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DECISION NO 120 OF 7 JULY 1982 ON THE MODEL FORMS NECESSARY FOR THE APPLICATION OF COUNCIL REGULATIONS ( EEC ) NO 1408/71 AND ( EEC ) NO 574/72 ( E 001 ; E 101 - 127 ; E 201 - 215 ; E 301 - 303 ; E 401 - 411 ) ( 83/311/EEC )

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 UNDER WHICH IT IS THE DUTY OF THE ADMINISTRATIVE COMMISSION TO DEAL WITH ALL ADMINISTRATIVE QUESTIONS 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 APPLICATION OF THE REGULATIONS ,

HAVING REGARD TO DECISION NO 112 OF 28 FEBRUARY 1980 LAYING DOWN AND AMENDING THE MODEL FORMS NECESSARY FOR THE APPLICATION OF COUNCIL REGULATIONS ( EEC ) NO 1408/71 AND ( EEC ) NO 574/72 ,

WHEREAS THESE MODEL FORMS SHOULD BE ADAPTED WITH A VIEW TO THEIR UTILIZATION IN THE COMMUNITY AS ENLARGED THROUGH THE ACCESSION OF GREECE ;

WHEREAS THESE MODEL FORMS SHOULD BE ADAPTED FOR THE PURPOSE OF TAKING ACCOUNT OF THE APPLICATION OF THE SAID REGULATIONS CONCERNING SELF-EMPLOYED PERSONS AND MEMBERS OF THEIR FAMILIES , WITH EFFECT FROM 1 JULY 1982 ;

WHEREAS , FURTHERMORE , ACCOUNT SHOULD BE TAKEN OF THE AMENDMENTS RESULTING FROM THE SETTING UP OF AN ITALIAN NATIONAL HEALTH SCHEME ;

WHEREAS THE NECESSARY AMENDMENTS HAVE ALREADY BEEN MADE TO THE MODEL FORM E 111 IN ACCORDANCE WITH DECISION NO 114 OF 7 JULY 1982 ;

WHEREAS THE LANGUAGE IN WHICH FORMS SHOULD BE ISSUED HAS BEEN SETTLED BY RECOMMENDATION NO 15 OF THE ADMINISTRATIVE COMMISSION ,

HAS DECIDED AS FOLLOWS :

1 . THE MODEL FORMS PRINTED IN DECISIONS NO 112 AND NO 114 SHALL BE REPLACED BY THE MODELS APPENDED HERETO .

2 . EACH FORM WILL 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 ( PERSONS ENTITLED TO CLAIM , INSTITUTION , EMPLOYER , ETC . ) TO RECEIVE THE FORM PRINTED IN THEIR OWN LANGUAGE .

3 . THIS DECISION SHALL APPLY FROM THE FIRST DAY OF THE MONTH FOLLOWING ITS PUBLICATION IN THE OFFICIAL JOURNAL OF THE EUROPEAN COMMUNITIES , ALTHOUGH THE MODEL FORMS PRINTED IN DECISION NO 112 MAY BE USED UNTIL STOCKS ARE EXHAUSTED .

THE CHAIRMAN OF THE ADMINISTRATIVE COMMISSION

A . TRIER

LIST OF FORMS

E 001 - REQUEST FOR INFORMATION , COMMUNICATION OF INFORMATION , REQUEST FOR FORMS , REMINDER , ON AN EMPLOYED PERSON , A SELF-EMPLOYED PERSON , A FRONTIER WORKER , A PENSIONER , AN UNEMPLOYED PERSON , A DEPENDANT

E 101 - CERTIFICATE CONCERNING THE APPLICABLE LEGISLATION

E 102 - EXTENSION OF TERM OF POSTING OR OF ACTIVITY AS A SELF-EMPLOYED PERSON

E 103 - EXERCISING THE RIGHT OF OPTION

E 104 - CERTIFICATE CONCERNING THE AGGREGATION OF PERIODS OF INSURANCE , EMPLOYMENT OR RESIDENCE

E 105 - CERTIFICATE CONCERNING THE MEMBERS OF THE FAMILY OF AN EMPLOYED PERSON OR SELF-EMPLOYED PERSON TO BE TAKEN INTO CONSIDERATION FOR THE CALCULATION OF CASH BENEFITS IN THE CASE OF INCAPACITY FOR WORK

