Request for reimbursement of contributions provisionally paid

R010 - Request for reimbursement of contributions provisionally paid
Article 73(2) 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 *

Case number *

Institution

Institution ID *

Institution Name *

Local Case Number

Concerns *

Please fill in the following if "Concerns" = "Person" :
Please fill in the following if "Concerns" = "Employer" :

Persons

Person *

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 about a person *

Status of the person *

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

Other status of the person

Nationality

Previous family name(s)

Previous forenames

Previous forename

Current family status

Date of death

Person's last known addresses

Person's last known address details *

Type of address *

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

Specify "Other" Type

Address detail *

Street

Building Name

Town *

Postal Code

Region

Country *

Person's last known address details

Person

Employer *

Name *

Identification numbers

Identification number

Number *

Type *

Identification number

Address

Street

Building Name

Town *

Postal Code

Region

Country *

Responsible person or section

Contact Information

Telephone Numbers

Telephone Number

Type

Number *

Telephone Number

Email Addresses

Email Address

Persons

Person *

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 about a person *

Status of the person *

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

Other status of the person

Nationality

Previous family name(s)

Previous forenames

Previous forename

Current family status

Date of death

Person

Decision on competent institution *

Date competence determined *

Date by which this request must be made *

Type of contributions *

Type of contribution *

Contribution *

Please fill in if 'Contribution' = 'Other' :

Other

Contribution period *

Start Date *

End Date *

Contribution amount *

Amount *

Currency of sending institution *

Amount employer part

Amount insured person part

Type of contribution

Bank details *

SEPA Bank details *

IBAN *

BIC-SWIFT

Account holder name *

Payment reference *

Receiving bank address

Street

Building Name

Town *

Postal Code

Region

Country *

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R010 - Request for reimbursement of contributions provisionally paid Article 73(2) of Regulation (EC) No 987/2009

R010 - Request for reimbursement of contributions provisionally paid
Article 73(2) of Regulation (EC) No 987/2009