2002/864/EC: Decision No 184 of 10 December 2001 on the model forms necessary for the application of Council Regulations (EEC) No 1408/71 and (EEC) No 574/72 (E 201 to E 207, E 210, E 213 and E 215) (Text with EEA relevance.)
Date: 2001-12-10
Institutions: Administrative Commission on Social Security for Migrant Workers, European Commission
Subjects: civil servant, form, self-employment, social-security benefit, social-security harmonisation, student, wage earner

6.11.2002

EN

Official Journal of the European Communities

L 304/1

II

(Acts whose publication is not obligatory)

COMMISSION

DECISION No 184

of 10 December 2001

on the model forms necessary for the application of Council Regulations (EEC) No 1408/71 and
(EEC) No 574/72 (E 201 to E 207, E 210, E 213 and E 215)

(Text with EEA relevance)

(2002/864/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 (1) of 14 June 1971 on the
application of social security schemes to employed persons, to self-employed persons and to members of
their families moving within the Community, pursuant to 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 (2), pursuant to 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 its Decision No 158 (3) on the model forms necessary for the application of Council
Regulations (EEC) No 1408/71 and (EEC) No 574/72 (E201 to E 215),

Having regard to Council Regulation (EC) No 1606/98 (4) amending Regulations (EEC) No 1408/71 and
(EEC) No 574/72 with a view to extending them to cover special schemes for civil servants,

Having regard to Council Regulation (EC) No 307/1999 (5) amending Regulations (EEC) No 1408/71 and
(EEC) No 574/72 with a view to extending them to cover students,

Having regard to Council Regulation (EC) No 1399/1999 (6) amending Regulations (EEC) No 1408/71
and (EEC) No 574/72,

(1) OJ L 149, 5.7.1971, p. 2.
(2) OJ L 74, 27.3.1972, p. 1.
(3) OJ L 336, 27.12.1996, p. 1.
(4) OJ L 209, 25.7.1998, p. 1.
(5) OJ L 38, 12.2.1999, p. 1.
(6) OJ L 164, 30.6.1999, p. 1.

L 304/2

EN

Official Journal of the European Communities

6.11.2002

Whereas;

(1)

(2)

(3)

(4)

(5)

The Agreement on the European Economic Area of 2 May 1992, as supplemented 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.

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 shall be adapted and used within the European
Economic Area.

For practical reasons identical forms should be used within the Community and within the
European Economic Area.

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.

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.

2.

3.

The model forms E 201, E 202, E 203, E 204, E 205 (Belgium (B), Denmark (DK), Germany (D),
Greece (GR), Spain (E), France (F), Ireland (IRL), Italy (I), Luxembourg (L), the Netherlands (NL),
Austria (A), Portugal (P), Finland (FIN), Sweden (S), United Kingdom (GB), Iceland (IS), Liechtenstein
(FL) and Norway (N), E 206, E 207, E 210, E 213 and E 215 printed in Decision No 158 of
27 November 1995 shall be replaced by the model appended hereto.

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.

Each form shall be available in the official languages of the Community and laid out in such 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 forms
printed in their own language.

4.

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

The Chairman

of the Administrative Commission

J. DONIS

EUROPEAN COMMUNITIES
Social Security Regulations
EEA*

See ‘Instructions’ overleaf

E 201                  (1)

CERTIFICATE CONCERNING THE AGGREGATION OF PERIODS OF INSURANCE OR PERIODS OF RESIDENCE

Reg. 1408/71: Art. 9.2; Art. 15.3
Reg. 574/72: Art. 6.2

This certificate should be drawn up at the request of the person concerned by the institution or institutions of the Member States where he/she
was insured. He/she should send if to the institution of the Member State in question with a view to his/her admission to voluntary or optional
continued insurance for invalidity, old age and death (pension).

1

Insured person

1.1

Surname (1a)

...................................................................................................................................................................................................................

1.2

Forenames

Previous names (1a)

Place of birth (2)

.........................................................................

...............................................................

.............................................................

1.3

Date of birth

Sex

Nationality (3)

D.N.I. (4)

...................................

...............................

...............................................................

.............................................................

1.4

Address (5)

.........................................................................................................................................................................

...................................................................................................................................................................................................................

1.5

Insurance No

...................................................

2

Last employment entailing compulsory insurance (6)

2.1 M Type of occupation as employed person

...................................................................................................................................................................................................................

Name of employer or firm

2.2
2.3 M Type of occupation as self-employed person
2.4

Address (5)

...................................................................................................

...................................................................................................

.........................................................................................................................................................................

...................................................................................................................................................................................................................

3

The worker named in box 1

M is

M was

insured by us

from/to

periods (7)

as (6) (8)

type of insurance (9)

for the risk of (10)

.....................

.....................

.....................

.....................

.....................

/

/

/

/

/

.......................................................................................................................................................................................................

.......................................................................................................................................................................................................

.......................................................................................................................................................................................................

.......................................................................................................................................................................................................

.......................................................................................................................................................................................................

4

The worker named in box 1 completed the following periods of residence (11)

from

to

Years

Duration

Months

Days

....................................................................................................................................................................................................................................

....................................................................................................................................................................................................................................

....................................................................................................................................................................................................................................

....................................................................................................................................................................................................................................

....................................................................................................................................................................................................................................

1

E 201

5

(12)

5.1

The person concerned

M has

M has not

submitted an application in another Member State for registration for voluntary or optional continued insurance.

If he/she has, state

5.2

5.3

the country

the risk (10)

6

(8)

...................................................

...................................................

The person concerned

6.1
6.2 M an invalidity pension
6.3 M an old-age pension
6.4 M a survivor’s pension
6.5

Date from which pension is paid

M receives

M does not receive

...............................................................

7

Institution issuing the certificate

7.1
7.2

Name
Address (5)
...................................................................................................................................................................................................................

...................................................................................................................................................................

...................................................................................................................................................................

7.3

Stamp

7.4

7.5

Date

Signature

................................................

..........................................................................

INSTRUCTIONS

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

NOTES

*

(1)

(1a)

(5)
(6)

(7)
(8)
(9)

(10)

(2)
(3) Where applicable, indicate the date of naturalisation.
(4)

EEA Agreement on the European Economic Area, Annex VI, Social Security: for the purposes of this Agreement the present form shall
also apply to Iceland, Liechtenstein and Norway.
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; A = Austria; P = Portugal; FIN = Finland; S = Sweden;
GB = United Kingdom; IS = Iceland; FL = Liechtenstein; N = Norway.
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.
In the case of Portuguese districts state also the parish and the local authority.

In the case of Spanish nationals over 16 years of age, state the Número de Identificación Fiscal (N.I.F.). Failing this, indicate the number
of the Documento Nacional de Identidad (D.N.I.) or passport, even if they are out of date. If the aforementioned documents do not exist,
state ‘none’.
Street, number, post code, town, country, telephone number.
If  the  certificate  is  issued  by  a  Belgian,  French,  Irish,  United  Kingdom  or  Norwegian  institution,  the  information  given  is  based  on
particulars  supplied  by  the  worker  himself. In  Norway  the  information  concerning  employees  may  be  checked  in  a  register  of
employers/employees.
Indicate the number of quarters, months, weeks, days, in accordance with the provisions of national legislation.
Complete only if the form is being sent to a German, Greek, Spanish, Luxembourg, Austrian, Liechtenstein or Norwegian institution.
Indicate the type of insurance by using the following symbols:
A = compulsory
B = voluntary
C = optional continued
D = assimilated periods
Indicate the risks covered by using the following symbols:
E = invalidity
F = old age
G = death.

(11) Complete only if the certificate is issued by a Danish, Finnish, Swedish, Icelandic or Norwegian institution.
(12)

In Norway this information must be given by the insured person.

2

EUROPEAN COMMUNITIES
Social Security Regulations
EEA*

See ‘Instructions’ on pages 8 and 9

E 202                  (1)

Country

Identification No (2)

Institution concerned (where applicable, liaison body)

1)

2)

3)

4)

5)

..........................................................................................................................................................................................................................

..........................................................................................................................................................................................................................

..........................................................................................................................................................................................................................

..........................................................................................................................................................................................................................

..........................................................................................................................................................................................................................

INVESTIGATION OF A CLAIM FOR AN OLD-AGE PENSION

Reg. 1408/71: Art. 44 to 51a; Art. 77
Reg. 574/72: Art. 36 to 38; Art. 41 to 43; Art. 45 to 47; Art. 49; Art. 90 (**); Art. 111

The  investigating institution should complete this form and send one copy to each of the institutions with which the employed  or self-employed
person has been insured (institutions concerned) or to the liaison body.

1

Institution to which the form is addressed (institution concerned or liaison body, as applicable)

1.1

1.2

Name

Address (3)

...............................................................................................................................................................................

...............................................................................................................................................................................

...................................................................................................................................................................................................................

A. Information concerning insured person (4)

2

2.1

2.2

2.3

2.4

2.5

2.6

2.7

2.8

Surname (5)

...................................................................................................................................................................

Surname at birth (5)

...................................................................................................................................................................

Forenames (6)

...................................................................................................................................................................

Previous names (7)

...................................................................................................................................................................

Sex (8)

...................................................................................................................................................................

Father’s surname and forenames (9)

.........................................................................................................................................

Mother’s surname and forenames (9)

.........................................................................................................................................

Civil status
M single

M divorced (10)
since (11)

............................

M married since (11)

........................ M remarried (10)

M separated
since (11)

M widow or widower

.........................

M cohabiting since (12) (4)
Taxpayer’s number (13)

2.9

Code of tax district

2.10

Insurance number (14)

since (11)

............................

since (11)

.........................

.............................................................................................................................................

3

4

4.1

4.2

4.3

4.4

Nationality (15)

............................................................................................ D.N.I. (16)

.............................

Details of birth

Date of birth (17)

...............................................................................................................................................................................

Place of birth (18)

...............................................................................................................................................................................

Province, department, county (19)

.........................................................................................................................................

Country (20)

...............................................................................................................................................................................

(**) Art. 90 of Reg. 574/72 is not applicable in the Netherlands.

1

E 202

5

Address and bank particulars

5.1

Address (3) (21) (22)

............................................................................................................................................................................

............................................................................................................................................................................

............................................................................................................................................................................

5.2

Bank particulars or address for direct payment

Name of the beneficiary as recognised by the bank

Name of the bank

Address of the bank

Bank identification code

Bank account

......................................................................................

......................................................................................

......................................................................................

......................................................................................

......................................................................................

6

6.1

6.2

7

Insurance No at the registering institution

.............................................................................................

Reference No of file at the investigating institution

.............................................................................................

7.1 M The insured person is still pursuing gainful employment

M as an employed person M civil servant M as a self-employed person
M entailing compulsory pension insurance cover (23)

7.2 M The insured person has ceased to pursue gainful employment M as an employed person M civil servant M as a self-employed person

since

...................................

7.3 M The insured person intends to retire from gainful employment M as an employed person M civil servant M as a self-employed person

on

...................................

7.4 M The insured person intends to take up gainful employment (24)

M as an employed person M civil servant

M as a self-employed person (state nature of activity)

.....................................................

7.5

Amount

M of salary

M of professional income

M of  other income

..........................................

(25)

7.6

Nature of other income

......................................................................................................................................................

7.7 M The claimant states that he/she has no income (26)

8

8.1

The insured person

has applied

for the following

is receiving

the following

8.2

8.3

8.4

8.5

8.6

8.7

8.8

8.9

Continued wage or salary payments in case of illness

Sickness insurance cash benefits for incapacity for work

Rehabilitation allowances

Invalidity pension (27)

Old-age pension (27)

Survivor’s pension (27)

Pension for accident at work or occupational disease

Pension-type benefit payable under compulsory motor insurance

(road accident indemnity) (28)

8.10 Unemployment benefits or early retirement benefit

8.11

8.12

8.13

Family benefit (29)

Refund of contributions

Transfer of contributions (30)

8.14 Other benefits (please specify)

8.15

Institutions responsible for paying the benefits indicated in 8.3 to 8.11

[name, address (3)]:

benefits
M
M
M
M
M
M
M

M
M
M
M
M
M  Yes

benefits
M
M
M
M
M
M
M

M
M
M
M
M
M  No

8 ........

8 ........

8 ........

8 ........

...................................................................................................................................................................................................

...................................................................................................................................................................................................

...................................................................................................................................................................................................

...................................................................................................................................................................................................

2

8.16

Additional information on the benefits listed in 8.3 to 8.10

E 202

Re benefits in item

File reference No

Period or date on which due

Amount

8  ........................

.............................................................................................................. M weekly
M monthly
M annual
...............................................................

8  ........................

.............................................................................................................. M daily

M daily

M weekly
M monthly
M annual

8  ........................

..............................................................................................................................................................................

M daily
M weekly
M monthly
.............................................................................................................. M annual

8  ........................

