Claim for Pre-retirement Benefit

M040 - Claim for Pre-retirement Benefit
Articles 3(1)(i), 66 of Regulation (EC) No 883/2004

SED API version: 0.16.2 build 2
Model version: 4.2.0

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 the person

Nationality

Previous name(s)

Previous family name(s)

Previous forename(s)

Person employment / self-employment details

Status of activity

Country

Person is still pursuing

Person ceased to pursue

Date

Person reduced

Date

Person suspended

Date

Person intends to retire from

Date

Person intends to take up

Date

Status of activity

If person still pursuing or intends to take up employment or self-employment please state the monthly amount of income from the employment/self-employment in question

Amount

Currency

Country of the last employment or self-employment activity

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Country which legislation was applicable during last employment or self-employment activity

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Last employer details

Name *

Identification numbers

Identification number

Number *

Type *

Identification number

Address

Street

Building Name

Town *

Postal Code

Region

Country *

Last employer details

Reason for termination of the last employment or self-employment

Termination reason of employment

Please fill in the following if "Termination reason of employment" = "Other" :

Other termination

Termination reason of self-employment

Other information on employment or self-employment

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The date of termination of the last employment or self-employment

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Person benefit details

Benefits

Please fill in the following if "Benefits" = "Other benefit" :

Other benefit

Status

Institution

Institution ID *

Institution Name *

Period of benefits payment

Fixed period*
Open period*

Start date *

End date *

Type of Open Period *

Start date *

Person benefit details

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 *

Miscellaneous *

Date of claim *

Remarks

Additional Information

Please find attached following document(s)

Attached document(s)

M040 - Claim for Pre-retirement Benefit Articles 3(1)(i), 66 of Regulation (EC) No 883/2004

M040 - Claim for Pre-retirement Benefit
Articles 3(1)(i), 66 of Regulation (EC) No 883/2004