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DECISION N112

OF 28 FEBRUARY 1980

ON THE MODEL FORMS NECESSARY FOR THE APPLICATION OF COUNCIL REGULATIONS ( EEC ) N 1408/71 AND ( EEC ) N 574/72 ( E 001 ; E 101 _ 127 ; E 201 _ 215 ; E 301 _ 303 ; E 401 _ 411 )

( 80/1011/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 ON THE APPLICATION OF SOCIAL SECURITY SCHEMES TO EMPLOYED PERSONS AND THEIR FAMILIES MOVING WITHIN THE COMMUNITY , UNDER WHICH IT IS THE DUTY OF THE ADMINISTRATIVE COMMISSION TO DEAL WITH ALL ADMINISTRATIVE QUESTIONS ARISING FROM REGULATION ( EEC ) N 1408/71 AND SUBSEQUENT REGULATIONS ,

HAVING REGARD TO ARTICLE 2 ( 1 ) OF COUNCIL REGULATION ( EEC ) N 574/72 OF 21 MARCH 1972 FIXING THE PROCEDURE FOR IMPLEMENTING REGULATION ( EEC ) N 1408/71 , 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 DECISIONS N 72 , N 88 , N 107 AND N 108 LAYING DOWN AND AMENDING THE MODEL FORMS NECESSARY FOR THE APPLICATION OF COUCNIL REGULATIONS ( EEC ) N 1408 / 71 AND ( EEC ) N 574 / 72 ,

WHEREAS VARIOUS AMENDMENTS HAVE ALREADY BEEN ADOPTED AND OTHERS ARE NECESSARY IN ORDER TO SIMPLIFY THE LAYOUT AND UTILIZATION OF THE FORMS , STANDARDIZE COMMON ELEMENTS AND ECONOMIZE ON THE COMPILATION OF THE FORMS AND ON INVENTORY CONTROL ;

WHEREAS IT IS DESIRABLE TO CREATE THREE NEW FORMS AND TO REPUBLISH THE MODEL FORMS ,

HAS DECIDED AS FOLLOWS :

1 . THE MODEL FORMS PRINTED IN DECISIONS N 88 , N 107 AND N 108 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 . THE DETERMINATION OF THE LANGUAGE IN WHICH FORMS SHOULD BE ISSUED SHALL BE SETTLED BY A RECOMMENDATION OF THE ADMINISTRATIVE COMMISSION .

4 . 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 DECISIONS NO 88 , NO 107 AND NO 108 MAY BE USED UNTIL STOCKS ARE EXHAUSTED .

THE CHAIRMAN OF THE ADMINISTRATIVE COMMISSION

S . BOVA

LIST OF FORMS

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

E 101 _ CERTIFICATE CONCERNING THE APPLICABLE LEGISLATION

E 102 _ EXTENSION OF TERM OF POSTING

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 WORKERS'S FAMILY 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 WORKER'S FAMILY AND THE UPDATING OF LISTS

E 110 _ CERTIFICATE CONCERNING WORKERS 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 _ GRANT OF PROSTHESES , MAJOR APPLIANCES , ETC .

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 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 WORKER'S INSURANCE HISTORY

E 208 _ DETERMINATION OF RIGHTS TO PENSION

E 209 _ DETERMINATION OF PENSION AMOUNTS FOR

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 A WORKER 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 A WORKER OR UNEMPLOYED PERSON WHO RESIDE 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