...............................................................
M daily
M weekly
M monthly
M annual
...............................................................

8.17

The following are regarded as advances on the pension claimed
M sickness insurance benefits for incapacity for work
M unemployment benefits
M  ..............................................................................................................................................................................................................

8.18

The insured person is entitled to sickness benefits in kind under the legislation administered by the investigating institution

M Yes

M No

M Not yet determined

8.19

The benefit referred to in 8.6 or 8.7 is based on (31):
M the claimant’s own insurance periods: see E 205
M insurance periods completed by the (former) spouse: see E 205

3

9

Additional information for the application of provisions on overlapping benefits

9.1

When benefits of the same kind are granted by the institution or institutions concerned, the pension calculated by the investigating

E 202

institution may be reduced
M Yes
The pension calculated by the investigating institution may be reduced
M Yes
— because one or several of the benefits specified at point 8 are taken into account

M No

M No

M Not yet determined

M Not yet determined

8 ............

8 ............

8 ............

8 ............

— because of income other than the benefits specified at point 8
M income from employment/self-employment
M other
The institution concerned is requested to specify the part of the pension accruing from voluntary contribution payments (point 6.7 in

............................................................................................................................................

(32)

form E 210)
M Yes
The benefit due from the investigating institution is (partly or entirely) based on voluntary contributions
M Yes

M No

M No

Information to be supplied if the form is to be sent to Danish (10.1, 10.2 and 10.3), German, Greek, Spanish, Austrian (10.1 and
10.2), French (10.1, 10.2 and 10.4), Icelandic (10.2 and 10.3), Portugese, Finnish or Norwegian (10.2) institutions

9.2

9.3

9.2

10

10.1

The claimant (33)

10.2

The claimant (33) (34) 

M declares that he/she is unfit for work (see medical report enclosed)
M declares that he/she is not unfit for work
M declares that he/she needs someone in constant attendance for the performance of one of

the ordinary activities of everyday life (see medical report enclosed)

M declares that he/she does not need someone in constant attendance for the performance

of one of the ordinary activities of everyday life

M declares that his or her functional capacity has on account of an illness or injury diminished
with the result that he or she is not capable of performing ordinary activities of everyday life

unaided or that the illness or injury imposes an added long-term financial strain (28)

10.3

10.4

The claimant (33)

M declares that he/she does not have sufficient means of subsistence

The investigating institution awards an increase in benefits to the extent that the applicant is incapable of carrying out normal day-

to-day activities unaided
M Yes
— In addition to the benefit referred to at point 8 .........., the applicant receives an additional benefit if he/she is incapable of carrying

M Not yet determined

M No

out normal day-to-day activities

— The additional benefit may be reduced if a similar benefit is granted by another institution concerned

M Yes

M No

M Not yet determined

4

E 202

B. Information concerning the members of the insured person’s family (4)

11

M Spouse

11.1

Surname (5)

M Cohabiting partner (12) (35)

...................................................................................................................................................................................................................

11.2

Forenames (6)

Previous names (7)

..............................................................................................

................................................................................................................

11.3

Date of birth

11.4 Nationality (16)

11.5

Address (3)

................................................

Place of birth (18)

.............................................................

................................................

.....................................................................................................................................................................

...................................................................................................................................................................................................................

...................................................................................................................................................................................................................

Sofi number (14)

..........................................................................................................................................................................

Date of marriage/cohabiting ..........................................................................................................................................................................

The spouse/partner

M pursues

M does not pursue gainful employment

If in the affirmative, state amount of
M weekly earnings (36)

.......................... M annual earnings (37)  .......................................................................................................

11.6

11.7

11.8

11.9

11.10 The spouse/partner aged between 60 and 65 declares himself/herself

M fit for work
11.11 The spouse/partner

M unfit for work (33)

M has submitted a claim for a pension under the scheme for

M receives a pension under the scheme for

M employed persons
M civil servants
M self-employed persons
M all residents

M does not receive a pension
Where appropriate, indicate

11.12 Type of pension (38)

11.13 Pension No (16)

............................................................................................................................

............................................................................................................................

11.14 institution responsible for payment

............................................................................................................................

...................................................................................................................................................................................................................

11.15 Amount

M monthly

11.16 The spouse/partner

M unemployment M sickness

M quarterly
M receives
M occupational accident 

M does not receive other benefits (39)

M invalidity

M other

M annual

...................................

or illness

11.17 Date of commencement ...............................................................................................................................................................................

11.18 Amount

M monthly

11.19 Other known resources

M quarterly
Type

M annual

...................................

.....................................................................................................................

...................................................................................................................................................................................................................

Amount (40)

............................................................................................................

11.20 The benefit referred to in 11.11 is based on (31):

M the claimant’s own insurance periods: see E 205
M insurance periods completed by the (former)  spouse: see E 205

5

E 202

12

Children

12.1

Surname (5)

Forenames

Place and date of
birth, marriage or
death (41)

Relationship
(i.e.: own child,
adopted child, foster child)

1.

.......................................................................

........................................

.................................

.................................................

.......................................................................

........................................

.................................

.................................................

.......................................................................

........................................

.................................

.................................................

.......................................................................

........................................

.................................

.................................................

2.

.......................................................................

........................................

.................................

.................................................

.......................................................................

........................................

.................................

.................................................

.......................................................................

........................................

.................................

.................................................

.......................................................................

........................................

.................................

.................................................

3.

.......................................................................

........................................

.................................

.................................................

.......................................................................

........................................

.................................

.................................................

.......................................................................

........................................

.................................

.................................................

.......................................................................

........................................

.................................

.................................................

4.

.......................................................................

........................................

.................................

.................................................

.......................................................................

........................................

.................................

.................................................

.......................................................................

........................................

.................................

.................................................

.......................................................................

........................................

.................................

.................................................

12.2

The following institution is competent to grant benefits pursuant to Art. 77 of Reg. 1408/71
M the investigating institution
M the institution designated as follows

...................................................................................................................................

12.3

The investigating institution
M for the children referred to in lines No

............ of item 12.1,

is granting benefits until

...................................

inclusive.

amount of pension increase and family allowance per child

.........................................................................

(42)

.............................................................................................................................................................................................................

.............................................................................................................................................................................................................

M is not granting benefits in respect of the children referred to in lines No

............ of item 12.1 (43)

M has not yet taken a decision regarding entitlement to benefits

12.4

Address (3) (44)
...................................................................................................................................................................................................................

...............................................................................................................................................................................

...................................................................................................................................................................................................................

12.5

Remarks (45) (46)
...................................................................................................................................................................................................................

...............................................................................................................................................................................

C. Miscellaneous information

M Date of submission of this claim
............................................................................................................
M Date chosen by claimant for commencement of pension payments
.........................................................................
...................................................................................................................................................................................................................
M Date from which the pension is payable in the country of the investigating institution
................................................
...................................................................................................................................................................................................................
The claimant has asked for payment (47)
M directly in the State of residence
M to a representative in the State of origin
Additional information for the purposes of the Finnish institutions
M The claimant wishes to have the decision

M in Swedish

M in Finnish

13

6

E 202

14

The claimant
deferment of the calculation of an old-age pension to which he/she would be entitled.
Where appropriate, indicate the country

M has requested

M has not requested

................................................................................................................

15

15.1

M pays
The investigating institution
benefits on a provisional basis under Art. 45.1 of Reg. 574/72
If not, the institutions concerned are requested to investigate the possibility of paying benefits on a provisional basis under Art. 45.2
of Reg. 574/72

M does not pay

16

M There are grounds
for making deductions to compensate for overpayment in accordance with Art. 111 of Reg. 574/72

M There are no grounds

16.1

Any pension arrears
M can
be paid direct to the beneficiary

M cannot

17.1
17.2

Attached forms
Please send us your

M E 205

M E 206

M E 207 (48)

M E 205

M E 210

M Decision

M Arrears

Remarks

...............................................................................................................................................................................

...................................................................................................................................................................................................................

...................................................................................................................................................................................................................

18

Investigating institution

18.1 Name

18.2

Address (3)
...................................................................................................................................................................................................................

...............................................................................................................................................................................
...............................................................................................................................................................................

18.3

Stamp

18.4

18.5

Date

Signature

................................................

..........................................................................

7

E 202

INSTRUCTIONS

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

NOTES

*

(1)

EEA Agreement on the European Economic Area, Annex VI, Social Security: for the purposes of this Agreement the present form shall
also apply to Iceland, Liechtenstein and Norway.
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;  A  =  Austria;  P  =  Portugal;  FIN  =  Finland;
S = Sweden; GB = United Kingdom; IS = Iceland; FL = Liechtenstein; N = Norway.

(2) Where the form is being sent to a Danish institution, indicate the CPR number; to a Finnish institution, indicate the Finnish population 
register number; to a Swedish institution, indicate the Swedish personal number; to an Icelandic institution, indicate the Icelandic personal
identification number (kennitala); to a Liechtenstein institution, indicate the AHV insurance number; to a Norwegian institution, indicate the
Norwegian personal identification number (fødselsnummer); to a German institution of the general social security scheme, indicate the
insurance number (VSNR); to an institution of the social security scheme for civil servants, indicate the personal identification number
(PRS-Kenn-Nr.), to a Portuguese institution indicate also the registration number with the general pensions scheme, if the person con-
cerned has been insured under the social security scheme for civil servants in Portugal.
Street, number, post code, town, country, telephone number.
For the purpose of Norwegian institutions, complete also form E 202/additional page No 3. For Germany and Austria, the term ‘insured 
persons’ encompasses individuals insured under the general social security scheme as well as civil servants and individuals treated as
such who are insured under a special scheme. The term ‘pension’ is considered to encompass pensions for civil servants.

(3)
(4)

(5) — For  surname  please  state  usual  surname  or  surname  acquired  by  marriage.  If  the  form  is  being    completed  by  a  Netherlands
institution, in cases where the insured person or the rightful claimant is a married woman or a woman who was married before, put
the present or last husband’s surname for current surname.

— The ‘surname at birth’ must always be given; if same as current surname, put ‘IDEM’. If the form is being completed by a Netherlands
institution, in cases where the insured person or the righful claimant is a married woman or a woman who was married before, put
the maiden name for surname at birth.

— Expressions such as ‘called …’ or ‘alias …’ and prefixes to surnames must be written in full in the order in which they appear on the

birth certificate.

— 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.

(6)
(7)

(8)
(9)

Give all forenames in the order in which they appear on the birth certificate.
To be stated particularly in the case of adoption or in the case of other names in current use; expressions such as ‘called …’ or ‘alias …’
and prefixes to surnames must be written in full in the order in which they appear on the birth certificate.
Put M for male and F for female.
This information is required when the worker is a Spanish national, or when the form is to be sent to a French institution, regardless of the
worker’s nationality.

(11)

(12)

(10) Complete where possible if the form is being sent to a German, Belgian, French, Italian, Luxembourg, Netherlands, Austrian, Liechtenstein
or Norwegian institution. If the sending institution does not have this information available, the competent institution should contact the
person concerned directly.
For the purposes of Belgian, United Kingdom, Liechtenstein and Netherlands institutions, specify also the date beside the corresponding
box.
For the purposes of Netherlands, Finnish, Icelandic and Norwegian institutions, this information is based on a statement from the person
concerned.
Under  the  Netherlands  General  Law  on  Old-Age  Insurance  the  following  persons  are  also  regarded  as  ‘married’  or  ‘spouse’: 
unmarried persons of the same or different sexes who are living in a joint household on a permanent basis. A joint household means that
two unmarried persons are jointly providing for their housing with each contributing to the costs of the household or providing for each
other’s upkeep in another way.
To be completed only if the form is to be forwarded to a Portuguese institution.
For the purposes of Netherlands institutions complete Sofi number, if known. For the purpose of Belgian institutions complete national
social security number (NISS).

(13)
(14)

(15) Where appropriate, indicate the date of naturalisation.
(16)

(17)
(18)

In the case of Spanish nationals over 16 years of age, state the Número de Identificación Fiscal (N.I.F.). Failing this, indicate the number
of the Documento Nacional de Identidad (D.N.I.) or passport, even if they are out of date. If the aforementioned documents do not exist,
state ‘none’.
The day and the month should be shown by two digits each and the year by four digits (example: 1 August 1921 = 01.08.1921).
For French towns comprising several arrondissements, please give the number of the arrondissement (example: Paris 14). In the case of
Portuguese districts state also the parish and the local authority. In the case of Netherlands towns state also the name of the municipality.
(19)  This information is obligatory for insured persons of Spanish, French or Italian nationality. Here, the territorial area or district in which the
place of birth is located should be stated (example: in the case of France if the place (commune) of birth is Lille, the department of birth
should be shown as ‘Nord’ followed by the area code if known to the insured person; in this case: 59. The complete entry should therefore
read: ‘Nord 59’). In the case of persons born in Spain, state only the province.
The symbol of the insured person’s country of birth in accordance with the international motor vehicle registration code.
If the form is being sent to a German, Austrian or Liechtenstein institution, state — if applicable – the address of the legal representative
(legal counsellor, guardian, curator…) in the box below.

