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)
Date: 1994-07-06
Institutions: Administrative Commission on Social Security for Migrant Workers, European Commission
Subjects: Community migration, European integration, family benefit, form, self-employment, wage earner













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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 155of 6 July 1994on 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 Chairmanof the Adminstrative CommissionArno BOKELOH>START OF  GRAPHIC>EUROPEAN COMMUNITIESSocial Security RegulationsEEA*See 'Instructions' on page 4E  401(1)CERTIFICATE CONCERNING THE COMPOSITION OF THE FAMILY FOR THE PURPOSE OF THE GRANTING FAMILY  BENEFITSReg. 1408/71: Art. 73; Art. 74; Art. 77; Art. 78Reg. 574/72: Art. 86.2; Art. 88; Art.  90; Art. 91; Art. 92A. Request for certificate1   Employed person   Pensioner (scheme for  employed persons) (4)  Self-employed person   Pensioner (scheme for self-employed persons) (4)   Person supporting the orphan   Orphan1.1 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 pensioner1S    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   No2.5 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   No3.6 Address: Street . No . Post code . Town . Country . E 4014 Family members for whom the family benefits are claimed, living with the person named  either in box 2 or in box 3SurnameForenamesDate of birth (10)Relationship (11)Place  ofresidence. . . . . . . . . . . . . . . . . . 5 Name and address of the institution competent as regards the granting of family benefits5.1  Name . 5.2 Address (12): . . 5.3 File reference number . E 401B. CertificatePart 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 paidfor from public funds7.3 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 pension8 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 Stamp8.3 Date . 8.4 Signature. E 401INSTRUCTIONSPlease 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 COMMUNITIESSocial Security RegulationsEEA*See  'Instructions' on page 3E 402(1)CERTIFICATE OF CONTINUATION OF STUDIES FOR THE PURPOSE OF THE  GRANTING OF FAMILY BENEFITSReg. 1408/71: Art. 73; Art. 74; Art. 77; Art. 78Reg. 574/72: Art. 86;  Art. 88; Art. 90; Art. 91; Art. 92A. Request for certificateTo 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 attached1 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   Orphan1.1 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 student2.1 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 benefits3.1 Name: . 3.2 Address (5): . . 3.3 File reference No: . 3.4 Stamp3.5 Date . 3.6 Signature. E 402B. CertificateTo 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 6since . 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 isfollowed (7)4.4 His/Her education in this establishment will probablylast  until . 4.5 The number of hours of the course is . a weekThese hours are spread over . half days (8)4.6  Estimate the number of hours required to dohomework . a week (9)5 Information to be provided only  for the institutions in France, Luxembourg and the Netherlands5.1 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   No5.4.1 Amount of study grant  . 6 School, university or establishment of higher education6.1 Name: . 6.2 Address (5): . . 6.3 Stamp: 6.4 Date: . 6.5 Signature: . E 402INSTRUCTIONSPlease 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 formE 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 regularlyIf 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 includehours 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 includehours of practical lessons which take place in the establishment. If they do, show the number of hours a week: . (c)   include   do not includehours 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 education1.6 The student   has been  preparing   has not been preparinga thesisIf 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 State1.8 Show the periods of holidays-  Christmas holidays: from . to . - Easter holidays: from . to . - Summer holidays: from . to . 2 School, university or establishment of higher education2.1 Name: . . 2.2 Address (5): . . 2.3 Stamp2.4 Date: . 2.5 Signature. >END OF GRAPHIC>>START OF GRAPHIC>EUROPEAN COMMUNITIESSocial Security  RegulationEEA*See 'Instructions' page 3E 403(1)CERTIFICATION OF APPRENTICESHIP AND/OR  VOCATIONAL TRAINING FOR THE PURPOSE OF THE GRANTINGOF FAMILY BENEFITSReg. 