# EUR-Lex - 31995D0353 - EN

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# 31995D0353

**95/353/EC: Decision No 155 of 6 July 1994 on the model forms necessary for the application of Council Regulations (EEC) No 1408/71 and (EEC) No 574/72 (E 401 to 411) **

*
Official Journal L 209 , 05/09/1995 P. 0001 - 0002 *

DECISION No 155

of 6 July 1994

on the model forms necessary for the application of Council Regulations (EEC) No 1408/71 and (EEC) No 574/72 (E 401 to 411) (1)

(95/353/EC)

THE ADMINISTRATIVE COMMISSION OF THE EUROPEAN COMMUNITIES ON SOCIAL SECURITY FOR MIGRANT WORKERS,

Having regard to Article 81 (a) of Council Regulation (EEC) No 1408/71 of 14 June 1971 on the application of social security schemes to employed persons, to self-employed persons and to members of their family moving within the Community, under which it is the duty of the Administrative Commission to deal with all administrative matters arising from Regulation (EEC) No 1408/71 and subsequent Regulations,

Having regard to Article 2 (1) of Council Regulation (EEC) No 574/72 of 21 March 1972, under which it is the duty of the Administrative Commission to draw up models of certificates, certified statements, declarations, applications and other documents necessary for the applications of the Regulations,

Having regard to Decision No 144 of 9 April 1990, Decision No 145 of 27 June 1990, and Decision No 147 of 10 October 1990 laying down and adapting the model forms necessary for the application of the Regulations,

Whereas these model forms should be adapted for the purpose of taking account of the amendments which have been introduced into the national legislation of Member States;

Whereas the Agreement of the European Economic Area of 2 May 1992, as adjusted by the Protocol of 17 March 1993, Annex VI, implements Regulations (EEC) No 1408/71 and (EEC) No 574/72 within the European Economic Area;

Whereas by Decision of the EEA Joint Committee the model forms necessary for the application of Regulations (EEC) No 1408/71 and (EEC) No 574/72 will be adapted and implemented within the European Economic Area;

Whereas for practical reasons identical forms should be used within the Community and within the European Economic Area;

Whereas with a view to the envisaged participation of Liechtenstein in the EEA at a later stage, these forms should also be adapted as regards Liechtenstein;

Whereas the language in which the forms should be drawn up has been decided by Recommendation No 15 of the Administrative Commission,

HAS DECIDED AS FOLLOWS:

1. The model forms E 401 411 printed in Decision Nos 144, 145, 146 and 147 shall be replaced by the models appended hereto with the following adjustments:

(a) model form E 407 is introduced;

(b) model forms E 401, E 402, E 403, E 404, E 405, E 406F and E 411 are amended;

(c) model forms E 407F, E 408F, E 409 and E 412F are repealed;

(d) model form E 413F is maintained, but cannot be used in the EEA.

2. The competent authorities of the Member States shall make available to the person concerned (rightful claimants, institutions, employers, etc.) the forms according to the attached models.

3. Each form shall be available in the official languages of the Community and laid out in such a manner that the different versions are perfectly superposable, thereby making it possible for each person or body to which a form is addressed (rightful claimant, institution, employer, etc.) to receive the form printed in their own language.

4. This Decision shall be applicable from the first day of the month following its publication in the Official Journal of the European Communities.

The Chairman

of the Adminstrative Commission

Arno BOKELOH

>START OF GRAPHIC>

EUROPEAN COMMUNITIES

Social Security Regulations

EEA*

See 'Instructions' on page 4

E 401

(1)

CERTIFICATE CONCERNING THE COMPOSITION OF THE FAMILY FOR THE PURPOSE OF THE GRANTING FAMILY BENEFITS

Reg. 1408/71: Art. 73; Art. 74; Art. 77; Art. 78

Reg. 574/72: Art. 86.2; Art. 88; Art. 90; Art. 91; Art. 92

A. Request for certificate

1 Employed person Pensioner (scheme for employed persons) (4)

Self-employed person Pensioner (scheme for self-employed persons) (4)

Person supporting the orphan Orphan

1.1 Surname (1a)

.

1.2 Forenames Previous names (1a) Place of birth (2)

. . .

1.3 Date of birth Sex Nationality D.N.I. (3)

. . . .

1.4 Identification number .

1.5 Civil status single married widow/widower

divorced separated (5) cohabiting (6) (7)

1.6 Address in the country of residence of the members of thefamily:

Street . No .

Post code . Town . Country .

2 Spouse Spouse divorced or separated from the worker or pensioner

1S

Surviving parent (8) cohabiting partner (6) (7)

2.1 Surname (1a)

.

2.2 Forenames Previous names (1a) Place of birth (2)

. . .

2.3 Date of birth Sex Nationality D.N.I. (3)

. . . .

2.4 Pursuit of gainful employment: Yes No

2.5 Address:

Street . No .

Post code . Town . Country .

3 Person or persons, other than the spouse in whose household the members of the family are living (9)

3.1 Surname (1a)/Name (legal person)

.

3.2 Forenames Previous names (1a) Place of birth (2)

. . .

3.3 Date of birth Sex Nationality D.N.I. (3)

. . . .

3.4 Family relationship with child or children .

3.5 Pursuit of gainful employment: Yes No

3.6 Address:

Street . No .

Post code . Town . Country .

E 401

4 Family members for whom the family benefits are claimed, living with the person named either in box 2 or in box 3

SurnameForenamesDate of birth (10)Relationship (11)Place of

residence.

.

.

.

.

.

.

.

.

.

.

.

.

.

.

.

.

.

5 Name and address of the institution competent as regards the granting of family benefits

5.1 Name .

5.2 Address (12): .

.