(20)
(21)

Address (3)

....................................................................................................................................................................................

.....................................................................................................................................................................................................................

8

E 202

(22)

If the form is being sent to a Danish, Finnish, Icelandic or Norwegian institution, give the claimant’s last address in the corresponding
country in the box below.

Address (3)

..................................................................................................................................................................................

.....................................................................................................................................................................................................................

(23)
(24)

(25)

(26)

(27)

(28)
(29)
(30)
(31)
(32)
(33)
(34)
(35)
(36)
(37)

(38)

(39)

(40)

(41)
(42) 
(43)

(44)

the pension of the occupational scheme as cash compensation.

For the purposes of Spanish institutions.
Complete  if  the  form  is  being  sent  to  a  Belgian,  German,  Spanish,  Irish,  Luxembourg,  Portuguese,  Austrian  or  Norwegian 
institution.
Complete if the form is being sent to a Belgian, Danish, French, Italian, Luxembourg, Austrian, Icelandic or Norwegian institution (annual
amount) or to a Greek or Portuguese institution (monthly amount). If the form is being sent to an Italian institution, indicate all income
except  for  the  following:  the  claimant’s  home,  family  benefits,  cash  benefits  for  accident  at  work  or  occupational 
disease, purely assistance benefits.
Complete  if  the  form  is  being  sent  to  an  Italian  or  Greek  institution. In  Italy  the  following  sources  are  not  considered  as  income:  the
claimant’s home, family benefits, cash benefits for accident at work or occupational diseases or purely assistance benefits.
For the purposes of Liechtenstein institutions indicate also if the insured person
M applied for
M or received
For the purposes of Finnish institutions.
Complete if the form is being sent to an Italian institution.
For the purposes of Liechtenstein institutions.
To be completed for Netherlands institutions.
State the type of income taken into account by the investigating institution in applying its overlapping rules.
The Greek, Spanish, French and Austrian institutions may subsequently request an  E 213 form.
For the purposes of Portuguese institutions, complete also form E 202/additional page No 2.
For the Netherlands institutions a form E 205 for the (former) spouse/partner should be submitted at the same time.
Complete also if the form is being sent to an Irish, Austrian or United Kingdom institution.
Complete  if  the  form  is  being  sent  to  a  Belgian,  Danish,  Spanish,  French,  Italian,  Luxembourg,  Netherlands,  Austrian,  Icelandic  or
Norwegian institution. For the purposes of Netherlands institutions also add proof.
For Spanish, French, Austrian or Liechtenstein institutions, indicate the nature of the risk (invalidity, old age) and the type of entitlement
(direct or indirect).
Complete if the form is being sent to a Belgian, Danish, Spanish, French, Irish, Italian, Netherlands, Austrian, United Kingdom, Icelandic
or Norwegian institution.
Complete if the form is being sent to a Danish, Spanish, Netherlands, Austrian, Icelandic or Norwegian institution (annual amount), to a
French institution (quarterly amount) or to an Italian institution (monthly amount).
Indicate with the following symbols which date you are referring to: * birth, °° marriage, † death.
Provide details of rates from date of pension award with any subsequent change of rate.
Complete form E 202/additional page No 1 if the form is being sent to an Italian or Norwegian institution. Additional information is also
given on additional page No 1 if the institution concerned specially asked for it.
Indicate the common address. If any of the children live at a different address, indicate in the box below.

Surname and forenames
Address (3)

........................................................................................................................................................................
........................................................................................................................................................................

.....................................................................................................................................................................................................................

(45)

(46)

(47)
(48)

For the purposes of Spanish institutions, state whether the children are economically dependent on the insured person and whether any
of the children have a disability. In the latter case, state whether the child receives an invalidity pension in his or her own right.
Indicate whether the child is married, an invalid, deceased (date of death), an apprentice or a student. For the purposes of a Liechtenstein
institution, a copy of the indentures of apprenticeship or a certificate of the training centre should be attached for each child being a
student or apprentice between the age of 18 and 25.
Complete if the form is being sent to an Italian or Greek institution.
If form E 202 is to be sent to a Liechtenstein institution, add form(s) E 207 for the insured person and — if applicable — for the (actual
and former) spouse(s) of the insured person.

9

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
E 202 additional page No 1

ITEM 12 ‘CHILDREN’
ADDITIONAL INFORMATION
(complete a separate page for each child)

1

The child named in line No

...............................

of item 12.1

M pursues gainful employment

M does not pursue gainful employment

1.1

If the answer is in the affirmative, please state

Type of occupation (employed or self-employed)

.....................................................................................................

Amount of income (1) per

M week

M month

M year

........................................................

2

The child named in line No

...............................

of item 12.1

M has other sources of income

M does not have any other sources of income

2.1

If the answer is in the affirmative, please specify

— nature of income

M social security benefits
amount per

M other income (2)
amount per

M week

M month

M year

........................................................

M week

M month

M year

........................................................

3

In respect of the child named in line No

...............................

of item 12.1 the following person

(surname, forename)

...........................................................................................................................................................................

(address)

...........................................................................................................................................................................

.........................................................................................................................................................................................................................
is entitled to family benefits or allowances by virtue of his/her pursuit of a professional activity or trade
(Art. 79.3 or Reg. 1408/71)

Amount

..................................................................................................................................................................................

Commencing on 

..................................................................................................................................................................................

3.1

The following institutions are responsible for paying these family benefits or allowances:

(name)

(address)

..................................................................................................................................................................................

..................................................................................................................................................................................

.........................................................................................................................................................................................................................

(name)

(address)

..................................................................................................................................................................................

..................................................................................................................................................................................

.........................................................................................................................................................................................................................

4

The child named in line No

...............................

of item 12.1 is unfit for work. Form E 404 is enclosed.

(1)

(2)

All income should be declared with the exception of severance payments, family benefits, wage arrears, life annuities for accidents at work
or  occupational  disease,  war  pensions,  pensions  for  disablement  sustained  during  military  service,  attendance  allowance,  travel
allowance.
‘Other  income’  means  income  from  real  estate  or  capital  (bank  or  postal  deposits  or  current  accounts,  government  stock,  investment
funds, shares, bonds, etc.).

1

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
E 202 additional page No 2

ITEM 10.2
ADDITIONAL INFORMATION FOR THE PURPOSES OF PORTUGUESE INSTITUTIONS

To  be  completed  where  the  claimant  has  declared  that  he/she  needs  the  assistance  of  another  person  to  perform  the  ordinary  activities  of
everyday life.

1

Identity of the other person

1.1

Surname

........................................................................................................................................................................................

Forenames

........................................................................................................................................................................................

1.2

Address (street, number, post code, district, country)

...........................................................................................................

.........................................................................................................................................................................................................................

2

Information provided by the investigating institution

2.1 M We have ascertained that the person referred to above is the other person who actually assists the claimant in performing the ordinary

activities of everyday life (personal hygiene, feeding, movement, etc.)

2.2 M Assistance provided by the other person referred to above has not been ascertained

3

Has the need for assistance been caused by a third party?

M Yes

M No

4

Is the person concerned in receipt of an allowance for assistance by a third party or a similar benefit?

M Yes

M No

4.1

Name and address of paying institution

........................................................................................

.........................................................................................................................................................................................................................

4.2

Monthly amount

..................................................................................................................................................................................

1

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
E 202 additional page No 3

ADDITIONAL INFORMATION FOR THE PURPOSES OF NORWEGIAN INSTITUTIONS

1

The claimant

has applied 

is receiving 

1.1

Basic benefit covering extra expenses
due to permanent illness

1.2

Assistance benefit

M

M

M

M

2

The spouse

M has applied for a pension as a non-working person

M is receiving a pension as a non-working person

M is not receiving a pension as a non-working person

3

Children

3.1

Are all of the children supported by the claimant?

If ‘No’, state the name of the child (children) and the amount of the child’s income per year

...............................

.........................................................................................................................................................................................................................

M Yes

M No

3.2

If the parents are married

Do all the children live with both parents?

M Yes

M No

If ‘No’, state which child (children)

.........................................................................................................................................................................................................................

.........................................................................................................................................................................................................................

3.3

If the parents are not married

Do all the children live with both parents?

M Yes

M No

If ‘Yes’, give information about the other parent

Name

Date of birth

..................................................................................................................................................

..................................................................................................................................................

Income per year (All kinds. Specify)

.....................................................................................................

.........................................................................................................................................................................................................................

Name of the child (children) if not all children are concerned

............................................................................

.........................................................................................................................................................................................................................

.........................................................................................................................................................................................................................

4

Cohabiting partner

4.1

Has the claimant previously been married to the cohabiting partner?

M Yes

M No

4.2

Does the claimant have or has he/she had children by the cohabiting partner?

M Yes

M No

1

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
EUROPEAN COMMUNITIES
Social Security Regulations
EEA*

See ‘Instructions’ on pages 7, 8 and 9

E 203                  (1)

Country

Identification No  (2)

Institution concerned (where applicable, liaison body)

1)

2)

3)

4)

5)

..........................................................................................................................................................................................................................

..........................................................................................................................................................................................................................

..........................................................................................................................................................................................................................

..........................................................................................................................................................................................................................

..........................................................................................................................................................................................................................

INVESTIGATION OF A CLAIM FOR A SURVIVOR’S PENSION

Reg. 1408/71: Art. 44 to 51a; Art. 78, 78a, 79 and 79a
Reg. 574/72: Art. 36 to 38; Art. 41 to 43; Art. 45 to 47; Art. 49; Art. 90 (**); Art. 111

The investigating institution should complete the form and send one copy to each of the institutions with which the worker has been insured
(institutions concerned) or to the liaison body.

1

Institution to which the form is addressed (institution concerned or liaison body, as applicable)

1.1

1.2

Name

Address (3)

...............................................................................................................................................................................

...................................................................................................................................................................................................................

A. Information concerning the deceased insured person (3a)

2

2.1

2.2

2.3

2.4

2.5

2.6

2.7

2.8

Surname (4)

...................................................................................................................................................................

Surname at birth (4)

...................................................................................................................................................................

Forenames (5)

...................................................................................................................................................................

Previous names (6)

...................................................................................................................................................................

Sex (7)

...................................................................................................................................................................

Father’s surname and forenames  (8)

.........................................................................................................................................

Mother’s surname and forenames (8)

.........................................................................................................................................

Civil status
M single

M divorced (9)
since (10)

............................

M married since (10)

..................... M remarried (9)

M separated
since (10)

M widow or widower

.........................

M cohabiting since (11)

................................................................................................................................................

since (10)

............................

since (10)

.........................

3

Nationality (12)

.................................................................................................

D.N.I. (13)                   ..............................

4

Details of birth

4.1

4.2

4.3

4.4

Date of birth (14)

...............................................................................................................................................................................

Place of birth (15)

...............................................................................................................................................................................

Province, department, country  (16)

.........................................................................................................................................

Country (17)

...............................................................................................................................................................................

5

Last address of the deceased insured person (3) (18)

...................................................................................................................................................................................................................

...................................................................................................................................................................................................................

(**) Art. 90 of Reg. 574/72 is not applicable in the Netherlands.

1

6

6.1

6.2

7

8

8.1

8.2

E 203

Insurance No at the registering institution

Reference No of file at the investigating institution

................................................................................

................................................................................

On the date of death, the insured person
M was still pursuing

M no longer pursued gainful employment

Date and place of death

Death (19)

8.3

Death (21)

8.4

Death (22)

.......................................................................................................................................................
M is assumed

M is not assumed
to  have been the result of an accident at work (20) or of an occupational disease
M is not assumed

M is assumed

to  have been caused by a third party

M is assumed

M is not assumed

to  have been the result of a road accident (compulsory motor insurance) (22)

8.5

In the case of a missing person

M date last heard of

...................................................

date of death officially

presumed (23) (24)

...................................................

9

9.1

At the date of his/her marriage, the insured person  (25)

receiving a pension under the scheme for

M was
M employed persons
M civil servant or person treated as such covered by a special scheme

M was not
M self-employed persons

9.2

At the date of his/her death, the insured person

receiving a pension under the scheme for

9.3

At the time of death, the deceased (employed person)

insured under legislation for survivor’s insurance  (26)

M  was
M employed persons
M civil servant or person treated as such covered by a special scheme
M all residents
M was

M  was not
M self-employed persons

M was not

Where appropriate, indicate

9.4 — Type of pension

9.5 — Pension No

.......................................................................................................................

...................................................

9.6 — Institution responsible for payment of pension

.......................................................................................................................

....................................................................................................................................................................................................................

9.7 — Date from which the pension was due

...................................................

9.8 — Date when payment ceased, where applicable

......................................