E 106 - CERTIFICATE OF ENTITLEMENT TO SICKNESS AND MATERNITY INSURANCE BENEFITS IN KIND FOR PERSONS RESIDING IN A COUNTRY OTHER THAN THE COMPETENT COUNTRY

E 107 - APPLICATION FOR A CERTIFICATE OF ENTITLEMENT TO BENEFITS IN KIND

E 108 - NOTIFICATION OF SUSPENSION OR WITHDRAWAL OF THE RIGHT TO SICKNESS AND MATERNITY INSURANCE BENEFITS IN KIND

E 109 - CERTIFICATE FOR THE REGISTRATION OF MEMBERS OF THE EMPLOYED OR SELF-EMPLOYED PERSON'S FAMILY AND THE UPDATING OF LISTS

E 110 - CERTIFICATE CONCERNING EMPLOYED PERSONS IN INTERNATIONAL TRANSPORT

E 111 - CERTIFICATE OF ENTITLEMENT TO BENEFITS IN KIND DURING A STAY IN A MEMBER STATE

E 112 - CERTIFICATE CONCERNING THE RETENTION OF THE RIGHT TO SICKNESS OR MATERNITY BENEFITS CURRENTLY BEING PROVIDED

E 113 - HOSPITALIZATION : NOTIFICATION OF ENTERING AND LEAVING HOSPITAL

E 114 - GRANTING OF MAJOR BENEFITS IN KIND

E 115 - CLAIM FOR CASH BENEFITS FOR INCAPACITY FOR WORK

E 116 - MEDICAL REPORT RELATING TO INCAPACITY FOR WORK ( SICKNESS , MATERNITY , ACCIDENT AT WORK , OCCUPATIONAL DISEASE )

E 117 - GRANTING OF CASH BENEFITS IN THE CASE OF INCAPACITY FOR WORK

E 118 - NOTIFICATION OF NON-RECOGNITION OR OF END OF INCAPACITY FOR WORK

E 119 - CERTIFICATE CONCERNING THE ENTITLEMENT OF UNEMPLOYED PERSONS AND THE MEMBERS OF THEIR FAMILY TO SICKNESS AND MATERNITY INSURANCE BENEFITS

E 120 - CERTIFICATE OF ENTITLEMENT TO BENEFITS IN KIND FOR PENSION CLAIMANTS AND MEMBERS OF THEIR FAMILY

E 121 - CERTIFICATE FOR THE REGISTRATION OF PENSIONERS AND THE UPDATING OF LISTS

E 122 - CERTIFICATE FOR THE GRANTING OF BENEFITS IN KIND TO MEMBERS OF THE FAMILY OF PENSIONERS

E 123 - CERTIFICATE OF ENTITLEMENT TO BENEFITS IN KIND UNDER INSURANCE AGAINST ACCIDENTS AT WORK AND OCCUPATIONAL DISEASES