5.3 File reference number .

E 401

B. Certificate

Part B of this form should be completed by the population registration office or the authority or administration competent in matters of civil status in the country of residence of the members of the family (13).

6 Composition of the family in which the members named in box 4 live.

6.1Surname (1a)ForenamesDate of birth (10)Relationship (11) 1.

.

2.

.

3.

.

4.

.

5.

.

6.

.

7.

.

8.

.

9.

.

10.

6.2 Remarks (14):

.

.

7 Information to be supplied if the form is to be sent to a Danish, Icelandic or Norwegian institution (15)

7.1 Person exercising the parental authority

.

7.2 The maintenance of the children is is not paid

for from public funds

7.3 The mother and/or father of the children are/is are/is not dead (16)

If he/she is, please indicate the date of death .

7.4 The mother and/or father of the children do/does do/does not (16)

receive an old-age or invalidity pension

8 Population registration office or authority or administration competent in matters of civil status (13)

The accuracy of the information given above has been verified from the official documents in our possession by:

8.1 Name and address of the registration office, authority or administration (12) : .

.

8.2 Stamp

8.3 Date .

8.4 Signature

.

E 401

INSTRUCTIONS

Please complete this form in block letters, writing on the dotted lines only. It consists of four pages, none of which may be left out even if it does not contain any relevant information. It should be completed in the language of the authority designated in box 8.

NOTES

- EEA Agreement on the European Economic Area, Annex VI, Social Security: for the purpose of this agreement the present form shall also apply to Austria, Finland, Iceland, Liechtenstein, Norway and Sweden.

(1) Symbol of the country in which the institution completing the form is situated: B = Belgium; DK = Denmark; D = Germany; GR = Greece; E = Spain; F = France; IRL = Ireland; I = Italy; L = Luxembourg; NL = The Netherlands; P = Portugal; GB = United Kingdom; A = Austria; FIN = Finland; IS = Iceland; FL = Liechtenstein; N = Norway; S = Sweden.

(1a) In the case of Spanish nationals state both names at birth.

In the case of Portuguese nationals state all names (forenames, surname, maiden name) in the order of civil status in which they appear on the identity card or passport.

(2) In the case of Portuguese districts, state also the parish and the local authority.

(3) In the case of Spanish nationals state the number appearing on the national identity card (D.N.I.), if it exists, even if the card is out of date. Failing this, indicate 'None'.

(4) Denmark, Liechtenstein and Norway do not differentiate between Pensioner (scheme for employed persons) and Pensioners (scheme for self-employed persons).

(5) For the purpose of Norwegian institutions state date of separation

.

(6) For the purpose of Danish, Icelandic and Norwegian institutions.

(7) This information is based on a statement from the person concerned.

(8) Except if already mentioned in box 1.

(9) Under Portuguese law family allowances are due to the offspring of gainfully employed persons and also of pensioners. Descendants beyond the first degree (e.g. grand-children) qualify for family allowances only if their entitlement is not recognised under social security for either parent.

(10) For the purpose of Danish and Norwegian institutions indicate only children under the age of 18.

(11) Show the relationship of each member of the family to the worker, using the following symbols:

A = legitimate child. In Spain child born in wedlock (matrimonial) and child born out of wedlock (non-matrimonial).

B = legitimized child.

C = adopted child.

D = natural child (if the form is completed for a male worker, the natural children must be mentioned only if the paternity or the worker's obligation to maintain them has been officially recognized).

E = child of a spouse belonging to the worker's household.

F = grandchildren, brothers and sisters whom the person concerned has taken into his household. Also nephews and nieces to the third degree where the competent institution is a Greek institution.

G = other children belonging permanently to the household on the same footing as the worker's children (foster children).

Other relationships (e.g. grandfather) must be written in full. If a child is married, divorced, a widow or a widower, mention this in item 4 and 6.1. Also, if a child has no father or no mother, for the purposes of Greek institutions.

(12) Street, number, post code, town, country.

(13) In Spain, the 'Dirección Provincial del Instituto Nacional de Seguridad Social' (Provincial Directorate of the National Social Security Institute) of the place of residence, or the 'Autoridad Municipal' (Municipal Authority) where appropriate. In case of seamen 'Direccion Provincial del Instituto Social de la Marina' (Provincial Directorate of the Marine's Social Institute);

in France, the 'mairie' (registrar's office) or the 'caisse d'allocations familiales' (fund for family allowances);

in Ireland, Child Benefit Section, Department of Social Welfare, St. Oliver Plunkett Road, Letterkenny, Co. Donegal;

in Portugal, the 'Junta de Freguesia' (Parish Council) of the place of residence of the members of the family;

in the United Kingdom, the Department of Social Security, Benefits Agency, Child Benefit Centre (Washington), PO Box 1, Newcastle-upon-Tyne NE 88 IAA or the Northern Ireland Social Security Agency, Child Benefit Office, Belfast, as appropriate;

in Finland, the Social Insurance Institution, Helsinki;

in Sweden, the 'foersaekringskassan' (social insurance office) at the place of residence.

(14) If the child resides at an address other than that indicated at point 2.5 or 3.6, please indicate the other address. For the purpose of Norwegian institutions please state if the child resides in an orphanage, a special school or another residential institution.

(15) This information is supplied only if the civil administrations have the necessary data at their disposal.

(16) Strike out the alternative that is not relevant.