9.9

The benefit referred to in 9.4 is based on  (26)
M the claimant’s own insurance periods, see E 205
M insurance periods completed by the (former) spouse, see E 205

10

The deceased insured person

M had requested

M had not requested

deferment of the calculation of an old-age pension to which he/she would have been entitled.

(Where appropriate, indicate the country

10.1 M The deceased insured person

M had requested

...................................................)
M The spouse
M had obtained

M refund of contributions
M transfer of contributions
M lump-sum payment of the deceased person’s insurance 

2

E 203   

B. Information concerning the claimants

11

M Widow

M Widower

M Other claimants, excluding children  (27) (28) (29)

11.1

Surname (4)

...................................................................................................................................................................................................................

11.2

Forenames

Previous names

Place of birth (15)

..........................................................................

..............................................................

.................................................................

11.3

Date of birth

Nationality

D.N.I. (13)

..........................................................................

..............................................................

.................................................................

11.4

Address (3) (30)

...................................................................................................................................................................

...................................................................................................................................................................................................................

11.5

Bank particulars or address for direct payment

Name of the beneficiary as recognised by the bank

Name of the bank

Address of the bank

Bank identification code

Bank account

11.6

Taxpayer’s number (31)
Code of tax district

Sofi number

................................................................................

................................................................................

................................................................................

................................................................................

................................................................................

................................................................................

(32)

11.7

11.8

Date of marriage with the deceased insured person

...............................................................................................

Do the spouses have or have they had a child in common (either natural or adopted children) (33)
M No
M Yes

11.9 Where applicable, date of M separation from bed and board (34)
11.10 Where applicable, date of remarriage

M divorce

..........................................

.......................................................................................................

11.11 Surname and forenames of other spouse(s) (35)

.......................................................................................................

11.12 Is the widow/widower living together with another person as husband and wife (11)

M Yes

M No
11.13 Relationship and civil status (for claimants other than the widow or widower)

M Not known

...................................................................................................................................................................................................................

3

12

The person named in box 11

12.1a M is engaged in
12.1b M is engaged in 

M is not engaged in gainful employment
M is not engaged in an activity covered under a special scheme for civil servants

E 203

12.2 M is
12.3 M states that he/she has no income (36)
12.4 Where appropriate, state amount of annual income (37)

M is not self-employed

The person named in box 11

12.5
12.6 M was

..................................................

in

.....................................

M was not a dependant of the deceased insured person (36)

12.7 M is 

M is not

M permanently unfit for work
M temporarily unfit for work, namely for more than three months (39)

12.8 M needs (40)
12.9

The person named in box 11

M does not need someone in constant attendance (41)
has applied for

is receiving..................................

Basic benefit covering extra expenses 
due to permanent illness

Assistance benefit

Educational training benefit for widows/widowers

M

M

M

Benefit covering expenses for care

M
of children due to the widow’s/widower’s work or education

M

M

M

M

12.10 The person named in box 11
M receives a pension from
M does not receive a pension

12.11 Type of pension (42)

12.12 Pension No

12.13 Amount on date of claim

.......................................
M may qualify for a (survivor’s) pension
................................................................................................................

......................................

to

...............................................................

...........................................................................................

12.14 Institution responsible for payment of pension

............................................................................................................................

12.15 The person named in box 11 (43)

M is entitled to a survivor’s pension under accident insurance from

the following institution

Pension No

12.16 The widow/widower (44)

............................................................................................................................

...................................................

M is raising a child

M is not raising a child
for whom he/she receives a family allowance or an orphan’s pension

M Yes

M No

12.17 Institution responsible for payment thereof

............................................................................................................................

12.18 If the person named in box 11 is pregnant, give the expected date of her confinement

...................................................................................................................................................................................................................

12.19 The person named in box 11 is entitled to sickness benefits in kind under the legislation administered by the investigating

institution
M Yes

13

M No

M Not yet determined

13.1 Other resources of the widow/widower (45)

nature

amount (46)

..............................................................................

............................

in     ......................................

M none

13.2 Other

nature

.............................................................................................................................................................................................

amount (46):

............................

in     ......................................

4

14

Additional information permitting the implementation of provisions concerning overlapping (this information does not concern orphans)

14.1 When benefits of the same kind are granted by the institution or institutions concerned, the pension calculated by the investigating

E 203

14.2

institution may be reduced
M Yes
The pension calculated by the investigating institution may be reduced
M Yes
— because one or several of the benefits specified at point 12 are taken into account

M No

M No

M Not yet determined

M Not yet determined

12   ....... 

12   ....... 

12   .......

12   .......

— because of income other than the benefits specified at point 12

M income from employment/self-employment
M other

.................................................................................................................................................................. (47)

14.3

The institution concerned is requested to specify the part of the pension accruing from voluntary contribution payments (point 6.7 in

form E 210)
M Yes
The benefit due from the investigating institution is (partly or entirely) based on voluntary contributions
M Yes

M No

M No

14.4

15

Children (13) (48) (49) 

15.1

Surname (4)

Forenames

Nationality

Place and date of
birth, marriage or
death (50)

Relationship
(i.e.: own child, adopted 
child, foster child) (51)

1. ...............................................

......................................

.............................

............................

.......................................

...............................................

......................................

.............................

............................

.......................................

...............................................

......................................

.............................

............................

.......................................

2. ...............................................

......................................

.............................

............................

.......................................

...............................................

......................................

.............................

............................

.......................................

...............................................

......................................

.............................

............................

.......................................

3. ...............................................

......................................

.............................

............................

.......................................

...............................................

......................................

.............................

............................

.......................................

...............................................

......................................

.............................

............................

.......................................

4. ...............................................

......................................

.............................

............................

.......................................

...............................................

......................................

.............................

............................

.......................................

...............................................

......................................

.............................

............................

.......................................

15.2

The following institution is competent to grant benefits pursuant to Art. 78 of Reg. 1408/71
M the investigating institution
M the institution designated as follows

...................................................................................................................................

15.3

The investigating institution
M in respect of the children referred to in lines No

............ of item 15.1 is granting

benefits until

...............................................................................................

inclusive

amount of orphan’s pension and family allowance per child

....................................................................

(52)

M is not granting benefits in respect of the children referred to in lines No

............ of item 15.1 (53)

M has not yet taken a decision concerning entitlement to benefits

15.4

Address (3) (54)
...................................................................................................................................................................................................................

.........................................................................................................................................................................

...................................................................................................................................................................................................................

15.5

Remarks (55) (56) (57)

.........................................................................................................................................................................

5

C. Miscellaneous information

E 203

16

M Date of submission of this claim
M Date from which the pension is payable in the country of the investigating institution
...................................................................................................................................................................................................................

....................................................................................................................

...............................

The claimant has asked for payment (58)
M directly in the State of residence
M to a representative in the State of origin
Additional information for the purposes of the Finnish institutions
M The claimant wishes to have the decision

M in Finnish

M in Swedish

17

The investigating institution

M pays

M does not pay

benefits on a provisional basis under Art. 45.1 of Reg. 574/72.

17.1

If not, the institutions concerned are requested to investigate the possibility of paying benefits on a provisional basis under

Art. 45.2 of Reg. 574/72.

18

M There are grounds
for making deductions to compensate for overpayment in accordance with Art. 111 of Reg. 574/72.

M There are no grounds

18.1 M Any pension arrears

M may
be paid direct to the beneficiary

may not

19.1

19.2

Attached forms

Please send us your

M E 205
M E 205

M E 206
M E 210

M E 207 (59)
M Decision

M Arrears

Remarks

...............................................................................................................................................................................

...................................................................................................................................................................................................................

...................................................................................................................................................................................................................

20

Investigating institution

20.1 Name

.................................................................................................................................................................................

...................................................................................................................................................................................................................

20.2

Address (3)

...............................................................................................................................................................................

...................................................................................................................................................................................................................

20.3

Stamp

20.4  Date

................................................

20.5

Signature

.........................................................................

6

E 203   

INSTRUCTIONS

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

NOTES

*

(1)

EEA Agreement on the European Economic Area, Annex VI, Social Security: for the purposes of this Agreement the present form shall
also apply to Iceland, Liechtenstein and Norway.
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;  A  =  Austria;  P  =  Portugal;  FIN  =  Finland;
S = Sweden; GB = United Kingdom; IS = Iceland; FL = Liechtenstein; N = Norway.

(2) Where the form is being sent to a Danish institution, indicate the CPR number; to a Finnish institution, indicate the Finnish population 
register number; to a Swedish institution, indicate the Swedish personal number, to an Icelandic institution, indicate the Icelandic personal
identification  number (kennitala); to a Liechtenstein institution, indicate the AHV insurance number; to a Norwegian institution, indicate
the  Norwegian  personal  identification  number  (fødselsnummer);  to  a  Belgian  institution,  indicate  the  national  social  security  number
(NISS); to a German institution of the general social security scheme, indicate the insurance number (VSNR); to an institution of the social
security scheme for civil servants, indicate the personal identification number (PRS-Kenn-Nr.); to a Portuguese institution indicate also the
registration number with the general pensions scheme, if the person concerned has been insured under the social security scheme for
civil servants in Portugal.
Street, number, post code, town, country, telephone number.
For Germany and Austria the term ‘insured persons’ encompasses individuals insured under the general social security scheme as well
as civil servants and invididuals treated as such who are insured under a special scheme. The term ‘pension’ is considered to encompass
pensions for civil servants.

(3)
(3a)

(4) — For  surname  please  state  usual  surname  or  surname  acquired  by  marriage.  If  the  form  is  being    completed  by  a  Netherlands 
institution, in cases where the insured person or the rightful claimant is a married woman or a woman who was married before, put
the present or last husband’s surname for current surname.

— The ‘surname at birth’ must always be given; if same as current surname, put ‘IDEM’. If the form is being completed by a Netherlands
institution, in cases where the insured person or the righful claimant is a married woman or a woman who was married before, put
the maiden name for surname at birth.

— Expressions such as ‘called …’ or ‘alias …’ and prefixes to surnames must be written in full in the order in which they appear on the

birth certificate.

— 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.

(5)
(6)

(7)
(8)

(9)

(10)

(11)

Give all forenames in the order in which they appear on the birth certificate.
To be stated particularly in the case of adoption or in the case of other names in current use; expressions such as ‘called …’ or ‘alias …’
and prefixes to surnames must be written in full in the order in which they appear on the birth certificate.
Put M for male and F for female.
This information is required where the worker is a Spanish national, or when the form is to be sent to a French institution, regardless of
the worker’s nationality.
Complete where possible if the form is being sent to a German, Belgian, French, Italian, Luxembourg, Netherlands, Austrian, Portuguese,
Swedish, Liechtenstein or Norwegian institution.
For  the  purposes  of  Belgian,  Netherlands,  Swedish,  United  Kingdom  and  Liechtenstein  institutions,  specify  also  the  date  beside  the
corresponding box.
This  information  is  based  on  a  statement  from  the  person  concerned. For  the  purposes  of  Norwegian  institutions,  complete  also 
additional page No 5. For the Netherlands, it should be noted that under the General Surviving Dependants’ Insurance Act (Algemene
Nabestaandenwet), the following persons are also regarded as married or spouses: single persons of the same or different sex perma-
nently sharing a household, unless they are blood relations of first degree. A shared household means that two persons together provide
for their home, and that each contributes towards the household costs or makes other provision for their subsistence costs.

(12) Where appropriate, indicate the date of naturalisation.
(13)

In the case of Spanish nationals over 16 years of age, state the Número de Identificación Fiscal (N.I.F.). Failing this, indicate the number
of the Documento Nacional de Identidad (D.N.I.) or passport, even if they are out of date. If the aforementioned documents do not exist,
state ‘none’.
The day and the month should be shown by two digits each and the year by four digits (example: 1 August 1921 = 01.08.1921).
For French towns comprising several arrondissements, please give the number of the arrondissement (example: Paris 14). In the case of
Portuguese  districts  state  also  the  parish  and  the  local  authority.  In  the  case  of  Netherlands  towns  state  also  the  name  of  the 
municipality.

(14)
(15)

(16)  Must be stated for insured persons of Spanish, French or Italian nationality. Here, the territorial area or district in which the place of birth
is located should be stated (example: in the case of France if the place (commune) of birth is Lille, the department of birth should be shown
as ‘Nord’ followed by the area code if known to the insured person; in this case: 59. The complete entry should therefore read: ‘Nord 59’).
In the case of persons born in Spain, state only the province.
The symbol of the insured person’s country of birth in accordance with the international motor vehicle registration code.
If  the  form  is  being  sent  to  a  Danish,  Finnish,  Icelandic  or  Norwegian  institution,  give  the  deceased  person’s  last  address  in  the 
corresponding country in the box below.

(17)
(18)

Address (3)

................................................................................................................................................................................

......................................................................................................................................................................................................................

