Transmission of claim/document/information

H065 - Transmission of claim/document/information
Article 2 (3) (4) of Regulation (EC) No 987/2009

SED API version: 0.16.2 build 2
Model version: 4.2.0

Person *

Person identification *

Family name(s) *

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Forename(s) *

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Date of birth *

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Sex *

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Family name(s) at birth

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Forename(s) at birth

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PIN of the person in each institution

Personal Identification Number(s) *

Country *

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Personal Identification Number (PIN) *

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Sector

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Institution

Institution ID *

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Institution Name *

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Personal Identification Number(s)

If PIN not provided for every institution, please provide

Place of birth

Town *

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Region

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Country *

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Father's family name at birth

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Forename of father

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Mother's family name at birth

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Forename of mother

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Additional information on the person

Nationality

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Address of the person

Address of the person

Type of Address

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Address

Street

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Building Name

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Town *

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Postal Code

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Region

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Country *

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Address of the person

Additional information concerning claim/document/information

Additional information concerning claim/document/information

Claim/document/information concerns

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Please fill in the following if "Claim/document/information" = "Other benefit" :

Other benefits

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Other correspondence

Other information

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Please fill in the following if "Other correspondence " = "Other" :

Type of correspondence

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Transfer of claim/document/information to

Transfer of claim/document/information to

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Institution code

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Institution name

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Date of receipt of the claim/document/information *

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The person is the claimant

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Reasons for transmission

Reasons

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Please find attached the following documents:

Predefined Documents

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Other Documents Attached

Other Document

Document

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Other Document

Additional information

Additional information

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