E 124 - CLAIM FOR DEATH GRANT

E 125 - INDIVIDUAL RECORD OF ACTUAL EXPENDITURE

E 126 - RATES FOR REFUND OF BENEFITS IN KIND

E 127 - INDIVIDUAL RECORD OF MONTHLY LUMP-SUM PAYMENTS

E 201 - CERTIFICATE CONCERNING THE AGGREGATION OF PERIODS OF INSURANCE OR PERIODS OF RESIDENCE

E 202 - INVESTIGATION OF A CLAIM FOR AN OLD-AGE PENSION

E 203 - INVESTIGATION OF A CLAIM FOR A SURVIVOR'S PENSION

E 204 - INVESTIGATION OF A CLAIM FOR AN INVALIDITY PENSION

E 205 - CERTIFICATE CONCERNING INSURANCE HISTORY IN BELGIUM

- CERTIFICATE CONCERNING PERIODS OF INSURANCE AND PERIODS OF RESIDENCE IN DENMARK

- CERTIFICATE CONCERNING INSURANCE HISTORY IN GERMANY

- CERTIFICATE CONCERNING INSURANCE HISTORY IN GREECE

- CERTIFICATE CONCERNING INSURANCE HISTORY IN FRANCE

- CERTIFICATE CONCERNING INSURANCE HISTORY IN IRELAND

- CERTIFICATE CONCERNING INSURANCE HISTORY IN ITALY

- CERTIFICATE CONCERNING INSURANCE HISTORY IN LUXEMBOURG

- CERTIFICATE CONCERNING INSURANCE HISTORY IN THE NETHERLANDS

- CERTIFICATE CONCERNING INSURANCE HISTORY IN THE UNITED KINGDOM

E 206 - CERTIFICATE CONCERNING PERIODS OF EMPLOYMENT IN MINES AND SIMILAR UNDERTAKINGS

E 207 - INFORMATION CONCERNING THE INSURED PERSON'S INSURANCE HISTORY

E 208 - DETERMINATION OF ENTITLEMENT TO PENSION

E 209 - DETERMINATION OF PENSION AMOUNTS REGARDING THE POSSIBLE APPLICATION OF ART . 46.3 OF REG . 1408/71

E 210 - NOTIFICATION OF DECISION CONCERNING A CLAIM FOR PENSION

E 211 - SUMMARY OF DECISIONS

E 212 - APPEALS AND PERIODS ALLOWED FOR APPEALS

E 213 - DETAILED MEDICAL REPORT

E 214 - MEDICAL REPORT CONCERNING ASSESSMENT OF FUNCTIONAL ABILITIES AND LIMITATIONS

E 215 - ADMINISTRATIVE REPORT ON THE POSITION OF A PENSIONER

E 301 - CERTIFICATE CONCERNING THE PERIODS TO BE TAKEN INTO ACCOUNT FOR THE GRANTING OF UNEMPLOYMENT BENEFITS

E 302 - CERTIFICATE RELATING TO MEMBERS OF THE FAMILY OF AN UNEMPLOYED PERSON WHO MUST BE TAKEN INTO ACCOUNT FOR THE CALCULATION OF BENEFITS

E 303 - CERTIFICATE CONCERNING RETENTION OF THE RIGHT TO UNEMPLOYMENT BENEFITS

E 401 - CERTIFICATE CONCERNING THE COMPOSITION OF A FAMILY FOR THE PURPOSE OF THE GRANTING OF FAMILY BENEFITS

E 402 - CERTIFICATE OF CONTINUATION OF STUDIES FOR THE PURPOSE OF THE GRANTING OF FAMILY BENEFITS

E 403 - CERTIFICATE OF APPRENTICESHIP FOR THE PURPOSE OF THE GRANTING OF FAMILY BENEFITS

E 404 - MEDICAL CERTIFICATE FOR THE PURPOSE OF THE GRANTING OF FAMILY BENEFITS

E 405 - PAYMENT OF FAMILY BENEFITS OR FAMILY ALLOWANCES IN THE CASE OF SUCCESSIVE EMPLOYMENT IN SEVERAL MEMBER STATES , BETWEEN THE DATES ON WHICH PAYMENT IS DUE ACCORDING TO THE LEGISLATION OF THESE STATES

E 406 - CLAIM FOR FAMILY ALLOWANCES TO BE SUBMITTED BY AN EMPLOYED PERSON WHO IS SUBJECT TO FRENCH LEGISLATION AND WHOSE FAMILY RESIDES IN A MEMBER STATE OTHER THAN FRANCE

E 407 - CERTIFICATE OF PERIODS OF EMPLOYMENT IN FRANCE , OR PERIODS OF UNEMPLOYMENT IN FRANCE FOR WHICH BENEFITS WERE PAID , FOR THE PURPOSE OF GRANTING FAMILY ALLOWANCES TO MEMBERS OF THE FAMILY OF AN EMPLOYED PERSON OR AN UNEMPLOYED PERSON WHO WAS FORMERLY EMPLOYED WHO RESIDES IN A MEMBER STATE OTHER THAN FRANCE

E 408 - REQUEST FOR INFORMATION

E 409 - VERIFICATION OF THE DECLARATION OF LACK OF ENTITLEMENT TO FAMILY ALLOWANCES BY VIRTUE OF AN OCCUPATION PURSUED IN THE COUNTRY OF RESIDENCE OF THE FAMILY

E 410 - NOTIFICATION OF CANCELLATION OF ENTITLEMENT TO FAMILY ALLOWANCES

E 411 - REQUEST FOR INFORMATION ON ENTITLEMENT TO FAMILY BENEFITS ( FAMILY ALLOWANCES ) IN THE MEMBER STATE OF RESIDENCE OF THE MEMBERS OF THE FAMILY