(19)

(20)

Complete  if  the  form  is  being  sent  to  a  Belgian,  German,  Greek,  Spanish,  Irish,  Italian,  Luxembourg,  Austrian,  Portuguese,  United
Kingdom, Finnish, Icelandic or Norwegian institution.
For the purposes of the Belgian and Luxembourg institutions, mark the first box for any accident, irrespective ot its nature.

7

E 203   

(21)
(22)
(23)

(24)
(25)
(26)
(27)

(28)

(29)

Complete if the form is being sent to a German, Greek, Spanish, Luxembourg, Austrian, Portuguese or Liechtenstein institution.
Complete if the form is being sent to a Finnish institution.
If the form is being sent to a Greek, French, Finnish or Swedish institution, complete indicating the declared date of the disappearance
to the police.
For the purposes of Spanish, Finnish, Swedish or Liechtenstein institutions, state also the circumstances of the disappearance.
Complete if the form is being sent to a Greek, French, Luxembourg or Austrian institution.
This information is required by the Netherlands institutions.
If there are several persons to be entered in box 11, please insert on one or more additional copies of page 3, as boxes 11 and 12 must
be completed for each person separately. Please note that in the Netherlands, widows, divorced or separated women may be entitled to
a widow’s pension if they are younger than 65 years of age. Widows, divorced or separated women who are older than 65 years of age
are entitled to an old-age pension. In these cases, an E 202 form must be drawn up in the name of the woman concerned.
In Portugal, the survivor’s pension is payable to relatives of the deceased in the ascending order if they were dependants of the deceased
and where there are no other members of the family (spouse, ex spouse and relatives in the descending order) who are entitled to receive
the benefits.
In Liechtenstein, the widow and the divorced or separated wife may be entitled to a widow’s pension, if they are less than 62 years of
age. This entitlement is terminated by remarriage. The widow, the divorced or separated wives beyond the age of 62 may have a claim
to an old-age pension. In this case, a form E 202 has to be completed on behalf of the woman.
In Norway, both separated and divorced spouses may be entitled to a survivor’s pension.
For the purposes of Italian institutions, complete also additional page No 1.
For the purposes of Swedish institutions, complete also additional page Nos 6 to 8.
If the form is being sent to a German, Austrian or Liechtenstein institution, state — if applicable — the address of the legal representative
(legal counsellor, guardian, curator, …) in the box below.

Address (3)

................................................................................................................................................................................

......................................................................................................................................................................................................................

(30)

If the form is being sent to a Danish, Finnish, Icelandic or Norwegian institution, give the claimant’s last address in the corresponding
country in the box below.

Address (3)

................................................................................................................................................................................

......................................................................................................................................................................................................................

To be completed only if the form is to be forwarded to a Portuguese institution.
To be completed for the purposes of Netherlands institutions, if known.
For the purposes of Netherlands institutions complete Sofi number, if known. For the purposes of Belgian institutions complete national
social security number (NISS).
For the purposes of Spanish or Swedish institutions, state whether the separation is a de facto or de jure.
For the purposes of a Liechtenstein institution, state also the date of birth of the spouse.
Complete  if  the  form  is  being  sent  to  an  Italian,  Netherlands or  Greek  institution. In  Italy  the  following  sources  are  not  considered  as
income: the claimant’s home, family benefits, cash benefits for accident at work or occupational diseases or purely assistance benefits.
Complete if the form is being sent to a Belgian, Danish, Portuguese, Spanish, French, Italian, Luxembourg, Netherlands, Finnish, Swedish,
Icelandic  or  Norwegian  institution.  If  the  form  is  being  sent  to  an  Italian  institution,  indicate  all  income  except  for  the  following:  the
claimant’s home, family benefits, cash benefits for accident at work or occupational disease or purely assistance benefits.
Complete if the form is being sent to a German, Greek, French, Italian, Luxembourg, Netherlands, Austrian, Portuguese, Finnish, Swedish,
Icelandic  institution.
Complete if the form is being sent to a Belgian, Netherlands or Swedish institution (add form E 213).
For the purposes of Portuguese institutions, complete also additional page No 3.
Complete if the form is being sent to a Greek, French, Irish, Netherlands, Austrian or United Kingdom institution.
If the form is being sent to a Belgian, German, Spanish, French, Italian, Netherlands, Austrian, Portuguese or Finnish institution, please
specify whether this is a personal or a survivor’s pension.
Complete if the form is being sent to a Belgian, German, Luxembourg, Austrian, Portuguese or Finnish institution.
Complete if the form is being sent to a Belgian, German, French, Italian, Luxembourg, Netherlands, Austrian, Finnish, Swedish, Icelandic
or Norwegian institution.
For the purposes of Finnish institutions, please state income from interest, rent and dividend.
Complete if the form is being sent to a Danish, Spanish, Luxembourg, Netherlands, Austrian, Icelandic or Norwegian institution (annual
amount) to an French institution (quarterly amount) or to an Italian institution (monthly amount).
State the type of income taken into account by the investigating institution in applying its overlapping rules.

(31)
(32)
(33)

(34)
(35)
(36)

(37)

(38)

(39)
(40)
(41)
(42)

(43)
(44)

(45)
(46)

(47)

8

E 203   

(48)

(49)
(50)

(51)

(52)
(53)

(54)

(55)

(56)

(57)

Complete  if  the  form  is  being  sent  to  a  Danish,  German,  Greek,  Spanish,  French,  Irish,  Italian,  Luxembourg,  Netherlands,  Austrian,
Portuguese, Finnish, Swedish, United Kingdom, Icelandic or Liechtenstein institution. If the form is being sent to a Portuguese institution
please indicate the names of any stepchildren for whom the deceased was required to provide food, and the names of any grandchildren.
For an Italian institution, if the entitled person is an only child, E 203/additional page No 2 should also be completed. If the form is being
sent to a Spanish institution, E 203/additional page No 2 should also be completed.
For Norwegian institutions, state only the children of the deceased.
Indicate with the following symbols which date you are referring to: * birth, °° marriage, † death. If the form is being sent to a Finnish insti-
tution, indicate the Finnish population register number.
If the form is being sent to a Finnish institution, please state whether the child in question is common to the widow/widower and the
deceased or whether the child is of either the deceased or of the widow/widower alone. Please state also if the widow/widower is raising
the child. State also nationality in case of adoption.
This information should be provided from the date of the parent’s death, showing any subsequent change in rate.
Please complete also additional page No 2 if the form is being sent to a German or Italian institution. Please complete additional page
No 4 if the form is being sent to a Portuguese institution.
Indicate the common address. If any of the children live at a different address, indicate in the box below.

Surname and forenames

............................................................................................................................................................................

Address (3)

............................................................................................................................................................................

........................................................................................................................................................................................................................

Indicate whether the child is married, an invalid, deceased (date of death), an apprentice or a student. for the purposes of Portuguese
institutions, in the case of an invalid child requiring the assistance of another person, complete additional page No 3. For the purposes
of a Liechtenstein institution, a copy of the indentures of apprenticeship or a certificate of the training centre should be attached for each
child being a student or apprentice between the age of 18 and 25.
For the purposes of Spanish and Norwegian institutions, state whether the children are economically dependent on the insured person
and whether any of the children have a disability. In the latter case, state whether the child receives any invalidity pension in his or her
own right.
For  the  purposes  of  Portuguese  or  Norwegian  institutions,  if  one  of  the  children  has  a  legal  representative  other  than  the  person 
representing the other children, indicate this in the box below:

Child

— Surname

— Forename

Legal representative

— Surname

— Forenames

— Address (3)

.....................................................................................................................................................................

.....................................................................................................................................................................

.....................................................................................................................................................................

.....................................................................................................................................................................

.....................................................................................................................................................................

....................................................................................................................................................................................................................

(58)
(59)

To be completed for the Italian and Greek institutions.
If the form is to be sent to a Liechtenstein institution, add form E 207 concerning the insured deceased person and concerning the (last
and any former) spouse(s) of the insured person.

9

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
E 203 additional page No 1

ITEM 11 ‘RIGHTFUL CLAIMANTS OTHER THAN CHILDREN’
ADDITIONAL INFORMATION FOR ITALIAN INSTITUTIONS

To be completed if the pension is claimed abroad by the sole surviving parent, an unmarried brother or an unmarried sister of the deceased 

worker.

1

If the claimant is the sole surviving parent, please state whether the deceased worker is survived by

M spouse

M children

M yes

M yes

M no

M no

2

If the claimant is a brother or sister of the deceased worker, please state whether the latter is survived by

M spouse

M children

M parents

M yes

M yes

M yes

M no

M no

M no

1

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
E 203 additional page No 2

ITEM 15 ‘CHILDREN’
ADDITIONAL INFORMATION

(complete a separate page for each child)

1

M The child named in line No

.........................

of item 15.1

M pursues gainful employment

M does not pursue gainful employment

1.1

If the answer is in the affirmative, please state

Type of occupation (employed or self-employed)

Amount of income (1) per

M week

M month

M year

.....................................................

2

M The child named in line No

......................... of item 15.1

M Has other sources of income

M does not have any other sources of income

2.1

If the answer is in the affirmative, please specify

— nature of income

M social security benefits
amount per

M other income  (2)
amount per

M week

M month

M year

.....................................................

M week

M month

M year

.....................................................

3

In respect of the child named in line No

......................... of item 15.1 the following person

(surname, forename)

..........................................................................................................................................................................

(address)

..........................................................................................................................................................................

..........................................................................................................................................................................................................................

is entitled to family benefits or allowances by virtue of his/her pursuit of a professional activity or trade 

(Art. 79.3 of Reg. 1408/71)

Amount

...............................................................................................................................................................................................

Commencing on

.....................................................................................................................................................................................

3.1

The following institutions are responsible for paying these family benefits or allowances:

(name)

.................................................................................................................................................................................

(address)

.................................................................................................................................................................................

..........................................................................................................................................................................................................................

(name)

.................................................................................................................................................................................

(address)

.................................................................................................................................................................................

..........................................................................................................................................................................................................................

4

The child named in line No

............................

of item 15.1 is unfit for work. Form E 404 is enclosed.

(1)

(2)

All income should be declared with the exception of severance payments, family benefits, wage arrears, life annuities for accidents at work or occupational
disease, war pensions, pensions for disablement sustained during military service, attendance allowance, travel allowance.
‘Other income’ means income from real estate or capital (bank or postal deposits or current accounts, government stock, investment funds, shares, bonds,
etc.).

1

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
E 203 additional page No 3

ITEM 12 (12.8)
ADDITIONAL INFORMATION FOR THE PURPOSES OF PORTUGUESE INSTITUTIONS

To be completed where the claimant has declared that he/she needs the assistance of another person to perform the ordinary activities of

everyday life.

1

Identity of the other person

1.1

Surname

.......................................................................................................................................................................................

Forenames

.......................................................................................................................................................................................

1.2

Address (street, number, post code, district, country)

...........................................................................................................

..........................................................................................................................................................................................................................

2

Information provided by the investigating institution

2.1 M We have  ascertained that the person referred to above is the other person who actually assists the claimant in performing the

ordinary activities of everyday life (personal hygiene, feeding, movement, etc.)

2.2 M Assistance provided by the other person referred to above has not been ascertained

3

Has the need for assistance been caused by a third party?

M Yes

M No

4

Is the person concerned in receipt of an allowance for assistance by a third party or a similar benefit?

M Yes

M No

4.1

Name and address of paying institution

.......................................................................................

..........................................................................................................................................................................................................................

4.2 Monthly amount

.................................................................................................................................................................................

1

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
ITEM 15 ‘CHILDREN’
ADDITIONAL INFORMATION FOR THE PURPOSES OF PORTUGUESE INSTITUTIONS

E 203 additional page No 4

The descendants shown in box 15.1 are in one of the following situations:

1.

Attending school: indicate for each child whether the educational institution in question is at secondary, intermediate or higher

education level or whether the course being attended is a first degree course or a postgraduate course.

..........................................................................................................................................................................................................................

..........................................................................................................................................................................................................................

..........................................................................................................................................................................................................................

2

Undergoing vocational training: indicate for each child the level of school education (secondary, intermediate or higher) required to

enrol for the course in question and the monthly income received, if any.

..........................................................................................................................................................................................................................

..........................................................................................................................................................................................................................

..........................................................................................................................................................................................................................

3

Actively employed: indicate for each child the monthly income received.

..........................................................................................................................................................................................................................

..........................................................................................................................................................................................................................

..........................................................................................................................................................................................................................

4

Unable  to  work:  indicate  for  each  child  if  social  security  benefits  are  received  because  the  child  is  unable  to  work,  the  nature  of  the

disability and the monthly amount.

..........................................................................................................................................................................................................................

..........................................................................................................................................................................................................................

..........................................................................................................................................................................................................................

