Request for information

R012 - Request for information
Article 76 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. Type of claim *

2.1. Type of claim *

2.2. Sector code *

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

2.3.1. Other sector code

3. Concerns *

3.1. Concerns *

4. Declaration *

4.1. Declaration *

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

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

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4.4. Total amount *

4.4.1. Amount *

4.4.2. Currency *

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

5.1. Persons

5.1.1. Person *

5.1.1.1. Person Identification *

5.1.1.1.1. Family name(s) *

5.1.1.1.2. Forename(s) *

5.1.1.1.3. Date of birth *

5.1.1.1.4. Sex *

5.1.1.1.5. Family name(s) at birth

5.1.1.1.6. Forename(s) at birth

5.1.1.1.7. PIN of the person in each institution

5.1.1.1.7.1. Personal Identification Number(s) *

5.1.1.1.7.1.1. Country *

5.1.1.1.7.1.2. Personal Identification Number (PIN) *

5.1.1.1.7.1.3. Sector

5.1.1.1.7.1.4. Institution

5.1.1.1.7.1.4.1. Institution ID *

5.1.1.1.7.1.4.2. Institution Name *

5.1.1.1.7.1.Personal Identification Number(s)

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

5.1.1.1.8.1. Place of birth

5.1.1.1.8.1.1. Town *

5.1.1.1.8.1.2. Region

5.1.1.1.8.1.3. Country *

5.1.1.1.8.2. Father's family name at birth

5.1.1.1.8.3. Forename of father

5.1.1.1.8.4. Mother's family name at birth

5.1.1.1.8.5. Forename of mother

5.1.1.2. Additional information about a person *

5.1.1.2.1. Status of the person *

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

5.1.1.2.2.1. Other status of the person

5.1.1.2.3. Nationality

5.1.1.2.4. Previous family name(s)

5.1.1.2.4.1. Previous family name(s)

5.1.1.2.4.1.1. Previous family name(s)

5.1.1.2.4.1.Previous family name(s)

5.1.1.2.5. Previous forenames

5.1.1.2.5.1. Previous forename

5.1.1.2.5.1.1. Previous forename

5.1.1.2.5.1.Previous forename

5.1.1.2.6. Current family status

5.1.1.2.7. Date of death

5.1.1.3. Person's last known addresses

5.1.1.3.1. Person's last known address details *

5.1.1.3.1.1. Type of address *

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

5.1.1.3.1.2.1. Specify "Other" Type

5.1.1.3.1.3. Address detail *

5.1.1.3.1.3.1. Street

5.1.1.3.1.3.2. Building Name

5.1.1.3.1.3.3. Town *

5.1.1.3.1.3.4. Postal Code

5.1.1.3.1.3.5. Region

5.1.1.3.1.3.6. Country *

5.1.1.3.1.Person's last known address details

5.1.1.Person

6.1. Employer *

6.1.1. Name *

6.1.2. Identification numbers

6.1.2.1. Identification number

6.1.2.1.1. Number *

6.1.2.1.2. Type *

6.1.2.1.Identification number

6.1.3. Address

6.1.3.1. Street

6.1.3.2. Building Name

6.1.3.3. Town *

6.1.3.4. Postal Code

6.1.3.5. Region

6.1.3.6. Country *

6.2. Responsible person or section

6.2.1. Responsible person or section

6.2.2. Contact Information

6.2.2.1. Telephone Numbers

6.2.2.1.1. Telephone Number

6.2.2.1.1.1. Type

6.2.2.1.1.2. Number *

6.2.2.1.1.Telephone Number

6.2.2.2. Email Addresses

6.2.2.2.1. Email Address

6.2.2.2.1.1. Email Address

6.2.2.2.1.Email Address

6.3. Persons

6.3.1. Person *

6.3.1.1. Person Identification *

6.3.1.1.1. Family name(s) *

6.3.1.1.2. Forename(s) *

6.3.1.1.3. Date of birth *

6.3.1.1.4. Sex *

6.3.1.1.5. Family name(s) at birth

6.3.1.1.6. Forename(s) at birth

6.3.1.1.7. PIN of the person in each institution

6.3.1.1.7.1. Personal Identification Number(s) *

6.3.1.1.7.1.1. Country *

6.3.1.1.7.1.2. Personal Identification Number (PIN) *

6.3.1.1.7.1.3. Sector

6.3.1.1.7.1.4. Institution

6.3.1.1.7.1.4.1. Institution ID *

6.3.1.1.7.1.4.2. Institution Name *

6.3.1.1.7.1.Personal Identification Number(s)

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

6.3.1.1.8.1. Place of birth

6.3.1.1.8.1.1. Town *

6.3.1.1.8.1.2. Region

6.3.1.1.8.1.3. Country *

6.3.1.1.8.2. Father's family name at birth

6.3.1.1.8.3. Forename of father

6.3.1.1.8.4. Mother's family name at birth

6.3.1.1.8.5. Forename of mother

6.3.1.2. Additional information about a person *

6.3.1.2.1. Status of the person *

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

6.3.1.2.2.1. Other status of the person

6.3.1.2.3. Nationality

6.3.1.2.4. Previous family name(s)

6.3.1.2.4.1. Previous family name(s)

6.3.1.2.4.1.1. Previous family name(s)

6.3.1.2.4.1.Previous family name(s)

6.3.1.2.5. Previous forenames

6.3.1.2.5.1. Previous forename

6.3.1.2.5.1.1. Previous forename

6.3.1.2.5.1.Previous forename

6.3.1.2.6. Current family status

6.3.1.2.7. Date of death

6.3.1.Person

7. Information requested *

7.1. Please provide information about *

7.2. Please fill in the following if "Please provide information about" = "Other" :

7.2.1. Please provide details

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R012 - Request for information Article 76 of Regulation (EC) No 987/2009

R012 - Request for information
Article 76 of Regulation (EC) No 987/2009