>END OF GRAPHIC>

>START OF GRAPHIC>

EUROPEAN COMMUNITIES

Social Security Regulations

EEA*

See 'Instructions' on page 3

E 402

(1)

CERTIFICATE OF CONTINUATION OF STUDIES FOR THE PURPOSE OF THE GRANTING OF FAMILY BENEFITS

Reg. 1408/71: Art. 73; Art. 74; Art. 77; Art. 78

Reg. 574/72: Art. 86; Art. 88; Art. 90; Art. 91; Art. 92

A. Request for certificate

To be completed by the institution competent as regards the granting of family benefits. If the form is addressed to a Belgian institution, an 'E 402 Annex' form should be attached

1 Applicant for family benefits

Employed person Pensioner (scheme for employed persons)

Self-employed person Pensioner (scheme for self-employed persons)

Persons other than the aforementioned Orphan

1.1 Surname (1a)

.

1.2 Forenames Previous names (1a) Place of birth (2)

. . .

1.3 Date of birth Sex Nationality D.N.I. (3)

. . . .

1.4 Address (5): .

. 2 Pupil or student

2.1 Surname (1a)

.

2.2 Forenames Previous names (1a)

. .

2.3 Place of birth (2) (4) Date of birth Sex

. . .

2.4 Address (5): .

.

3 Institution competent as regards the granting of family benefits

3.1 Name: .

3.2 Address (5): .

.

3.3 File reference No: .

3.4 Stamp

3.5 Date .

3.6 Signature

.

E 402

B. Certificate

To be completed by the establishment (school, university or establishment of higher education) and sent to the institution named in box 3.

4

4.1 The person named in box 2 has been attending the establishment shown in box 6

since .

4.2 The school year started . (date)

4.3 Type of school (6) .

In case of attendance at a non-public establishment indicate if the state-approved curriculum or a similar curriculum is

followed (7)

4.4 His/Her education in this establishment will probably

last until .

4.5 The number of hours of the course is . a week

These hours are spread over . half days (8)

4.6 Estimate the number of hours required to do

homework . a week (9)5 Information to be provided only for the institutions in France, Luxembourg and the Netherlands

5.1 The person named in box 2 has been attending the establishment shown in box 6 where he has been following education of the following nature:

general education technical or vocational training

higher or university education other (please specify)

5.2 Special cases (please specify):

correspondence course evening courses

courses involving less than 20 hours a week

education of less than one school year, from

. to .

other .

5.3 Amount of college fee (9) .

5.4 Does the person named in box 2 receive a study grant (6)

Yes No

5.4.1 Amount of study grant .

6 School, university or establishment of higher education

6.1 Name: .

6.2 Address (5): .

.

6.3 Stamp:

6.4 Date: .

6.5 Signature:

.

E 402

INSTRUCTIONS

Please complete this form in block letters, writing on the dotted lines only. It should be completed in the language of the establishment named in box 6.

NOTES

- EEA Agreement on the European Economic Area, Annex VI, Social Security: for the purpose of this agreement the present form shall also apply to Austria, Finland, Iceland, Liechtenstein, Norway and Sweden.

(1) Symbol of the country to which the institution completing the form belongs: B = Belgium; DK = Denmark; D = Germany; GR = Greece; E = Spain; F = France; IRL = Ireland; I = Italy; L = Luxembourg; NL = Netherlands; P = Portugal; GB = United Kingdom; A = Austria; FIN = Finland; IS = Iceland; FL = Liechtenstein; N = Norway; S = Sweden.

(1a) In the case of Spanish nationals state both names at birth.

In the case of Portuguese nationals state all names (forenames, surname, maiden name) in the order of civil status in which they appear on the identity card or passport.

(2) In the case of Portuguese districts, state also the parish and the local authority.

(3) In the case of Spanish nationals state the number appearing on the national identity card (D.N.I.), if it exists, even if the card is out of date. Failing this, indicate 'None'.

(4) In the case of Swedish nationals information cannot be provided unless stated necessary.

(5) Street, number, post code, town, country.

(6) Please indicate whether it is a publicly maintained school, 'public school', or State-controlled school. To be completed only if the institution shown in box 3 is an institution in the United Kingdom.

(7) For the purpose of German institutions.

(8) To be completed if the form is to be sent to a Belgian or Finnish institution; the number of half-days is to be indicated in the case of primary and secondary schools.

(9) For the purpose of Netherlands institutions.

>END OF GRAPHIC>

>START OF GRAPHIC>

For instructions and notes see page 3 of an E 402 form

E 402 Annex

(1)

To be completed by the school or the establishment of higher or university education named in box 2 if the claim for family benefits must be submitted to a Belgian institution.

1

1.1 Over how many half-days and how many hours a week are the lessons spread?

half-days . hours .

1.2 The lessons are are not given before 7 p.m.

1.3 The pupil does does not attend lessons regularly

If he/she does not, show the number of days of absence and the reason

.

1.4 The lessons mentioned in 1.1 above

(a) include do not include

hours of practical training outside the establishment, required for obtaining an official diploma.

If they do, show the gross wage or salary paid or gross allowances granted:

.

(b) include do not include

hours of practical lessons which take place in the establishment.

If they do, show the number of hours a week: .

(c) include do not include

hours devoted to study in the establishment.

If they do, show the number of hours a week. .

1.5 Type of education provided

general education technical or vocational training art education

higher non-university education university education

1.6 The student has been preparing has not been preparing

a thesis

If he/she has, indicate

- since when? .

- when must he/she submit the thesis? .

1.7 The study programme

is is not recognized by the State

corresponds to does not correspond to a study programme recognized by the State

1.8 Show the periods of holidays

- Christmas holidays: from . to .

- Easter holidays: from . to .

- Summer holidays: from . to .

2 School, university or establishment of higher education

2.1 Name: .

.

2.2 Address (5): .

.