1

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
E 203 additional page No 5

ADDITIONAL INFORMATION FOR THE PURPOSES OF NORWEGIAN INSTITUTIONS

1

To be completed if the claimant was not married to the deceased at the time of death

1.1 Was the claimant previously married to the deceased?

M Yes

M No

1.2

Does the claimant have or has he/she had children by the deceased?

M Yes

M No

2

To be completed if the widow/widower is living with another person as husband and wife

2.1

Has the claimant been previously married to the cohabiting partner?

M Yes

M No

2.2

Does the claimant have or has he/she had children by the cohabiting partner?

M Yes

M No

1

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
ITEM 11
ADDITIONAL INFORMATION FOR THE PURPOSES OF SWEDISH INSTITUTIONS

E 203 additional pages No 6 to 8

1

Is the claimant living with a child under 21 for whom a child’s pension/annuity is being requested or received?

M No

2

Does the claimant have a child by the deceased?

M No

M Yes

M Yes

To be completed if the claimant was married to the deceased at the time of death

3.1 Was the claimant living with the deceased at the time of death?

M No

M Yes

Since

.....................................................

3.2

If the answer in 3.1 is ‘No’ was the survivor economically dependant on the deceased?

M No

M Yes

4

At the time of death, was the claimant living with a child under 12 of whom the claimant and/or the deceased had custody?

M No

M Yes

Name of the youngest child

........................................................................................................................................

Swedish personal number/date of birth

.................................................................................................................

To be completed if the claimant was married to but not living with the deceased

5

Did  the  claimant  after  having  ceased  living  with  the  spouse  but  before  his/her  death  lived  with  a  man/woman  to  whom

the claimant was previously married or by whom the claimant has or has had a child?

M No

M Yes

To be completed if the claimant was not married to the deceased at the time of death

6

Was the claimant previously married to the deceased?

M No

M Yes

7

Does the claimant have or has he/she had children by the deceased?

M No

M Yes

8

Was the claimant expecting a child by the deceased at the time of death

M No

M Yes

Anticipated confinement date

.................................................

(year, month, day)

9

Please answer question number 4

1

E 203 additional pages No 6 to 8

To  be  completed  by  women  born  in  1944  or  earlier  for  assessment  of  entitlement  to  widow’s  pension/widow’s  annuity  in 

accordance with previous legislation

10 Was the claimant married to the deceased at any time before 31 December 1989?

M No

M Yes

11

Did the claimant have a child by the deceased on or before 31 December 1989?

M No

M Yes

12 Was the claimant living with the deceased on 31 December 1989?

M No

M Yes

13

The marital status of the claimant on 31 December 1989?

M Unmarried

M Married

M Widow

M Divorced

14

The marital status of the deceased on 31 December 1989?

M Unmarried

M Married

M Widower

M Divorced

To be completed if, at the time of death, the claimant was under 50 years of age and/or at the time of death the claimant had not

been married to or living with the deceased for at least five years

15

Is the claimant living with a child under 16 of whom she has custody?

M No 

M Yes

Name of the youngest child

........................................................................................................................................

Swedish personal number/date of birth

.................................................................................................................

16

At the time of death, was this child permanently living with the claimant or in the common home of the claimant and the deceased?

M No

M Yes

17

If the child is not a child of the claimant, a copy of a court judgment or other document showing who has custody of the child, should

be enclosed

To be completed by women born in 1945 or subsequently for assessment to widow’s pension/widow’s annuity in accordance with

previous legislation

18

Please answer the questions number: 11 to 15

19

On 31 December 1989 was the claimant living with a child under 16 of whom she had custody?

M No

M Yes

Name of the youngest child

........................................................................................................................................

Swedish personal number/date of birth

.................................................................................................................

2

20 Was this child permanently living with the claimant or in the common home of the claimant and the deceased on 31 December 1989?

M No

M Yes

E 203 additional pages No 6 to 8

To be completed if the claimant was married to the deceased on 31 December 1989

21 Was the claimant living apart from her husband on 31 December 1989?

M No

M Yes

22

After ceasing to live with her husband but before his death did the claimant live with a man to whom she has been married or

by whom she has or has had a child?

M No

M Yes

23 Was the claimant living with a child under 16 of whom she had custody on 31 December 1989?

M No

M Yes

Name of the youngest child

........................................................................................................................................

Swedish personal number/date of birth

.................................................................................................................

24

On 31 December 1989 was this child permanently living with the claimant or in the common home of the claimant and the deceased?

M No

M Yes

To  be  completed  if,  at  the  time  of  death,  the  claimant  was  under  50  years  of  age  and/or  the  time  of  death  the  claimant  had  not

been married to or living with the deceased for at least five years

Please answer the questions number: 16 to 18

3

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
EUROPEAN COMMUNITIES
Social Security Regulations
EEA*

See ‘Instructions’ on pages 8 and 9

E 204                  (1)

Country

Identification No (2)

Institution concerned (where applicable, liaison body)

1)

2)

3)

4)

5)

..........................................................................................................................................................................................................................

..........................................................................................................................................................................................................................

..........................................................................................................................................................................................................................

..........................................................................................................................................................................................................................

..........................................................................................................................................................................................................................

INVESTIGATION OF A CLAIM FOR AN INVALIDITY PENSION

Reg. 1408/71: Art. 44 to 51a; Art. 77
Reg. 574/72: Art. 36 to 38; Art. 41 to 43; Art. 45 to 47; Art. 49; Art. 90 (**); Art. 111

The investigating institution should complete this form and send one copy to each of the institutions with which the worker has been insured
(institutions concerned) or to the liaison body.

1

Institution to which the form is addressed (institution concerned or liaison body, as applicable)

1.1

1.2

Name

Address (3)

...............................................................................................................................................................................

...............................................................................................................................................................................

...................................................................................................................................................................................................................

A. Information concerning insured person (3a)

2

2.1

2.2

2.3

2.4

2.5

2.6

2.7

2.8

Surname (4)

...................................................................................................................................................................

Surname at birth (4)

...................................................................................................................................................................

Forenames (5)

...................................................................................................................................................................

Previous names (6)

...................................................................................................................................................................

Sex (7)

...................................................................................................................................................................

Father’s surname and forenames (8)

.........................................................................................................................................

Mother’s surname and forenames (8)

.........................................................................................................................................

Civil status
M single

M divorced (9)
since (10)

............................

M married since (10)

....................... M remarried (9)

M separated
since (10)

M widow or widower

.........................

M cohabiting since (11) (12) (13)
Taxpayer’s number (14)

2.9

Code of tax district

2.10

Sofi number (15)

since (10)

............................

since (10)

.........................

............................................................................................................................................

3

4

4.1

4.2

4.3

4.4

Nationality (16)

.......................................................................................................

D.N.I. (17)

.............................

Details of birth (18)

Date of birth (18)

...............................................................................................................................................................................

Place of birth (19)

...............................................................................................................................................................................

Province, department, county (20)

.........................................................................................................................................

Country (21)

...............................................................................................................................................................................

(**) Art. 90 of Reg. 574/72 is not applicable in the Netherlands.

1

E 204

5

Address and bank particulars

5.1

Address (3) (22) (23)

.........................................................................................................................................................................

.........................................................................................................................................................................

.........................................................................................................................................................................

5.2

Bank particulars or address for direct payment

Name of the beneficiary as recognised by the bank

Name of the bank

Address of the bank

Bank identification code

Bank account

......................................................................................

......................................................................................

......................................................................................

......................................................................................

......................................................................................

6

6.1

6.2

7

7.1

7.2

7.3

Insurance No at the investigating institution

...................................................................................................

Reference No of file at the investigating institution

...................................................................................................

Date which has been determined as the commencement of invalidity

.........................................................................

Date of commencement of incapacity for work followed by invalidity:

.........................................................................

The person concerned
M is still engaged in

M gainful employment

M is no longer engaged in
M activity as a civil servant

M self employment

7.4

If he/she is engaged in gainful employment or in an activity as a civil servant indicate (24)

Amount of wage/salary

......................................

No of hours worked per week

.............................

7.5

7.6

7.7

Date of cessation of gainful employment
M as an employed person
M as a self-employed person
M as a civil servant
Type of activity (24a)

...................................................................................................................................

...................................................................................................................................

...................................................................................................................................

...................................................................................................................................

If he/she is carrying out an activity as a self-employed person indicate the amount of professional income (25): ......................................................

...................................................................................................................................................................................................................

Nature of activity

..............................................................................................................................................

.........................................................................................................

Other known resources (amount and nature) (26)
7.8
7.9 M The claimant states that he/she has no income(27)
7.10

The invalidity
M is assumed
M is the result of
M is the result of
At the moment of commencement of incapacity for work, the claimant was
M insured as a worker against invalidity
M insured other than as a worker against invalidity
M not insured against invalidity

M is not assumed
M is not the result of
M is not the result of

to have been caused by a liable third party

an accident at work or an occupational disease (28)

an accident other than an accident at work or an occupational disease (29)

Since the commencement of incapacity for work, the person concerned
M has followed occupational rehabilitation courses
M has not followed occupational rehabilitation courses
Where appropriate, indicate

for what kind of occupation

......................................................................................................................................................

the employer for whom he/she works in this new occupation

Name of employer or firm

......................................................................................................................................................

Address (3)
...................................................................................................................................................................................................................

......................................................................................................................................................

8.4

Date of commencement and of termination of this employment

................................................................................................................

2

7.11

8

8.1

8.2

8.3

9

9.1

The insured person

E 204

has applied

receives the

for the following benefits

following benefits

9.2

9.3
9.4

9.5

9.6

9.7

9.8

9.9

9.10

9.11

9.12

9.13

Continued wage or salary payments in case of illness

Sickness insurance cash benefits for incapacity of work
Rehabilitation allowances

Invalidity pension (30)

Old-age pension (30)

Survivor’s pension (30)

Pension for accident at work or occupational disease

Unemployment benefits or early retirement benefit

Benefits in respect of assistance by another person (31)

Family benefit (32)

Refund of contributions

Transfer of contributions (33)

9.14 Other benefits (please specify)

9.15

Institutions responsible for paying the benefits indicated in 9.2 to 9.11

[name, address (3)]

M
M
M
M
M
M
M
M
M
M
M
M
M  Yes

M
M
M
M
M
M
M
M
M
M
M
M
M  No

9 ........

9 ........

9 ........

9 ........

...................................................................................................................................................................................................

...................................................................................................................................................................................................

...................................................................................................................................................................................................

...................................................................................................................................................................................................

9.16

Additional information on the benefits listed in 9.2 to 9.11

Re benefits in item

File reference No

Period or date on which due

Amount

9  ........................

.............................................................................................................. M weekly
M monthly
M annual

M daily

9  ........................

.............................................................................................................. M daily

..............................................................

M weekly
M monthly
M annual

9  ........................

..............................................................................................................................................................................

M daily
M weekly
M monthly
.............................................................................................................. M annual

9..........................

...............................................................
M daily
M weekly
M monthly
M annual

...............................................................

3

E 204

9.17

The following are regarded as advances on the pension claimed
M sickness insurance benefits for incapacity for work
M unemployment benefits
M  ..............................................................................................................................................................................................................

9.18

The insured person is entitled to sickness benefits in kind under the legislation administered by the investigating institution

M Yes

M No

M Not yet determined

9.19

The investigating institution, or other institution, awards an increase in benefit to the extent that the applicant is incapable of carrying

out normal day-to-day activities unaided

M Yes

M No

M Not yet determined

— In addition to the benefit referred to at point 9…, the applicant receives an additional benefit if he/she is incapable of carrying out

normal day-to-day activities

— The additional benefit may be reduced if a similar benefit is granted by another institution concerned

M Yes

M No

M Not yet determined

10

Additional information for the application of provisions on overlapping benefits

10.1 When benefits of the same kind are granted by the institution or institutions concerned, the pension calculated by the investigating

10.2

institution may be reduced
M Yes
The pension calculated by the investigating institution may be reduced
M Yes
— because one or several of the benefits specified at point 9 are taken into account

M No

M No

M Not yet determined

M Not yet determined

9

............

9 ............

9 ............

9 ............

— because of income other than the benefits specified at point 9

M income from employment/self-employment
M other

..................................................................................................................................................

(34)

10.3

The institution concerned is requested to specify the part of the pension accruing from voluntary contribution payments (point 6.7 

in form E 210)
M Yes
The benefit due from the investigating institution is (partly or entirely) based on voluntary contributions
M Yes

M No

M No

10.4

4

E 204

B. Information concerning the members of the insured person’s family

11

M Spouse (13) (17) (35)

11.1

Surname (4) (17)

M Cohabiting partner (11)

...................................................................................................................................................................................................................

11.2

Forenames

Previous names

.............................................................................................

................................................................................................................

11.3

11.4

Date of birth

Address (3)

................................................

Place of birth (19)

...................................................................

...............................................................................................................................................................................

11.5

11.6

...................................................................................................................................................................................................................

