Claim for Death Grant

M030 - Claim for Death Grant
Articles 42, 43 of Regulation (EC) No 883/04; Article 42 of Regulation (EC) No 987/09

SED API version: 0.16.2 build 2
Model version: 4.2.0

Deceased person *

Deceased Person *

Family name(s) *

Forename(s) *

Date of birth *

Sex *

Family name(s) at birth

Forename(s) at birth

PIN of the person in each institution

Personal Identification Number(s) *

Country *

Personal Identification Number (PIN) *

Sector

Institution

Institution ID *

Institution Name *

Personal Identification Number(s)

If PIN not provided for every institution, please provide

Place of birth

Town *

Region

Country *

Father's family name at birth

Forename of father

Mother's family name at birth

Forename of mother

Additional information on deceased person

Nationality

Previous name(s)

Previous family name(s)

Previous forename(s)

Address of the deceased person before death

Street

Building Name

Town *

Postal Code

Region

Country *

Status of the deceased person before death

Please fill in the following if "Status of the deceased person before death" = "Other"

Other status

Status

Claimant *

Person Identification

Family name(s) *

Forename(s) *

Date of birth *

Sex *

Family name(s) at birth

Forename(s) at birth

PIN of the person in each institution

Personal Identification Number(s) *

Country *

Personal Identification Number (PIN) *

Sector

Institution

Institution ID *

Institution Name *

Personal Identification Number(s)

If PIN not provided for every institution, please provide

Place of birth

Town *

Region

Country *

Father's family name at birth

Forename of father

Mother's family name at birth

Forename of mother

Additional information on claimant

Nationality

Previous name(s)

Previous family name(s)

Previous forename(s)

Status of the claimant

Please fill in the following if "Status of the claimant" = "Other"

Other status

Status

Relationship to the deceased person

Please fill in the following if "Relationship to the deceased person" = "Other" :

Other relationship

The deceased person was dependant of the claimant

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The claimant was dependant of the deceased person

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Other Claimant

If the claimant is

Please fill in:

Name of legal person/undertaker

Identification of legal person/undertaker

Registration number

Social security number

Fiscal number

Name of person entitled to represent legal person/undertaker

Family name(s)

Forename(s)

Address

Street

Building Name

Town *

Postal Code

Region

Country *

Additional information on the claim for death grant *

Details of Death *

Death date of the deceased person *

Place of death

Date of the claim *

Legislation of sending institution *

The Claimant *

The Claimant

Information on representative/legal guardian

Status

Information on the representative/legal guardian

Name

Address

Street

Building Name

Town *

Postal Code

Region

Country *

Information on payment *

Payment to *

Bank details

SEPA account*
Non-SEPA account*

IBAN *

BIC-SWIFT

Account number *

BIC-SWIFT *

Bank Name *

Bank Address *

Street

Building Name

Town *

Postal Code

Region

Country *

Additional Information

Please find attached following document(s)

Attached document(s)

M030 - Claim for Death Grant Articles 42, 43 of Regulation (EC) No 883/04; Article 42 of Regulation (EC) No 987/09

M030 - Claim for Death Grant
Articles 42, 43 of Regulation (EC) No 883/04; Article 42 of Regulation (EC) No 987/09