1408/71: Art. 73; Art.  74; Art. 77; Art. 78Reg. 574/72: Art. 86; Art. 88; Art. 90; Art. 91; Art. 92A. Request for  certificateTo 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   Orphan1.1 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 benefits3.1 Name . 3.2 Address (4): . . 3.3 File reference No . 3.4 Stamp3.5 Date: . 3.6 Signature. E 403B. CertificateTo 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 apprenticeship4.1 The person named in box 2 has been apprenticed to  usfrom . to receive training in the following trade: . 4.2 The apprenticeship is provided   . days per week   . hours per weekand will last until . 4.3 The apprentice  is receiving1S    an apprenticeship allowance or wage   net   gross amounting  to1S  1S    weekly   monthly . 1S    other benefits (6) namely1S  1S    accommodation   full board   part board1S  1S    tips    . meals a day   other (7)from . to . amounting to: .   is not receiving1S    an apprenticeship allowance or wage   other benefits4.4 Place of work . 4.5 Name of the person, undertaking or institution responsible for the apprenticeship. 4.6 Address (4): . . 4.7 Stamp4.8 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 Stamp5.4 Date . 5.5 Signature. E 403INSTRUCTIONSPlease 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 403E 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 trainingfrom . to . 1.2 Does the person concerned have an employment contract for this training?  Yes   No1.3 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 month1.6 Does the person  concerned receive pay during training?   Yes   NoIf 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 Stamp1.11 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 COMMUNITIESSocial Security RegulationsEEA*See  'Instructions' on page 3E 404(1)MEDICAL CERTIFICATE FOR THE PURPOSE OF THE GRANTING OF FAMILY  BENEFITSReg. 1408/71: Art. 73; Art. 74; Art. 77; Art. 78Reg. 574/72: Art. 86; Art. 88; Art. 90;  Art. 91; Art. 92A. Request for certificateTo be completed by the institution competent as  regards the granting of family benefits1 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   Orphan1.1 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 relates2.1 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 benefits3.1 Name: . 3.2 Address (4): . . 3.3 File reference No: . 3.4 Stamp3.5 Date: . 3.6 Signature. E 404B. CertificateTo 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 404INSTRUCTIONSPlease 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 certificateNOTES*  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 COMMUNITIESSocial Security RegulationsEEA*See  'Instructions' on page 3E 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 STATESReg. 1408/71: Art.  12; Art. 72Reg. 574/72: Art. 10a; Art. 85.2 and 3This 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 person1.1 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 benefits2.1 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 requested3.1 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 person4.1 Name: . 4.2 Address (6): . . 5 Institution of the place of residence of the members of the family5.1 Name: . 5.2 Address (6): . . E 4056 Institution with which the insured person is currently registered6.1 Name: . 6.2 Address (6): . . 6.3 File reference No . 6.4 Stamp6.5 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 1was insured from . to . (8) . 7.2 in (9) . 7.3   He is entitled   He is not entitled to family benefits7.4 Family benefits were paid to him  from . to . 7.5 Family members for whom the family benefits were paid7.5.1 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 person8.1 Name: . 8.2 Address (6): . . . 8.3 Stamp8.4 Date: . 8.5 Signature. 9 Remarks: . . E 405INSTRUCTIONSPlease 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  informationNOTES* 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 receivedNo of daysin employmentNo of hoursin employmentGross wage/salary  receivedDuring the lastmonthDuring the last threemonthsDuring the last sixmonths(9) Country  in which the employment in question was pursued. >END OF GRAPHIC>>START OF GRAPHIC>EUROPEAN COMMUNITIESSocial Security RegulationsEEA*See  'Instructions' overleafE 406F(1)CERTIFICATE OF POST-NATAL MEDICAL EXAMINATIONSReg. 1408/71:  Art. 73; Art. 74Reg. 574/72: Art. 86; Art. 88Information for the insured personIn 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 certificateTo be completed by the institution responsible for the granting of  family benefits. 