Notification of withdrawal or reduction of claim

R025 - Notification of withdrawal or reduction of claim
Article 78 (5) 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. Reason for Withdrawal or Reduction *

5.1. Date the claim was withdrawn or reduced *

5.2. Reason the claim was withdrawn or reduced *

5.3. Please fill in the following if "Reason the claim was withdrawn or reduced" = "Other" :

5.3.1. Other reason

6. Action required *

6.1. Receiving institution is asked to *

6.2. Please fill in the following if "Receiving institution is asked to" = "Other" :

6.2.1. State action required

7. Revised claim

7.1. Claim details *

7.1.1. Currency

7.1.1.1. Currency of the Sending Institution *

7.1.1.2. Currency of the Receiving Institution *

7.1.2. Exchange rates used on date of request *

7.1.2.1. Exchange rate used on date of request *

7.1.2.1.1. Exchange rate *

7.1.2.1.Exchange rate used on date of request

7.1.3. Period

7.1.3.1. Start Date *

7.1.3.2. End Date *

7.1.4. Amount in the currency of the sending institution *

7.1.4.1. Principal amount

7.1.4.2. Interest

7.1.4.3. Fines

7.1.4.4. Administrative penalties

7.1.4.5. Other charges or costs

7.1.4.6. Total amount *

7.1.5. Amount In The Currency Of The Receiving Institution *

7.1.5.1. Principal amount

7.1.5.2. Interest

7.1.5.3. Fines

7.1.5.4. Administrative penalties

7.1.5.5. Other charges or costs

7.1.5.6. Total amount *

7.1.Claim details

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R025 - Notification of withdrawal or reduction of claim Article 78 (5) of Regulation (EC) No 987/2009

R025 - Notification of withdrawal or reduction of claim
Article 78 (5) of Regulation (EC) No 987/2009