Date of marriage/cohabiting  .....................................................................................................................................................................

The spouse/partner

M pursues
M does

M does not pursue gainful employment
M does not have other income

11.7 Where appropriate, state amount of

11.8

M weekly earnings (36)
The spouse/partner
M has submitted a claim for a pension under the scheme for

.....................

M monthly earnings (37)

.....................

M annual earnings (38)

........................

M employed persons
M civil servants
M self-employed persons
M does not receive a pension

M Receives a pension
In the affirmative, indicate
Type of pension

11.9

11.10 Pension No (17)

............................................................................................................................

............................................................................................................................

11.11 Institution responsible for payment

............................................................................................................................

...................................................................................................................................................................................................................

11.12 Amount
11.13 The spouse/partner M receives  
M Unemployment M sickness

M monthly

M quarterly
M does not receive other benefits (39)
M invalidity

M other

M annual

...................................

11.14 Date of commencement

..........................................................................................................................................................................

11.15 Amount

M monthly

11.16 Other known resources

M quarterly
Type  

M annual

...................................

....................................................................................................................

...................................................................................................................................................................................................................

Amount (40) 

.........................................................................................................

5

12

Children (13) (17)

12.1

Surname (4) (17)

Forenames

E 204

Place and date of
birth, marriage or
death (41)

Relationship
(i.e.: own child, adopted child,
foster child)

1.

.......................................................................

........................................

.................................

.................................................

.......................................................................

........................................

.................................

.................................................

.......................................................................

........................................

.................................

.................................................

.......................................................................

........................................

.................................

.................................................

2.

.......................................................................

........................................

.................................

.................................................

.......................................................................

........................................

.................................

.................................................

.......................................................................

........................................

.................................

.................................................

.......................................................................

........................................

.................................

.................................................

3.

.......................................................................

........................................

.................................

.................................................

.......................................................................

........................................

.................................

.................................................

.......................................................................

........................................

.................................

.................................................

.......................................................................

........................................

.................................

.................................................

4.

.......................................................................

........................................

.................................

.................................................

.......................................................................

........................................

.................................

.................................................

.......................................................................

........................................

.................................

.................................................

.......................................................................

........................................

.................................

.................................................

12.2

The following institution is competent to grant benefits pursuant to Art. 77 of Reg. 1408/71
M the investigating institution
M the institution designated as follows

...................................................................................................................................

12.3

The investigating institution
M for the children referred to in lines No

............ of item 12.1, is granting benefits until

inclusive

...............................................................................................

amount of family allowance and/or orphan’s pension per child

....................................................................

(42)

.............................................................................................................................................................................................................

.............................................................................................................................................................................................................

M is not granting benefits in respect of the children referred to in lines No

............ of item 12.1 (43)

M has not yet taken a decision regarding entitlement to benefits

12.4

Address (3) (44)
...................................................................................................................................................................................................................

.........................................................................................................................................................................

...................................................................................................................................................................................................................

12.5

Remarks (45) (46)
...................................................................................................................................................................................................................

.........................................................................................................................................................................

13

Ascendants and other members of the household (47)

13.1

Surname (4)

Forenames

Date of birth 

Relationship

............................................................................

........................................

.................................

.................................................

............................................................................

........................................

.................................

.................................................

............................................................................

........................................

.................................

.................................................

............................................................................

........................................

.................................

.................................................

............................................................................

........................................

.................................

.................................................

13.2

Address (3) (44)

...............................................................................................................................................................................

...................................................................................................................................................................................................................

13.3

Remarks

...............................................................................................................................................................................

...................................................................................................................................................................................................................

6

C. Miscellaneous information

14

14.1

M Date of submission of this claim
........................................................................................................
M Date from which the pension is payable in the country of the investigating institution
...................................
...................................................................................................................................................................................................................
The claimant has asked for payment (48)
M directly in the State of residence
M to a representative in the State of origin

E 204

15

15.1

M pays
The investigating institution
benefits on a provisional basis under Art. 45.1 of Reg. 574/72
If not, the institutions concerned are requested to investigate the possibility of paying benefits on a provisional basis under Art. 45.2
of Reg. 574/72

M does not pay

16

M There are grounds
for making deductions to compensate for overpayment in accordance with Art. 111 of Reg. 574/72

M There are no grounds

16.1

Any pension arrears
M can
be paid direct to the beneficiary

M cannot

17.1

Attached forms

M E 205

M E 206

M E 207 (49)

M E 213

17.2

Please send us your

M E 205

M E 210

M Decision

M Arrears

Remarks

...............................................................................................................................................................................

...................................................................................................................................................................................................................

...................................................................................................................................................................................................................

18

Investigating institution

18.1 Name

.........................................................................................................................................................................

18.2

Address (3)
...................................................................................................................................................................................................................

.........................................................................................................................................................................

18.3

Stamp

18.4

18.5

Date

Signature

................................................

..........................................................................

7

E 204

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

INSTRUCTIONS

NOTES

*

(1)

EEA Agreement on the European Economic Area, Annex VI, Social Security: for the purposes of this Agreement the present form shall
also apply to Iceland, Liechtenstein and Norway.
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;  A  =  Austria;  P  =  Portugal;  FIN  =  Finland;
S = Sweden; GB = United Kingdom; IS = Iceland; FL = Liechtenstein; N = Norway.

(2) Where the form is being sent to a Danish institution, indicate the CPR number; to a Finnish institution, indicate the Finnish population
register number; to a Swedish institution, indicate the Swedish personal number, to an Icelandic institution, indicate the Icelandic personal
identification number (kennitala); to a Liechtenstein institution, indicate the AHV insurance number; to a Norwegian institution, indicate the
Norwegian personal identification number (fødselsnummer), to a German institution of the general social security scheme, indicate the
insurance number (VSNR); to an institution of the social security scheme for civil servants, indicate the personal identification number
(PRS-Kenn-Nr.), to a Portuguese institution indicate also the registration number with the general pensions scheme, if the person con-
cerned has been insured under the social security scheme for civil servants in Portugal.
Street, number, post code, town, country, telephone number.
For Germany and Austria, the term ‘insured persons’ encompasses individuals insured under the general social security scheme as well
as civil servants and individuals treated as such who are insured under a special scheme. The term ‘pension’ is considered to encompass
pensions for civil servants.

(3)
(3a)

(4) — For  surname  please  state  usual  surname  or  surname  acquired  by  marriage.  If  the  form  is  being  completed  by  a  Netherlands
institution, in cases where the insured person or the rightful claimant is a married woman or a woman who was married before, put
the present or last husband’s surname for current surname.

— The ‘surname at birth’ must always be given; if same as current surname, put ‘IDEM’. If the form is being completed by a Netherlands
institution, in cases where the insured person or the righful claimant is a married woman or a woman who was married before, put
the maiden name for surname at birth.

— Expressions such as ‘called …’ or ‘alias …’ and prefixes to surnames must be written in full in the order in which they appear on the

birth certificate.

— 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.

(5)
(6)

(7)
(8)

(9)

(10)

(11)
(12)

(13)
(14)
(15)

Give all forenames in the order in which they appear on the birth certificate.
To be stated particularly in the case of adoption or in the case of other names in current use; expressions such as ‘called …’ or ‘alias …’
and prefixes to surnames must be written in full in the order in which they appear on the birth certificate.
Put M for male and F for female.
This information is required when the worker is a Spanish national, or when the form is to be sent to a French institution, regardless of the
worker’s nationality.
Complete where possible if the form is being sent to a German, Belgian, French, Italian, Luxembourg, Netherlands, Austrian, Portuguese,
Swedish, Liechtenstein or Norwegian institution.
For  the  purposes  of  Belgian,  Netherlands,  Swedish,  United  Kingdom  and  Liechtenstein  institutions,  specify  also  the  date  beside  the
corresponding box.
For the purposes of Belgian, Netherlands, Finnish, Icelandic and Norwegian institutions.
This information is based on a statement from the person concerned.
Under the Netherlands General Law on Old-Age Insurance the following persons are also regarded as ‘married’ or ‘spouse’: unmarried
persons of the same or different sexes who are living in a joint household on a permanent basis, unless they are persons who are blood
relations of first or second degree. A joint household means that two unmarried persons are jointly providing for their housing with each
contributing to the costs of the household or providing for each other’s upkeep in another way.
For the purposes of Norwegian institutions, please complete form E 204/additional page No 5.
To be completed only if the form is to be forwarded to a Portuguese institution.
For the purposes of Netherlands institutions complete Sofi number, if known. For the purposes of Belgian institutions complete national
social security number (NISS).

(16) Where appropriate, indicate the date of naturalisation.
(17)

In the case of Spanish nationals over 16 years of age, state the Número de Identificación Fiscal (N.I.F.). Failing this, indicate the number
of the Documento Nacional de Identidad (D.N.I.) or passport, even if they are out of date. If the aforementioned documents do not exist,
state ‘none’.
The day and the month should be shown by two digits each and the year by four digits (example: 1 August 1921 = 01.08.1921).
For French towns comprising several arrondissements, please give the number of the arrondissement (example: Paris 14). In the case of
Portuguese districts state also the parish and the local authority.

(18)
(19)

(20)  Must be stated for insured persons of Spanish, French or Italian nationality. Here, the territorial area or district in which the place of birth
is located should be stated (example: in the case of France if the place (commune) of birth is Lille, the department of birth should be shown
as ‘Nord’ followed by the area code if known to the insured person; in this case: 59. The complete entry should therefore read: ‘Nord 59’).
In the case of persons born in Spain, state only the province. In the case of Netherlands towns state also the name of the municipality.
The symbol of the insured person’s country of birth in accordance with the international motor vehicle registration code.
If the form is being sent to a German, Austrian or Liechtenstein institution, state — if applicable – the address of the legal representative
(legal counsellor, guardian, curator…) in the box below.

(21)
(22)

Address (3)

.....................................................................................................................................................................................

.....................................................................................................................................................................................................................

8

E 204

(23)

If  the  form  us  being  sent  to  a  Danish,  French,  Finnish,  Icelandic  or  Norwegian  institution,  give  the  claimant’s  last  address  in  the
corresponding country in the box below.

Address (3)

.....................................................................................................................................................................................

.....................................................................................................................................................................................................................

(24) Complete if the form is being sent to a Belgian, Danish, German, Greek, French, Italian, Luxembourg, Netherlands, Austrian, Swedish,

United Kingdom, Icelandic or Norwegian institution.

(24a) For the purposes of Portuguese institutions indicate the type of activity in which the person concerned was engaged during his/her last

three years of activity.

(25) Complete if the form is being sent to a Belgian, Danish, German, Greek, Spanish, French, Italian, Luxembourg, Netherlands, Austrian,

Portuguese, Icelandic or Norwegian institution.

(26) Complete if the form is being sent to a Danish, Spanish, Italian, Austrian, Portuguese, Icelandic or Norwegian institution. If the form is
being sent to an Italian institution all income should be indicated with the exception of the following: the claimant’s home, family benefits,
cash benefits for accident at work or occupational disease, purely assistance benefits.

(27) Complete  if  the  form  is  being  sent  to  an  Italian  or  Greek  institution.  In  Italy  the  following  sources  are  not  considered  as  income:  the

claimant’s home, family benefits, cash benefits for accident at work or occupational disease, purely assistance benefits.

(28) Complete if the form is being sent to a Belgian, German, Greek, Spanish, French, Italian, Luxembourg, Austrian, Portuguese or Norwegian

institution.

(31)

(29) Complete only if the form is being sent to a Greek, Spanish or Luxembourg institution.
(30)

For  the  purposes  of  Liechtenstein  institutions  indicate  also  if  the  insured  person  applied  for  M or  received  M the  pension  of  the
occupational scheme as cash compensation.
For the purposes of Portuguese institutions, where the insured person needs the assistance of another person, also complete additional
page No 2.
To be completed for Italian institutions.
For the purposes of Liechtenstein institutions.
State the type of income taken into account by the investigating institution in applying its overlapping rules.
For the purposes of a Liechtenstein institution, box 11 on page 5 is to be completed for each divorced or separated wife.

(32)
(33)
(34)
(35)
(36) Complete if the form is being sent to an Irish, Austrian or United Kingdom institution.
(37) Complete if the form is being sent to a Belgian institution.
(38) Complete if the form is being sent to a Danish, French, Italian, Luxembourg, Netherlands, Austrian, Icelandic or Norwegian institution.
(39) Complete if the form is being sent to a Belgian, Danish, German, French, Irish, Italian, Netherlands, Austrian, United Kingdom, Icelandic

or Norwegian institution.