1   Employed person   Self-employed person1.1 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 requested2.1 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 benefits3.1 Name: . 3.2 Address (2): . . 3.3 File reference No: . 3.4 Stamp: 3.5 Date: . 3.6 Signature: . E 406FB. CertificateTo be completed by the doctor treating the child or by the doctor chosen by  the person looking after the child4 4.1 The child named in box 2 above underwent on: . 4.2   a medical examination during the ninth or 10th month from birth4.3   a medical examination  during the 24th or 25th month5 5.1 Doctor's surname and forename: . 5.2 Address (2): . . 5.3 Date: . 5.4 Signature: . INSTRUCTIONSPlease complete this form in block letters, writing on the dotted lines onlyNotes*  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 COMMUNITIESSocial Security RegulationsEEA*See  'Instructions' on page 3E 407(1)MEDICAL CERTIFICATE FOR THE GRANT OF A SPECIAL FAMILY ALLOWANCE  OR OF INCREASED FAMILY ALLOWANCES FOR HANDICAPPED CHILDRENReg. 1408/71: Art. 73; Art. 74Reg.  574/72: Art. 86; Art. 88A. Request for certificateTo be completed by the institution responsible  for the granting of family benefits1   Employed person   Self-employed person1.1 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 requested2.1 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 benefits3.1 Name: . 3.2 Address (2): . . 3.3 File reference No: . 3.4 Stamp: 3.5 Date: . 3.6 Signature: . E 407B. CertificateThe 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 . monthsChild's weight: . kilograms . grams  height: . centimetres. 4.2 Psychomotor retardationRetardation taking account of normal level for the child's age:   Yes    NoIf yes, please specify: . 4.3 IndependenceCan the child sit up unaided   Yes   No Can he/she walk?   Yes   NoCan he/she  talk?   Yes   No Can he/she dress unaided?   Yes   NoCan he/she eat unaided?   Yes   No Does  he/she write   Yes   No (3)Is he/she incontinent?   Yes   No (3)4.4 AssistanceDoes the child's  condition necessitate attendance by another person?   Yes   NoConstant attendance?   Yes   No  Daily attendance though not continous?   Yes   Noor other measures (please specify): . 4.5 Nature of the principal disabilityIs the child's disabilitysensory? visual? . auditory? . motor: . mental: mental level . behaviour . other . 4.6 Origin of disability (3)- congenital anomaly .   Yes   No- disease .   Yes   Nodate of onset  of disability . - accident .   Yes   Nodate of accident . 4.7 Associated disabilitiesWhich ones? . Other deficiencies . 4.8 Additional observationsDisabilities 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 measuresWhat forms of education and training are being provided? . . Since when? . What education and training is recommended? . 4.11 PrognosisPlease specify: . . E 4075 5.1 Doctor's surname and forenames: . 5.2 Address (2): . . 5.3 Date: . 5.4 Signature: . INSTRUCTIONSPlease 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 COMMUNITIESSocial Security RegulationsEEA*See  'Instructions' on page 3E 411(1)REQUEST FOR INFORMATION ON ENTITLEMENT TO FAMILY BENEFITS IN THE  MEMBER STATES OF RESIDENCE OF THE MEMBERS OF THE FAMILYReg. 1408/71: Art. 76Reg. 574/72: Art.  10A. Request for certificateThe 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 verified2.1 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  ofresidence (7)3.1 . . . . . . . . . . . . . . . 3.2 . . . . . . . . . . . . . . . 3.3 . . . . . . . . . . . . . . . 4 Information concerning the occupation pursued received in the country of residence of the members  of the family4.1 Employer: . 4.2 Address (4) . . 4.3 Self-employment: . 4.4 Activity treated as an occupation as defined by Decision No 119. E 4115 Competent  institution5.1 Name: . 5.2 Address (4): . . . 5.3 File reference number (8): . 5.4 Stamp5.5 Date . 5.6 Signature. B. CertificateTo 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 employer6.1 During the period from .  to . the person named in box 2  pursued an occupation (or an activity treated as such as defined  inDecision No 119) from . to .   did not pursue an occupation (or an activity treated as such as definedin 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 Stamp8.4 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 Stamp9.5 Date: . 9.6 Signature. E 411INSTRUCTIONSPlease 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 childC = adopted childD = 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 householdF = 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 institutionG = 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.