber.$$warning}}
Sector
{{$select.selected[ 'name']}}
{{metaSection.sector.$$error}}
{{metaSection.sector.$$warning}}
Institution
Institution ID
*
{{metaSection.institutionID.$$error}}
{{metaSection.institutionID.$$warning}}
Institution Name
*
{{metaSection.institutionName.$$error}}
{{metaSection.institutionName.$$warning}}
If PIN not provided for every institution, please provide
Place of birth
Town
*
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{{metaSection.town.$$warning}}
Region
{{metaSection.region.$$error}}
{{metaSection.region.$$warning}}
Country
*
{{$select.selected[ 'name']}}
{{metaSection.country.$$error}}
{{metaSection.country.$$warning}}
Father's family name at birth
{{metaSection.fatherFamilyNameAtBirth.$$error}}
{{metaSection.fatherFamilyNameAtBirth.$$warning}}
Forename of father
{{metaSection.forenameFather.$$error}}
{{metaSection.forenameFather.$$warning}}
Mother's family name at birth
{{metaSection.motherFamilyNameAtBirth.$$error}}
{{metaSection.motherFamilyNameAtBirth.$$warning}}
Forename of mother
{{metaSection.forenameMother.$$error}}
{{metaSection.forenameMother.$$warning}}
Additional information about nationality
Nationalities
Nationality
*
{{$select.selected[ 'name']}}
{{metaSection.nationality.$$error}}
{{metaSection.nationality.$$warning}}
Since
{{metaSection.since.$$error}}
{{metaSection.since.$$warning}}
Addresses of the child
Address of the Person
Type of address
{{option.name}}
{{metaSection.typeAddress.$$error}}
{{metaSection.typeAddress.$$warning}}
Address
Street
{{metaSection.street.$$error}}
{{metaSection.street.$$warning}}
Building Name
{{metaSection.buildingName.$$error}}
{{metaSection.buildingName.$$warning}}
Town
*
{{metaSection.town.$$error}}
{{metaSection.town.$$warning}}
Postal Code
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{{metaSection.postalCode.$$warning}}
Region
{{metaSection.region.$$error}}
{{metaSection.region.$$warning}}
Country
*
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Relationship to claimant, spouse/partner or other person
Relationship per child
Relationship with
*
{{option.name}}
{{metaSection.relationshipWith.$$error}}
{{metaSection.relationshipWith.$$warning}}
Type
*
{{$select.selected[ 'name']}}
{{metaSection.type.$$error}}
{{metaSection.type.$$warning}}
Period of Relationship
Fixed period
*
Open period
*
Start date
*
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{{metaSection.startDate.$$warning}}
End date
*
{{metaSection.endDate.$$error}}
{{metaSection.endDate.$$warning}}
Type of Open Period
*
{{option.name}}
{{metaSection.typeOpenPeriod.$$error}}
{{metaSection.typeOpenPeriod.$$warning}}
Start date
*
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{{metaSection.startDate.$$warning}}
Joint custody
{{option.name}}
{{metaSection.jointCustodyIndicator.$$error}}
{{metaSection.jointCustodyIndicator.$$warning}}
Child(ren)'s household
Is the child a member of the same household as the claimant
{{option.name}}
{{metaSection.isChildAMemberSameHouseholdClaimantIndicator.$$error}}
{{metaSection.isChildAMemberSameHouseholdClaimantIndicator.$$warning}}
Is the child a member of the same household as the spouse/partner in question
{{option.name}}
{{metaSection.isChildAMemberSameHouseholdSpousePartnerInQuestionIndicator.$$error}}
{{metaSection.isChildAMemberSameHouseholdSpousePartnerInQuestionIndicator.$$warning}}
Is the child a member of the same household as the other person in question
{{option.name}}
{{metaSection.isChildAMemberSameHouseholdOtherPersonInQuestionIndicator.$$error}}
{{metaSection.isChildAMemberSameHouseholdOtherPersonInQuestionIndicator.$$warning}}
Is child in the institution
{{option.name}}
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Additional information
Additional information
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