2.3 Stamp

2.4 Date: .

2.5 Signature

. >END OF GRAPHIC>

>START OF GRAPHIC>

EUROPEAN COMMUNITIES

Social Security Regulation

EEA*

See 'Instructions' page 3

E 403

(1)

CERTIFICATION OF APPRENTICESHIP AND/OR VOCATIONAL TRAINING FOR THE PURPOSE OF THE GRANTING

OF FAMILY BENEFITS

Reg. 1408/71: Art. 73; Art. 74; Art. 77; Art. 78

Reg. 574/72: Art. 86; Art. 88; Art. 90; Art. 91; Art. 92

A. Request for certificate

To be completed by the institution competent as regards the granting of family benefits. If the form is to be sent to a French institution please enclose a form E 403 Annex if the person concerned attends vocational training.

1 Applicant for family benefits

Employed person Pensioner (scheme for employed persons)

Self-employed person Pensioner (scheme for self-employed persons)

Persons other than the aforementioned Orphan

1.1 Surname (1a)

.

1.2 Forenames Previous names (1a) Place of birth (2)

. . .

1.3 Date of birth Sex Nationality D.N.I. (3)

. . . .

1.4 Address in the apprentice's country of residence (4): .

. 2 Apprentice Vocational trainee (5)

2.1 Surname (1a)

.

2.2 Forenames Previous names (1a)

. .

2.3 Place of birth (2) Date of birth Sex

. . .

2.4 Address (4) .

.

3 Institution competent as regards the granting of family benefits

3.1 Name .

3.2 Address (4): .

.

3.3 File reference No .

3.4 Stamp

3.5 Date: .

3.6 Signature

.

E 403

B. Certificate

To be completed by the person, undertaking or institution responsible for the apprenticeship and sent to the body responsible for supervision of the apprenticeship, which must forward the completed form to the institution mentioned in box 3.

4 Information concerning the apprenticeship

4.1 The person named in box 2 has been apprenticed to us

from .

to receive training in the following trade: .

4.2 The apprenticeship is provided . days per week . hours per week

and will last until .

4.3 The apprentice

is receiving

1S an apprenticeship allowance or wage net gross amounting to

1S 1S weekly monthly .

1S other benefits (6) namely

1S 1S accommodation full board part board

1S 1S tips . meals a day other (7)

from . to . amounting to: .

is not receiving

1S an apprenticeship allowance or wage other benefits

4.4 Place of work .

4.5 Name of the person, undertaking or institution responsible for the apprenticeship

.

4.6 Address (4): .

.

4.7 Stamp

4.8 Date .

4.9 Signature

.

5 Endorsement of the body responsible for supervision of the apprenticeship (8)

5.1 Name: .

5.2 Address (4): .

.

5.3 Stamp

5.4 Date .

5.5 Signature

.

E 403

INSTRUCTIONS

Please complete this form in block letters, writing on the dotted lines only. It consists of three pages, none of which may be left out even if it does not contain any relevant information. It should be completed in the language of the institution indicated in box 5.

NOTES

- EEA Agreement on the European Economic Area, Annex VI, Social Security: for the purpose of this agreement the present form shall also apply to Austria, Finland, Iceland, Liechtenstein, Norway and Sweden.

(1) Symbol of the country to which the institution completing part A of the form belongs. B = Belgium; DK = Denmark; D = Germany; GR = Greece, E = Spain; F = France; IRL = Ireland; I = Italy; L = Luxembourg; NL = The Netherlands; P = Portugal; GB = United Kingdom; A = Austria; FI = Finland; IS = Iceland; FL = Liechtenstein; N = Norway; S = Sweden.

(1a) In the case of Spanish nationals state both names at birth.

In the case of Portuguese nationals state all names (forenames, surname, maiden name) in the order of civil status in which they appear on the identity card or passport.

(2) In the case of Portuguese districts, state also the parish and the local authority.

(3) In the case of Spanish nationals state the number appearing on the national identity card (D.N.I.), if it exists, even if the card is out of date. Failing this, indicate 'None'.

(4) Street, number, post code, town, country.

(5) For the French institutions form E 403 Annex should be completed if the person concerned follows practical vocational training.

(6) When the form is being sent to a United Kingdom institution, give details of the amount of these benefits in the box below.

accommodation . other benefits .

full board .

part board .

tips .

meals .

(7) If applicable, give details of these other benefits in the box below.

.

.

.

.

(8) This box should be completed by the following institutions.

in Ireland: Child Benefit Section, Department of Social Welfare, St. Oliver Plunkett Road, Letterkenny, Co. Donegal, in the case of apprenticeships that are not supervised by the industrial training authority (FAS);

in Italy: by the 'Ufficio provinciale del lavoro e della massima occupazione' (Provincial Office of Labour and Employment);

in the United Kingdom: the Department of Social Security, Benefits Agency, Overseas Benefits Directorate, Newcastle-upon-Tyne, or the Northern Ireland Social Security Agency, Child Benefit Office.

(9) In relation to French legislation, in the preliminary training and training for a professional career, aimed at allowing those without professional qualifications and without a work contract to reach a level necessary to follow a formal professional training course or to enter professional employment directly.

(10) Indicate the amount received in the currency of the State in the territory in which the professional training is followed.

(11) Complete if such an organization exists in the territory in which the professional training is followed.

>END OF GRAPHIC>

>START OF GRAPHIC>

See 'Instructions' and 'Notes' on page 3 of form E 403

E 403 Annex

(1)

To be completed if the claim for family benefits must be submitted to a French institution and if it concerns a person undergoing practical vocational training (9)

1 Information concerning the vocational training (9)

1.1 The person named in box 2 of form E 403

has been attending vocational training since .

attended vocational training

from . to .

