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: 0.14.2 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 request *

2.1. Type of request *

3. Declaration *

3.1. Declaration *

3.1.1. Claim and or instrument permitting enforcement is: *

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3.1.2. 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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3.1.3. Claim is under 5 years old (Art82(1)(b) of Regulation (EC) 987/2009) *

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

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

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

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4. Type of claim *

4.1. Type of claim *

4.2. Sector code *

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

4.3.1. Other sector code

5. Concerns *

5.1. Concerns *

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

6.1. Persons

6.1.1. Person *

6.1.1.1. Person Identification *

6.1.1.1.1. Family name(s) *

6.1.1.1.2. Forename(s) *

6.1.1.1.3. Date of birth *

6.1.1.1.4. Sex *

6.1.1.1.5. Family name(s) at birth

6.1.1.1.6. Forename(s) at birth

6.1.1.1.7. PIN of the person in each institution

6.1.1.1.7.1. Personal Identification Number(s) *

6.1.1.1.7.1.1. Country *

6.1.1.1.7.1.2. Personal Identification Number (PIN) *

6.1.1.1.7.1.3. Sector

6.1.1.1.7.1.4. Institution

6.1.1.1.7.1.4.1. Institution ID *

6.1.1.1.7.1.4.2. Institution Name *

6.1.1.1.7.1.Personal Identification Number(s)

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

6.1.1.1.8.1. Place of birth

6.1.1.1.8.1.1. Town *

6.1.1.1.8.1.2. Region

6.1.1.1.8.1.3. Country *

6.1.1.1.8.2. Father's family name at birth

6.1.1.1.8.3. Forename of father

6.1.1.1.8.4. Mother's family name at birth

6.1.1.1.8.5. Forename of mother

6.1.1.2. Additional information about a person *

6.1.1.2.1. Status of the person *

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

6.1.1.2.2.1. Other status of the person

6.1.1.2.3. Nationality

6.1.1.2.4. Previous family name(s)

6.1.1.2.4.1. Previous family name(s)

6.1.1.2.4.1.1. Previous family name(s)

6.1.1.2.4.1.Previous family name(s)

6.1.1.2.5. Previous forenames

6.1.1.2.5.1. Previous forename

6.1.1.2.5.1.1. Previous forename

6.1.1.2.5.1.Previous forename

6.1.1.2.6. Current family status

6.1.1.2.7. Date of death

6.1.1.3. Person's last known addresses

6.1.1.3.1. Person's last known address details *

6.1.1.3.1.1. Type of address *

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

6.1.1.3.1.2.1. Specify "Other" Type

6.1.1.3.1.3. Address detail *

6.1.1.3.1.3.1. Street

6.1.1.3.1.3.2. Building Name

6.1.1.3.1.3.3. Town *

6.1.1.3.1.3.4. Postal Code

6.1.1.3.1.3.5. Region

6.1.1.3.1.3.6. Country *

6.1.1.3.1.Person's last known address details

6.1.1.Person

7.1. Employer *

7.1.1. Name *

7.1.2. Identification numbers

7.1.2.1. Identification number

7.1.2.1.1. Number *

7.1.2.1.2. Type *

7.1.2.1.Identification number

7.1.3. Address

7.1.3.1. Street

7.1.3.2. Building Name

7.1.3.3. Town *

7.1.3.4. Postal Code

7.1.3.5. Region

7.1.3.6. Country *

7.2. Responsible person or section

7.2.1. Responsible person or section

7.2.2. Contact Information

7.2.2.1. Telephone Numbers

7.2.2.1.1. Telephone Number

7.2.2.1.1.1. Type

7.2.2.1.1.2. Number *

7.2.2.1.1.Telephone Number

7.2.2.2. Email Addresses

7.2.2.2.1. Email Address

7.2.2.2.1.1. Email Address

7.2.2.2.1.Email Address

7.3. Persons

7.3.1. Person *

7.3.1.1. Person Identification *

7.3.1.1.1. Family name(s) *

7.3.1.1.2. Forename(s) *

7.3.1.1.3. Date of birth *

7.3.1.1.4. Sex *

7.3.1.1.5. Family name(s) at birth

7.3.1.1.6. Forename(s) at birth

7.3.1.1.7. PIN of the person in each institution

7.3.1.1.7.1. Personal Identification Number(s) *

7.3.1.1.7.1.1. Country *

7.3.1.1.7.1.2. Personal Identification Number (PIN) *

7.3.1.1.7.1.3. Sector

7.3.1.1.7.1.4. Institution

7.3.1.1.7.1.4.1. Institution ID *

7.3.1.1.7.1.4.2. Institution Name *

7.3.1.1.7.1.Personal Identification Number(s)

