Reimbursement Request

U020 - Reimbursement Request
Articles 65(6), 65(7) of Regulation (EC) No 883/2004, Article 70 of Regulation (EC) No 987/2009

SED API version: 0.16.2 build 2
Model version: 4.2.0

Local case numbers

Local Case Number

Country *

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Case number *

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Institution

Institution ID *

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Institution Name *

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Local Case Number

General information *

Reimbursement request ID *

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Number of individual claims *

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Total amount requested *

Amount *

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Currency *

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Bank information *

SEPA Bank Details *

IBAN *

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BIC-SWIFT

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Bank transfer: subject or transaction reference *

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Individual claims *

Individual claim *

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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Institution

Institution ID *

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Institution Name *

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Personal Identification Number(s)

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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Forename of mother

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Additional information on the person

Nationality

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Reimbursement request ID *

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Sequential number of Individual claim *

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Institution which certified insurance record *

Institution ID *

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Institution Name *

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Working periods considered *

Working period considered *

Start Date *

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End Date *

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Working period considered

Reimbursement period *

Start Date *

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End Date *

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Last payment date *

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Requested amount for reimbursement *

Amount *

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Currency *

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Individual claim

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