1.2 Does the person concerned have an employment contract for this training?

Yes No

1.3 Nature of the training provided: .

.

1.4 Total duration of training: . (months, weeks)

1.5 Number of hours of training

theoretical part . per week . per month

practical training . per week . per month

1.6 Does the person concerned receive pay during training? Yes No

If yes, please specify nature: .

Net amount per month (10): .

1.7 Place of training: .

1.8 Name of the person, undertaking or institution responsible for providing training:

.

1.9 Address (4): .

.

1.10 Stamp

1.11 Date: .

1.12 Signature

. 2 Endorsement of the body responsible for supervision of training (11)

2.1 Name: .

.

2.2 Address (4): .

.

2.3 Stamp:

2.4 Date: .

2.5 Signature:

. >END OF GRAPHIC>

>START OF GRAPHIC>

EUROPEAN COMMUNITIES

Social Security Regulations

EEA*

See 'Instructions' on page 3

E 404

(1)

MEDICAL CERTIFICATE FOR THE PURPOSE OF THE GRANTING OF FAMILY BENEFITS

Reg. 1408/71: Art. 73; Art. 74; Art. 77; Art. 78

Reg. 574/72: Art. 86; Art. 88; Art. 90; Art. 91; Art. 92

A. Request for certificate

To be completed by the institution competent as regards the granting of family benefits

1 Applicant for family benefits

Employed person Pensioner (scheme for employed persons)

Self-employed person Pensioner (scheme for self-employed persons)

Person other than the aforementioned Orphan

1.1 Surname (1a)

.

1.2 Forenames Previous names (1a) Place of birth (2)

. . .

1.3 Date of birth Sex Nationality D.N.I. (3)

. . . .

1.4 Address (4): .

. 2 Person to whom the medical certificate relates

2.1 Surname (1a)

.

2.2 Forenames Previous names (1a)

. .

2.3 Place of birth (2) Date of birth Sex

. . .

2.4 Address (4): .

.

3 Institution competent as regards the granting of family benefits

3.1 Name: .

3.2 Address (4): .

.

3.3 File reference No: .

3.4 Stamp

3.5 Date: .

3.6 Signature

.

E 404

B. Certificate

To be completed by the doctor designated by the liaison body (5) in the country of residence of the person examined and to be sent to the institution mentioned in box 3.

4

4.1 (a) The physical or mental faculties of the person examined

have diminished have not diminished.

If they have, indicate percentage of diminution: . %

(b) The person examined is capable of earning his/her living

is incapable of earning his/her living owing to physical

or mental deficiency.

(c) The person examined is is not a housewife.

If she is, indicate whether: she is she is not in a fit condition to look after her home.

(d) Observations:

.

.

.

(e) Description of the condition of the person examined:

.

.

.

4.2 Date of commencement of disability or illness (as precise as possible):

.

4.3 Probable duration: .

4.4 (a) A further examination is necessary is not necessary.

(b) If it is, indicate date of the examination: .

5

5.1 Surname and forenames of the doctor: .

5.2 Address (4): .

.

5.3 Date: .

5.4 Signature

.

E 404

INSTRUCTIONS

Please complete this form in block letters, writing on the dotted lines only. It consists of three pages, none of which may be left out even if it does not contain any relevant information. It should be completed in the language of the doctor issuing the certificate

NOTES

- EEA Agreement on the European Economic Area, Annex VI, Social Security: for the purpose of this agreement the present form shall also apply to Austria, Finland, Iceland, Liechtenstein, Norway and Sweden.

(1) Symbol of the country to which the institution completing part A of the form belongs: B = Belgium; DK = Denmark; D = Germany; GR = Greece; E = Spain; F = France; IRL = Ireland; I = Italy; L = Luxembourg; NL = The Netherlands; P = Portugal; GB = United Kingdom; A = Austria; FIN = Finland; IS = Iceland; FL = Liechtenstein; N = Norway; S = Sweden.

(1a) In the case of Spanish nationals state both names at birth.

In the case of Portuguese nationals state all names (forenames, surname, maiden name) in the order of civil status in which they appear on the identity card or passport.

(2) In the case of Portuguese districts, state also the parish and the local authority.

(3) In the case of Spanish nationals state the number appearing on the national identity card (D.N.I.), if it exists, even if the card is out of date. Failing this, indicate 'None'.

(4) Street, number, post code, town, country.

(5) Or the doctor of the fund designated by the liaison body.

>END OF GRAPHIC>

>START OF GRAPHIC>

EUROPEAN COMMUNITIES

Social Security Regulations

EEA*

See 'Instructions' on page 3

E 405

(1)

CERTIFICATE CONCERNING THE AGGREGATION OF PERIODS OF INSURANCE, EMPLOYMENT OR SELF-EMPLOYMENT OR CONCERNING SUCCESSIVE EMPLOYMENT IN SEVERAL MEMBER STATES, BETWEEN THE DATES ON WHICH PAYMENT IS DUE ACCORDING TO THE LEGISLATION OF THESE STATES

Reg. 1408/71: Art. 12; Art. 72

Reg. 574/72: Art. 10a; Art. 85.2 and 3

This certificate should be issued to the insured person at his request. Where necessary, the competent institution should request it from the institution with which the insured person was last registered.

A. To be completed by the institution competent as regards the granting of family benefits with which the insured person is registered.

1 Employed person Self-employed person Unemployed person

1.1 Surname (1a)

.

1.2 Forenames Previous names (1a) Place of birth (2)

. . .

1.3 Date of birth Sex Nationality D.N.I (3)

. . . .

