Reply with amount of reimbursable contributions

R011 - Reply with amount of reimbursable contributions
Article 73(2) of Regulation (EC) No 987/2009

SED API version: 0.14.2 PREVIEW build 3
Model version: 4.0.16

1. Local Case Numbers

1.1. Local Case Number

1.1.1. Country *

1.1.2. Case number *

1.1.3. Institution

1.1.3.1. Institution ID *

1.1.3.2. Institution Name *

1.1.Local Case Number

2. Concerns *

2.1. Concerns *

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

3.1. Persons

3.1.1. Person *

3.1.1.1. Person Identification *

3.1.1.1.1. Family name(s) *

3.1.1.1.2. Forename(s) *

3.1.1.1.3. Date of birth *

3.1.1.1.4. Sex *

3.1.1.1.5. Family name(s) at birth

3.1.1.1.6. Forename(s) at birth

3.1.1.1.7. PIN of the person in each institution

3.1.1.1.7.1. Personal Identification Number(s) *

3.1.1.1.7.1.1. Country *

3.1.1.1.7.1.2. Personal Identification Number (PIN) *

3.1.1.1.7.1.3. Sector

3.1.1.1.7.1.4. Institution

3.1.1.1.7.1.4.1. Institution ID *

3.1.1.1.7.1.4.2. Institution Name *

3.1.1.1.7.1.Personal Identification Number(s)

3.1.1.1.8. If PIN not provided for every institution, please provide

3.1.1.1.8.1. Place of birth

3.1.1.1.8.1.1. Town *

3.1.1.1.8.1.2. Region

3.1.1.1.8.1.3. Country *

3.1.1.1.8.2. Father's family name at birth

3.1.1.1.8.3. Forename of father

3.1.1.1.8.4. Mother's family name at birth

3.1.1.1.8.5. Forename of mother

3.1.1.2. Additional information about a person *

3.1.1.2.1. Status of the person *

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

3.1.1.2.2.1. Other status of the person

3.1.1.2.3. Nationality

3.1.1.2.4. Previous family name(s)

3.1.1.2.4.1. Previous family name(s)

3.1.1.2.4.1.1. Previous family name(s)

3.1.1.2.4.1.Previous family name(s)

3.1.1.2.5. Previous forenames

3.1.1.2.5.1. Previous forename

3.1.1.2.5.1.1. Previous forename

3.1.1.2.5.1.Previous forename

3.1.1.2.6. Current family status

3.1.1.2.7. Date of death

3.1.1.Person

4.1. Employer *

4.1.1. Name *

4.1.2. Identification numbers

4.1.2.1. Identification number

4.1.2.1.1. Number *

4.1.2.1.2. Type *

4.1.2.1.Identification number

4.1.3. Address

4.1.3.1. Street

4.1.3.2. Building Name

4.1.3.3. Town *

4.1.3.4. Postal Code

4.1.3.5. Region

4.1.3.6. Country *

4.2. Responsible person or section

4.2.1. Responsible person or section

4.2.2. Contact Information

4.2.2.1. Telephone Numbers

4.2.2.1.1. Telephone Number

4.2.2.1.1.1. Type

4.2.2.1.1.2. Number *

4.2.2.1.1.Telephone Number

4.2.2.2. Email Addresses

4.2.2.2.1. Email Address

4.2.2.2.1.1. Email Address

4.2.2.2.1.Email Address

4.3. Persons

4.3.1. Person *

4.3.1.1. Person Identification *

4.3.1.1.1. Family name(s) *

4.3.1.1.2. Forename(s) *

4.3.1.1.3. Date of birth *

4.3.1.1.4. Sex *

4.3.1.1.5. Family name(s) at birth

4.3.1.1.6. Forename(s) at birth

4.3.1.1.7. PIN of the person in each institution

4.3.1.1.7.1. Personal Identification Number(s) *

4.3.1.1.7.1.1. Country *

4.3.1.1.7.1.2. Personal Identification Number (PIN) *

4.3.1.1.7.1.3. Sector

4.3.1.1.7.1.4. Institution

4.3.1.1.7.1.4.1. Institution ID *

4.3.1.1.7.1.4.2. Institution Name *

4.3.1.1.7.1.Personal Identification Number(s)

4.3.1.1.8. If PIN not provided for every institution, please provide

4.3.1.1.8.1. Place of birth

4.3.1.1.8.1.1. Town *

4.3.1.1.8.1.2. Region

4.3.1.1.8.1.3. Country *

4.3.1.1.8.2. Father's family name at birth

4.3.1.1.8.3. Forename of father

4.3.1.1.8.4. Mother's family name at birth

4.3.1.1.8.5. Forename of mother

4.3.1.2. Additional information about a person *

4.3.1.2.1. Status of the person *

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

4.3.1.2.2.1. Other status of the person

4.3.1.2.3. Nationality

4.3.1.2.4. Previous family name(s)

4.3.1.2.4.1. Previous family name(s)

4.3.1.2.4.1.1. Previous family name(s)

4.3.1.2.4.1.Previous family name(s)

4.3.1.2.5. Previous forenames

4.3.1.2.5.1. Previous forename

4.3.1.2.5.1.1. Previous forename

4.3.1.2.5.1.Previous forename

4.3.1.2.6. Current family status

4.3.1.2.7. Date of death

4.3.1.Person

5. Request has been made within the 3 months period? *

5.1. Request has been made within the 3 months period? *

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5.2. Please fill in the following if "Request has been made within the 3 months period?" = "Yes" :

5.2.1. Type of contributions

5.2.1.1. Type of contribution *

5.2.1.1.1. Contribution *

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

5.2.1.1.2.1. Other

5.2.1.1.3. Contribution period *

5.2.1.1.3.1. Start Date *

5.2.1.1.3.2. End Date *

5.2.1.1.4. Contribution amount *

5.2.1.1.4.1. Amount *

5.2.1.1.4.2. Currency of sending institution *

5.2.1.1.4.3. Amount employer part

5.2.1.1.4.4. Amount insured person part

5.2.1.1.Type of contribution

5.3. Additional information

5.3.1. Amount of reimbursable contributions will be paid:

5.3.1.1. Amount for competent institution

5.3.1.2. Amount for person

5.3.1.3. Further information

5.3.2. Reimbursement is not possible

5.3.2.1. Reason why reimbursement is not possible

5.3.3. Please fill in this section if another institution is competent :

5.3.3.1. Competent institutions

5.3.3.1.1. Competent institution

5.3.3.1.1.1. Institution ID *

5.3.3.1.1.2. Institution Name *

5.3.3.1.1.Competent institution

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R011 - Reply with amount of reimbursable contributions Article 73(2) of Regulation (EC) No 987/2009

R011 - Reply with amount of reimbursable contributions
Article 73(2) of Regulation (EC) No 987/2009