Request for reimbursement of costs

R028 - Request for reimbursement of costs
Article 85(2) and 85(3) 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

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

Reason for request *

Reimbursement is requested under *

Actual costs and/or losses

Amounts in currency per institution

Amounts in currency

Institution ID *

Institution Name *

Currency

Costs

Losses

Total

Amounts in currency

Reimbursement is requested for

Additional information

Estimated costs and/or losses

Amounts in currency per institution

Amounts in currency

Institution ID *

Institution Name *

Currency

Costs

Losses

Total

Amounts in currency

Provisional agreement to reimbursement is requested for

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Additional information

Where recovery action was unfounded indicate the date by which actual costs/losses will be requested

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If estimated costs and /or losses concern further recovery action provide details of the action proposed

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Please fill in the following if "Type of request" = "Final" :

Bank details

SEPA Bank details *

IBAN *

BIC-SWIFT

Account holder name *

Payment reference *

Receiving bank address

Street

Building Name

Town *

Postal Code

Region

Country *

Request *

Please,

If further recovery action may result in unpaid costs/losses, your consent to accepting liability to reimburse the estimated costs / losses to enable continued recovery action must be received by

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R028 - Request for reimbursement of costs Article 85(2) and 85(3) of Regulation (EC) No 987/2009

R028 - Request for reimbursement of costs
Article 85(2) and 85(3) of Regulation (EC) No 987/2009