1.4 Civil status single married widow/widower

divorced separated cohabiting (4) (5)

1.5 Address (6): .

. 2 Person who should receive the family benefits

2.1 Surname (1a)

.

2.2 Forenames Previous names (1a) Place of birth (2)

. . .

2.3 Date of birth Sex Nationality D.N.I. (3)

. . . .

2.4 Address (6): .

. 3 Period for which the information is requested

3.1 From . to .

3.2 Name and address of employer (7): .

3.3 Nature of self-employment (7): . 4 Institution with which the insured person was last registrered as an employed or self-employed person

4.1 Name: .

4.2 Address (6): .

.

5 Institution of the place of residence of the members of the family

5.1 Name: .

5.2 Address (6): .

. E 405

6 Institution with which the insured person is currently registered

6.1 Name: .

6.2 Address (6): .

.

6.3 File reference No . 6.4 Stamp

6.5 Date .

6.6 Signature

.

B. To be completed by the institution competent as regards the granting of family benefits with which the person was previously registered.

7

7.1 We certify that the insured person named in box 1

was insured from . to . (8) .

7.2 in (9) .

7.3 He is entitled He is not entitled to family benefits

7.4 Family benefits were paid to him from . to .

7.5 Family members for whom the family benefits were paid

7.5.1 Surname Forenames Date of birth monthly amount

. . . .

. . . .

. . . .

. . . .

7.5.2 Are the amounts adjusted? .

.

8 Institution with which the insured person was last registered either as an employed or self-employed person

8.1 Name: .

8.2 Address (6): .

.

.

8.3 Stamp

8.4 Date: .

8.5 Signature

.

9 Remarks: .

.

E 405

INSTRUCTIONS

Please complete this form in block letters, writing on the dotted lines only. It consists of three pages, none of which may be left out even if it does not contain any relevant information

NOTES

- EEA Agreement on the European Economic Area, Annex VI, Social Security: for the purpose of this agreement the present form shall also apply to Austria, Finland, Iceland, Liechtenstein, Norway and Sweden.

(1) Symbol of the country to which the institution completing part A of the form belongs: B = Belgium; DK = Denmark; D = Germany; GR = Greece; E = Spain; F = France; IRL = Ireland; I = Italy; L = Luxembourg; NL = The Netherlands; P = Portugal; GB = United Kingdom; A = Austria; FIN = Finland; IS = Iceland; FL = Liechtenstein; N = Norway; S = Sweden.

(1a) In the case of Spanish nationals state both names at birth.

In the case of Portuguese nationals state all names (forenames, surname, maiden name) in the order of civil status in which they appear on the identity card or passport.

(2) In the case of Portuguese districts, state also the parish and the local authority.

(3) In the case of Spanish nationals state the number appearing on the national identity card (D.N.I.), if it exists, even if the card is out of date. Failing this, indicate 'None'.

(4) For the purpose of Danish, Icelandic and Norwegian institutions.

(5) This information is based on a statement from the person concerned.

(6) Street, number, post code, town, country.

(7) For the period preceding the worker's transfer to the Member State to whose legislation he is currently subject

(8) (a) For Greek institutions, state the number of days completed in the calendar year preceding the year in which the family benefits or family allowances are applied for.

(b) For Belgian institutions, state below the number of days as an employed or self-employed person:

number of days as an employed person: .

number of days as a self-employed person: .

(c) For French institutions, state below the number of days and hours of employment and the gross wage/salary received

No of days

in employment

No of hours

in employment

Gross wage/

salary received

During the last

month

During the last three

months

During the last six

months

(9) Country in which the employment in question was pursued.

>END OF GRAPHIC>

>START OF GRAPHIC>

EUROPEAN COMMUNITIES

Social Security Regulations

EEA*

See 'Instructions' overleaf

E 406

F

(1)

CERTIFICATE OF POST-NATAL MEDICAL EXAMINATIONS

Reg. 1408/71: Art. 73; Art. 74

Reg. 574/72: Art. 86; Art. 88

Information for the insured person

In order to qualify for French family benefits in accordance with Article 73 or 74, the child must undergo post-natal medical examinations, one examination during the ninth or 10th month from birth and the other during the 24th or 25th month. Failure to comply with this obligation and these deadlines will lead to loss of part of the entitlement.

A. Request for certificate

To be completed by the institution responsible for the granting of family benefits.

1 Employed person Self-employed person

1.1 Surname (1a):

.

1.2 Forenames: Previous names (1a): Place of birth (1b):

. . .

1.3 Date of birth: Sex: Nationality: D.N.I. (1c):

. . . .

1.4 Address (2): .

.

2 Child for whom the certificate is requested

2.1 Surname (1a):

.

2.2 Forenames:

.

2.3 Place of birth (1b) Date of birth: Sex:

. . .

2.4 Address (2): .

.

3 Institution responsible for the granting of family benefits

3.1 Name: .

3.2 Address (2): .

.

3.3 File reference No: .

3.4 Stamp:

3.5 Date: .

3.6 Signature:

.

E 406

F

B. Certificate

To be completed by the doctor treating the child or by the doctor chosen by the person looking after the child

4

4.1 The child named in box 2 above underwent on: .

4.2 a medical examination during the ninth or 10th month from birth

4.3 a medical examination during the 24th or 25th month

5

5.1 Doctor's surname and forename: .

5.2 Address (2): .

.

5.3 Date: .

5.4 Signature:

.

INSTRUCTIONS

Please complete this form in block letters, writing on the dotted lines only

Notes

- EEA Agreement on the European Economic Area, Annex VI, Social Security: for the purpose of this agreement the present form shall also apply to Austria, Finland, Iceland, Liechtenstein, Norway and Sweden.

