Request for recovery/precautionary measures

R017 - Request for recovery/precautionary measures
Articles 75, 78, 79, 80, 81(2), 82, 83, 84 or 90 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

Type of request *

Declaration *

Claim and or instrument permitting enforcement is: *

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Appropriate recovery procedures already taken by applicant party will not lead to payment in full of the claim and period of limitation under legislation in force in Member State of the applicant party has not expired *

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Claim is under 5 years old (Art82(1)(b) of Regulation (EC) 987/2009) *

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Please fill in the following if "Claim is under 5 years old (Art82(1)(b) of Regulation 987/2009)" = "No" :

Reason for request where the claim is more than 5 years old *

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The total amount (inclusive of interest, fines, penalties and/or costs) is: *

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Type of claim *

Sector code *

Please fill in the following if "Sector code" = "Other" :

Other sector code

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

Third parties holding assets of the debtor

Third party holding assets of the debtor

Third party

Third party name

Third party address

Street

Building Name

Town *

Postal Code

Region

Country *

Assets held by third party

Third party holding assets of the debtor

The Claim *

Claim details *

Claim information *

Currency

Currency of the Sending Institution *

Currency of the Receiving Institution *

Exchange rates used on date of request *

Exchange rate used on date of request *

Exchange rate *

Exchange rate used on date of request

Period

Start Date *

End Date *

Amount in the currency of the sending institution *

Principal amount

Interest

Fines

Administrative penalties

Other charges or costs

Total amount *

Amount In The Currency Of The Receiving Institution *

Principal amount

Interest

Fines

Administrative penalties

Other charges or costs

Total amount *

Identification of the claim *

Date of Instrument Permitting Enforcement *

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Date of notification *

Date on which enforcement becomes possible *

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Last day of period of limitation *

Reference to identify the instrument permitting enforcement *

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Claim details

Overall amount *

This request concerns *

Please fill in the following if "This request concerns" = "more than one claim and total amount" :

The combined total amount of the claims in the currency of the sending institution

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The combined total amount of the claims in the currency of the receiving institution

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Additional information

Please fill in the following if "Type of request" = "Recovery"

Agreement to accept payment by instalment *

Payment by instalment is *

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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R017 - Request for recovery/precautionary measures Articles 75, 78, 79, 80, 81(2), 82, 83, 84 or 90 of Regulation (EC) No 987/2009

R017 - Request for recovery/precautionary measures
Articles 75, 78, 79, 80, 81(2), 82, 83, 84 or 90 of Regulation (EC) No 987/2009