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

7.3.1.1.8.1. Place of birth

7.3.1.1.8.1.1. Town *

7.3.1.1.8.1.2. Region

7.3.1.1.8.1.3. Country *

7.3.1.1.8.2. Father's family name at birth

7.3.1.1.8.3. Forename of father

7.3.1.1.8.4. Mother's family name at birth

7.3.1.1.8.5. Forename of mother

7.3.1.2. Additional information about a person *

7.3.1.2.1. Status of the person *

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

7.3.1.2.2.1. Other status of the person

7.3.1.2.3. Nationality

7.3.1.2.4. Previous family name(s)

7.3.1.2.4.1. Previous family name(s)

7.3.1.2.4.1.1. Previous family name(s)

7.3.1.2.4.1.Previous family name(s)

7.3.1.2.5. Previous forenames

7.3.1.2.5.1. Previous forename

7.3.1.2.5.1.1. Previous forename

7.3.1.2.5.1.Previous forename

7.3.1.2.6. Current family status

7.3.1.2.7. Date of death

7.3.1.Person

8. Third parties holding assets of the debtor

8.1. Third party holding assets of the debtor

8.1.1. Third party

8.1.1.1. Third party name

8.1.1.2. Third party address

8.1.1.2.1. Street

8.1.1.2.2. Building Name

8.1.1.2.3. Town *

8.1.1.2.4. Postal Code

8.1.1.2.5. Region

8.1.1.2.6. Country *

8.1.2. Assets held by third party

8.1.Third party holding assets of the debtor

9. The Claim *

9.1. Claim details *

9.1.1. Claim information *

9.1.1.1. Currency

9.1.1.1.1. Currency of the Sending Institution *

9.1.1.1.2. Currency of the Receiving Institution *

9.1.1.2. Exchange rates used on date of request *

9.1.1.2.1. Exchange rate used on date of request *

9.1.1.2.1.1. Exchange rate *

9.1.1.2.1.Exchange rate used on date of request

9.1.1.3. Period

9.1.1.3.1. Start Date *

9.1.1.3.2. End Date *

9.1.1.4. Amount in the currency of the sending institution *

9.1.1.4.1. Principal amount

9.1.1.4.2. Interest

9.1.1.4.3. Fines

9.1.1.4.4. Administrative penalties

9.1.1.4.5. Other charges or costs

9.1.1.4.6. Total amount *

9.1.1.5. Amount In The Currency Of The Receiving Institution *

9.1.1.5.1. Principal amount

9.1.1.5.2. Interest

9.1.1.5.3. Fines

9.1.1.5.4. Administrative penalties

9.1.1.5.5. Other charges or costs

9.1.1.5.6. Total amount *

9.1.2. Identification of the claim *

9.1.2.1. Date of Instrument Permitting Enforcement *

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9.1.2.2. Date of notification *

9.1.2.3. Date on which enforcement becomes possible *

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9.1.2.4. Last day of period of limitation *

9.1.2.5. Reference to identify the instrument permitting enforcement *

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9.1.Claim details

10. Overall amount *

10.1. This request concerns *

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

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

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

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11. Additional information

11.1. Additional information

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

12.1. Agreement to accept payment by instalment *

12.1.1. Payment by instalment is *

12.2. Bank details

12.2.1. SEPA Bank details *

12.2.1.1. IBAN *

12.2.1.2. BIC-SWIFT

12.2.2. Account holder name *

12.2.3. Payment reference *

12.2.4. Receiving bank address

12.2.4.1. Street

12.2.4.2. Building Name

12.2.4.3. Town *

12.2.4.4. Postal Code

12.2.4.5. Region

12.2.4.6. 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