(1) Symbol of the country to whose legislation the worker is subject: F = France.

(1a) In the case of Spanish nationals state both names at birth.

In the case of Portuguese nationals state all names (forenames, surname, maiden name) in the order of civil status in which they appear on the identity card or passport.

(1b) In the case of Portuguese districts, state also the parish and the local authority.

(1c) In the case of Spanish nationals state the number appearing on the national identity card (D.N.I.), if it exists, even if the card is out of date. Failing this, indicate 'None'.

(2) Street, number, post code, town, country.

>END OF GRAPHIC>

>START OF GRAPHIC>

EUROPEAN COMMUNITIES

Social Security Regulations

EEA*

See 'Instructions' on page 3

E 407

(1)

MEDICAL CERTIFICATE FOR THE GRANT OF A SPECIAL FAMILY ALLOWANCE OR OF INCREASED FAMILY ALLOWANCES FOR HANDICAPPED CHILDREN

Reg. 1408/71: Art. 73; Art. 74

Reg. 574/72: Art. 86; Art. 88

A. Request for certificate

To be completed by the institution responsible for the granting of family benefits

1 Employed person Self-employed person

1.1 Surname (1a)

.

1.2 Forenames: Previous names (1a) Place of birth (1b):

. . .

1.3 Date of birth: Sex: Nationality: D.N.I. (1c)

. . . .

1.4 Address (2): .

.

2 Child for whom the certificate is requested

2.1 Surname (1a)

.

2.2 Forenames:

.

2.3 Place of birth (1b): Date of birth: Sex:

. . .

2.4 Address (2): .

.

3 Institution responsible for the granting of family benefits

3.1 Name: .

3.2 Address (2): .

.

3.3 File reference No: .

3.4 Stamp:

3.5 Date: .

3.6 Signature:

.

E 407

B. Certificate

The doctor designated by the institution of the place of residence of the examined child should complete this page and the next page and send it to the institution mentioned in box 3 above, enclosing all recent supporting medical documents (photographs, X-rays, results of medical examinations, etc.).

4

4.1 Child's age on date of examination: . years . months

Child's weight: . kilograms . grams height: . centimetres.

4.2 Psychomotor retardation

Retardation taking account of normal level for the child's age: Yes No

If yes, please specify: .

4.3 Independence

Can the child sit up unaided Yes No Can he/she walk? Yes No

Can he/she talk? Yes No Can he/she dress unaided? Yes No

Can he/she eat unaided? Yes No Does he/she write Yes No (3)

Is he/she incontinent? Yes No (3)

4.4 Assistance

Does the child's condition necessitate attendance by another person? Yes No

Constant attendance? Yes No Daily attendance though not continous? Yes No

or other measures (please specify): .

4.5 Nature of the principal disability

Is the child's disability

sensory? visual? .

auditory? .

motor: .

mental: mental level .

behaviour .

other .

4.6 Origin of disability (3)

- congenital anomaly . Yes No

- disease . Yes No

date of onset of disability .

- accident . Yes No

date of accident .

4.7 Associated disabilities

Which ones? . Other deficiencies .

4.8 Additional observations

Disabilities in the family: .

Supplementary examinations already carried out: .

(Copies of reports of examinations should be enclosed, where appropriate)

4.9 Treatment, including rehabilitation and remedial therapy. What forms of treatment are being provided?

.

Since when? .

What forms of treatment are recommended? .

4.10 Educational and training measures

What forms of education and training are being provided? .

.

Since when? .

What education and training is recommended? .

4.11 Prognosis

Please specify: .

.

E 407

5

5.1 Doctor's surname and forenames: .

5.2 Address (2): .

.

5.3 Date: .

5.4 Signature:

.

INSTRUCTIONS

Please complete this form in block letters, writing on the dotted lines only. It consists of three pages, none of which may be left out even if it does not contain any relevant information. It should be completed in the language of the doctor issuing the certificate.

NOTES

- EEA Agreement on the European Economic Area, Annex VI, Social Security: for the purpose of this agreement the present form shall also apply to Austria, Finland, Iceland, Liechtenstein, Norway and Sweden.

(1) Symbol of the country to which the institution completing part A of the form belongs: B = Belgium; DK = Denmark; D = Germany; GR = Greece; E = Spain; F = France; IRL = Ireland, I = Italy: L = Luxembourg; NL = The Netherlands; P = Portugal; GB = United Kingdom; A = Austria; FIN = Finland; IS = Iceland; FL = Liechtenstein; N = Norway; S = Sweden.

(1a) In the case of Spanish nationals both names at birth.

In the case of Portuguese nationals state all names (forenames, surname, maiden name) in the order of civil status in which they appear on the identiy card or passport.

(1b) In the case of Portuguese districts, state also the parish and the local authority.

(1c) In the case of Spanish nationals state the number appearing on the national identiy card (D.N.I.), if it exists, even if the card is out of date. Failing this, indicate 'None'.

(2) Street, number, post code, town, country.

(3) Need only to be filled in if a Belgian institution is responsible for the granting of family benefits.

>END OF GRAPHIC>

>START OF GRAPHIC>

EUROPEAN COMMUNITIES

Social Security Regulations

EEA*

See 'Instructions' on page 3

E 411

(1)

REQUEST FOR INFORMATION ON ENTITLEMENT TO FAMILY BENEFITS IN THE MEMBER STATES OF RESIDENCE OF THE MEMBERS OF THE FAMILY

Reg. 1408/71: Art. 76

Reg. 574/72: Art. 10

A. Request for certificate

The competent institution responsible for the payment of family benefits in the Member State in which the employed or self-employed person works, which wishes to know whether entitlement to family benefits exists in the Member State of residence of the members of the family, should complete two copies of Part A and send them to the institution of the place of residence of the members of the family.

1 Employed person Self-employed person

1.1 Surname (1a)

.

1.2 Forename(s) Previous names (1a) Place of birth (2)

. . .

1.3 Date of birth Sex Nationality DNI (3)

. . . .

1.4 Address (4):

.

.

2 Spouse (former spouse) or other persons whose entitlement to family benefits in the country of residence of the members of the family must be verified

2.1 Surname (1a)

.

2.2 Forename(s) Previous names (1a) Date of birth

. . .

2.3 Address (4): .

.

2.4 Relationship to the members of the family mentioned in box 3

.

2.5 Period for which the information is requested .

3 Members of the family (6)

Surname (1a) Forename(s) Date of birth Relationship (5) Actual place of

residence (7)

3.1 . . . . .

. . . . .

. . . . .

3.2 . . . . .

. . . . .

. . . . .

3.3 . . . . .

. . . . .

. . . . .

4 Information concerning the occupation pursued received in the country of residence of the members of the family

4.1 Employer: .

4.2 Address (4) .

.

4.3 Self-employment: .

4.4 Activity treated as an occupation as defined by Decision No 119

. E 411

5 Competent institution

5.1 Name: .

5.2 Address (4): .

. .

5.3 File reference number (8): .

5.4 Stamp

5.5 Date .

5.6 Signature

. B. Certificate

To be completed by the competent institution in the place of residence of the members of the family or by the employer of the person named in box 2 (9)

6 Certificate issued by the competent institution responsible for the payment of family benefits in the place of residence of the members of the family or by the employer

6.1 During the period from . to . the person named in box 2

pursued an occupation (or an activity treated as such as defined in

Decision No 119) from . to .

did not pursue an occupation (or an activity treated as such as defined

in Decision No 119) from . to .

6.2 For the period from . to . the person named in box 2

is entitled to family benefits for the members of the family

total amount of family benefits: .

is not entitled to family benefits for the following reasons:

.

has not submitted a claim (10)

.

7 Information concerning the family benefits referred to in box 6 per family members (11)

Surname Forename(s) Date of birth Relationship Place of Amount (12)

residence

. . . . . .

. . . . . .

. . . . . .

. . . . . .

. . . . . .

. . . . . .

. . . . . .

. . . . . .

8 Employer of the person named in box 2 (9)

8.1 Name of employer (if a company, the corporate name) .

8.2 Address (4): .

.

8.3 Stamp

8.4 Date: .

8.5 Signature

. 9 Institution of the place of residence of the members of the family (13)

9.1 Name: .

9.2 Address (4): .

.

9.3 File reference number .

9.4 Stamp

9.5 Date: .

9.6 Signature

. E 411

INSTRUCTIONS

Please complete this form in block letters, writing on the dotted lines only. It consists of three pages, none of which may be left out even if it does not contain any relevant information.

NOTES

- EEA Agreement on the European Economic Area, Annex VI, Social Security: for the purpose of this agreement the present form shall also apply to Austria, Finland, Iceland, Liechtenstein, Norway and Sweden.

(1) Symbol of the country to which the institution completing the form belongs: B = Belgium; DK = Denmark; D = Germany; GR = Greece; E = Spain; F = France; IRL = Ireland; I = Italy; L = Luxembourg; NL = The Netherlands; P = Portugal; GB = United Kingdom; A = Austria; FIN = Finland; IS = Iceland; FL = Liechtenstein; N = Norway; S = Sweden.

(1a) In the case of Spanish nationals state both names at birth.

In the case of Portuguese nationals state all names (forenames, surname, maiden name) in the order of civil status in which they appear on the identity card or passport.

(2) In the case of Portuguese districts, state also the parish and the local authority.

(3) In the case of Spanish nationals state the number appearing on the national identity card (D.N.I.), if it exists, even if the card is out of date. Failing this, indicate 'None'.

(4) Street, number, post code, town, country.

(5) Show the relationship of each member of the family to the worker, using the following symbols:

A = legitimate child. In Spain child born in wedlock (matrimonial) and child born out of wedlock (non-matrimonial)

B = legitimized child

C = adopted child

D = natural child (if the form is completed for a male worker, the natural children must be mentioned only if the paternity or the worker's obligation to maintain them has been officially recognized)

E = child of a spouse belonging to the worker's household

F = grandchildren, brothers and sisters whom the person concerned has taken into his household. Also, nephews and nieces to the third degree where the competent institution is a Greek institution

G = other children belonging permanently to the household on the same footing as the worker's children (foster children).

Other relationships (e.g. grandfather) must be written in full.

(6) For the purpose of Norwegian institutions state only children under the age of 16.

(7) If the member of the family resides at an address other than that indicated at 2.3, please indicate here.

For the purpose of Norwegian institutions please state if the child resides in an orphanage, a special school or another residential institution.

Surname and forenames .

.

Address (4) .

.

(8) For use by the sending institution.

(9) The certificate should be completed by the employer only if he has to pay the family benefits of the country of residence.

(10) In this case the institution of the place of residence should indicate the amount of family benefits that would have been granted if a claim had been submitted. If it does not have sufficient information to do so it should indicate in box 7 the tariffs provided for by its legislation for each member of the family.

(11) For Norwegian family benefits only total amount will be given.

(12) Where appropriate, indicate the tariffs referred to in footnote (10).

(13) To be completed by the institution of the place of residence of the members of the family or, failing this, by the liaison body.

>END OF GRAPHIC>

(1) Decision confirmed for Austria, Finland and Sweden by Decision No 157 of 1 July 1995 of the Administrative Commission of the European Communities.