(40) Complete  if  the  form  is  being  sent  to  a  Danish,  Italian,  Spanish,  Netherlands,  Icelandic  or  Norwegian  institution  (annual  amount);  to  a

French institution (quarterly amount) or to a Belgian, German, Greek or Austrian institution (monthly amount).
Indicate with the following symbols which date you are referring to:  * birth, °° marriage, † death.
Provide details of rates from date of pension award with any subsequent change of rate.
Please complete additional page No 1 enclosed if the form is being sent to a German, Italian or Norwegian institution.
Indicate the common address. If one of the children or ascendants lives at a different address, state this address in the box below.

(41)
(42)
(43)
(44)

Surname and forenames
Address (3)

...................................................................................................................................................................
...................................................................................................................................................................

.....................................................................................................................................................................................................................

(45)

(46)

Indicate whether the child is married, an invalid, deceased (date of death), an apprentice or a student, or if he/she receives a benefit or
has  his/she  own  source  of  income.  For  the  purposes  of  a  Liechtenstein  institution,  a  copy  of  the  indentures  of  apprenticeship  or  a
certificate of the training centre should be attached for each child being a student or apprentice between the age of 18 and 25.
For the purposes of Spanish and Norwegian institutions, please state whether the children are economically dependent on the insured
person and whether any of the children have a disability. In the latter case, state whether the child receives an invalidity pension in his or
her own right.

(47) Complete if the form is being sent to a Belgian or United Kingdom institution.
(48)
(49)

To completed for Italian and Greek institutions.
If form E 204 is to be sent to a Liechtenstein institution, add form(s) E 207 for the insured person and — if applicable — for the (actual
and former) spouse(s) of the insured person.

9

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
E 204 additional page No 1

ITEM 12 ‘CHILDREN’
ADDITIONAL INFORMATION

(complete a separate page for each child)

1

The child named in line No

...............................

of item 12.1

M pursues gainful employment

M does not pursue gainful employment

1.1

If the answer is in the affirmative, please state:

Type of occupation (employed or self-employed)

.....................................................................................................

Amount of income (1) per

M week

M month

M year

..................................................

2

The child name in line No

...............................

of item 12.1

M has other sources of income

M does not have any other sources of income

2.1

If the answer is in the affirmative, please specify

— nature of income

M social security benefits
amount per

M other income (2)
amount per

M week

M month

M year

..................................................

M week

M month

M year

..................................................

3

In respect of the children named in line No

...............................

of item 12.1 the following person

(surname, forename)

...........................................................................................................................................................................

(address)

...........................................................................................................................................................................

.........................................................................................................................................................................................................................
is entitled to family benefits or allowances by virtue of his/her pursuit of a professionnal activity or trade 
(Art. 79.3 of Reg. 1408/71)

Amount

..................................................................................................................................................................................

Commencing on 

..................................................................................................................................................................................

3.1

The following institutions are responsible for paying these family benefits or allowances:

(name)

(address)

..................................................................................................................................................................................

..................................................................................................................................................................................

.........................................................................................................................................................................................................................

(name)

(address)

..................................................................................................................................................................................

..................................................................................................................................................................................

.........................................................................................................................................................................................................................

4

The child named in line No

...............................

of item 12.1 is unfit for work. Form E 404 is enclosed.

(1)

(2)

All income should be declared with the exception of severance payments, family benefits, wage arrears, life annuities for accidents at work
or  occupational  disease,  war  pensions,  pensions  for  disablement  sustained  during  military  service,  attendance  allowance,  travel
allowance.
‘Other income’ means income from real estate or capital (bank or postal deposits or current account, government stock, investment funds,
shares, bonds, etc.).

1

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
E 204 additional page No 2

ITEM 9 (9.10)
ADDITIONAL INFORMATION FOR THE PURPOSES OF PORTUGUESE INSTITUTIONS

To  be  completed  where  the  claimant  has  declared  that  he/she  needs  the  assistance  of  another  person  to  perform  the  ordinary  activities  of
everyday life.

1

Identity of the other person

1.1

Surname

........................................................................................................................................................................................

Forenames

........................................................................................................................................................................................

1.2

Address (street, number, post code, district, country)

.....................................................................................................

.........................................................................................................................................................................................................................

2

Information provided by the investigating institution

2.1 M We have ascertained that the person referred to above is the other person who actually assists the claimant in performing the ordinary

activities of everyday life (personal hygiene, feeding, movement, etc.)

2.2 M Assistance provide by the other person referred to above has not been ascertained.

3

Has the need for assistance been caused by a third party?

M Yes

M No

4

Is the person concerned in receipt of an allowance for assistance by a third party or a similar benefit?

M Yes

M No

4.1

Name and address of paying institution

........................................................................................

.........................................................................................................................................................................................................................

4.2

Monthly amount

.....................................................................................................................................................................

1

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
E 204 additional page No 3

ADDITIONAL INFORMATION FOR THE PURPOSE OF FINNISH INSTITUTIONS

1

The claimant wishes to have the decision

M in Finnish

M in Swedish

2

2.1

2.2

2.3

3

3.1

3.2

4.

4.1

4.2

4.3

Item 9 ‘Insured person’

Is the claimant receiving or applying for any periodical pension-type benefits not reported in item 9 of E 204 form (for example benefits
payable under compulsory motor insurance due to a road accident)?

If in the affirmative, please specify

Type of the benefit

...........................................................................................................................................

Monthly gross amount of the benefit

...........................................................................................................................................

Institution paying the benefit

...........................................................................................................................................

The claimant’s education and training

Basic education

Item 2 ‘Insured person’

Further education and training (degrees, vocational training, courses; please give dates)

.........................................................................................................................................................................................................................

.........................................................................................................................................................................................................................

Employment — the latest contract of service

Primary occupation of the claimant

.....................................................................................................................................

Length of service in primary occupation

.....................................................................................................................................

Please check the alternatives that best characterise the claimant’s work

M light

M moderately hard

M hard

M indoor work

M outdoor work

M part time; please indicate the number of hours per day

................................... )

M full time

M time wages

M piece wages

M sedentary work

M day work

M standing work

M night work

4.4

Description of work (duties, working positions, tempo of work)

.........................................................................................................................................................................................................................

.........................................................................................................................................................................................................................

4.5

Description of work environment and circumstances (noise, dust, draught, heat, cold, potentially harmful substances, risk of accident,
etc.)

.........................................................................................................................................................................................................................

.........................................................................................................................................................................................................................

4.6

Have the claimant’s duties undergone a change?

M No

M Yes. Please indicate when and in what way

.....................................................................

..................................................................................................................................................

1

E 204 additional page No 3 (cont’d)

4.7

Has the claimant voluntarily taken a reduction in his or her working hours?

M No

M Yes. Please indicate how and when the claimant’s occupational activity was reduced, as well as to what extent the claimant remains

employed and what work he or she does (number of hours per week/month, amount of pay and fringe benefits)

.........................................................................................................................................................................................................................

.........................................................................................................................................................................................................................

4.8

4.9

Name and address of the claimant’s latest employer

...........................................................................................

Claimant’s duties in his or her latest occupation

...........................................................................................

4.10 When did the claimant’s latest contract of service begin?

...........................................................................................

4.11

If the contract of service is still in force, please indicate when it is to end (if known)

.........................................................................................................................................................................................................................

5

Self-employment

5.1

Has the claimant been self-employed?

M No —> please go to item 6

M Yes

5.2

5.3

If in the affirmative, please indicate since when

............................................................................

Is the claimant currently self-employed?

M No 

M Yes

5.4

Ownership particulars

M business is still owned by the claimant or his/her spouse

M business has been sold

M business has been leased

6

Unemployment

6.1

Has the claimant been unemployed during the last three years?

M No 

M Yes

6.2

If in the affirmative, has the claimant received or applied for unemployment benefits during the last three years?

M No

M The claimant has received or is currently receiving unemployment benefits

M The claimant is applying for unemployment benefits; please indicate the benefit and the institution

.........................................................................................................................................................................................................................

7

Pensioners’ care allowance under the National Pensions Act

The pensioners’ care allowance may be awarded to persons whose functional capacity has on account of an illness or injury diminished
with the result that he or she is not capable of performing ordinary activities of everyday life unaided, or that the illness or injury imposes
an added long-term financial strain.

7.1

Is the claimant applying for the pensioners’ care allowance?

M No

M Yes

2

E 204 additional page No 4

ADDITIONAL INFORMATION FOR THE PURPOSES OF NORWEGIAN INSTITUTIONS

1

The claimant

1.1 M The claimant has been employed/self-employed

Income during the period immediately preceding present disability
Weekly working hours preceding disability

.................. per year

1.2 M The claimant has, during the period immediately preceding present disability, been occupied partly by domestic work, partly been

employed/self-employed

1.3

The claimant

has applied for 

is receiving 

1.3.1 Basic benefit covering extra expenses

due to permanent illness

1.3.2 Assistance benefit

M

M

M

M

2

The spouse

M has applied for a pension as a non-working person
M is receiving a pension as a non-working person
M is not receiving a pension as a non-working person

3

Children

3.1

Are all of the children supported by the claimant

M Yes

M No

If ‘No’, state the name of the child (children) and the amount of the child’s income per year

.........................................................................................................................................................................................................................

3.2

If the parents are married
Do all the children live with both parents?

If ‘No’, state which child (children)

M Yes

M No

.........................................................................................................................................................................................................................

.........................................................................................................................................................................................................................

3.3

If the parents are not married
Do all the children live with both parents?

If ‘Yes’, give information about the other parent

M Yes

M No

Name

Date of birth

.............................................................................................................

.............................................................................................................

Income per year (All kinds, Specify)

.............................................................................................................

.........................................................................................................................................................................................................................

Name of the child (children) if not all children are concerned

.................................................................................

.........................................................................................................................................................................................................................

.........................................................................................................................................................................................................................

4

Cohabiting partner

4.1

Has the claimant previously been married to the cohabiting partner?

M Yes

M No

4.2

Does the claimant have or has he/she had children by the cohabiting partner?

M Yes

M No

1

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
EUROPEAN COMMUNITIES
Social Security Regulations
EEA*

See ‘Instructions’ on page 4

E 205         B     (1)

CERTIFICATE CONCERNING INSURANCE HISTORY IN BELGIUM

Reg. 1408/71; Art. 38; Art. 43a; Art. 45; Art. 48; Art. 51a; Art. 57.5
Reg. 574/72; Art. 42.1; Art. 43.1 to 3; Art. 69

1

Institution to which the form is addressed (institution concerned or investigating institution, as applicable)

1.1

1.2

Name

Address (2)

.............................................................................................................................................................................

.............................................................................................................................................................................

...................................................................................................................................................................................................................

...................................................................................................................................................................................................................

M Information concerning insured persons

M Information concerning deceased insured persons

2

2.1
2.2

2.3

2.4

2.5

2.6

2.7

2.8

3

4

4.1

4.2

4.3

4.4

Surname (3)
Surname at birth (3)

Forenames (4)

Previous names (5)

Sex (6)

...............................................................................................................................................................

...............................................................................................................................................................

...............................................................................................................................................................

...............................................................................................................................................................

...............................................................................................................................................................

Father’s surname and forenames (7)

.........................................................................................................................................

Mother’s surname and forenames (7)

.........................................................................................................................................

National social security number (NISS) (7a)

...................................................................................................

Nationality (8):

............................................................................................ D.N.I. (8a) 

.............................

Details of birth

Date of birth (9)

Place of birth (10)

...............................................................................................................................................................

...............................................................................................................................................................

Province, department, county (11)

................................................................................................................................................

Country (12)

...............................................................................................................................................................

5

Address (2)

....................................................................................................................................................................................................................

....................................................................................................................................................................................................................

6

6.1

6.2

6.3

Insurance No at the investigating institution

Reference No of file at the investigating institution

Reference No of file at the institution concerned

....................................................................

....................................................................

....................................................................

7

Rightful claimant (13)

7.1

Surname (3)
...................................................................................................................................................................................................................

7.2

Forenames

Surname at birth

Place of birth (10)

...................................................................

...............................................................

...................................................................

7.3

Date of birth

Sex

Nationality

D.N.I. (8a)

7.4

...................................
...................................................................
......................................................................................................................................................................................
Address (2)
...................................................................................................................................................................................................................

...................................................

......................................

1

E 205

B

Occupation (15) (16)

Remarks (14) (**) (17)

8

Year from
1 January
to 31
December

Before
1926

Number of days

Insurance
periods

Equivalent
periods

1926

1927

1928

1929

1930

1931

1932

1933

1934

1935

1936

1937

1938

1939

1940

1941

1942

1943

1944

1945

1946

1947

1948

1949

1950

1951

1952

1953

1954

1955

1956

1957

1958

2

8

(continued)

Year from
1 January
to 31
December

Number of days

Insurance
periods

Equivalent
periods

Occupation (15) (16)

Remarks (14) (**) (17)

E 205

B

1959

1960

1961

1962

1963

1964

1965

1966

1967

1968

1969

1970

1971

1972

1973

1974

1975

1976

1977

1978

1979

1980

1981

1982

1983

1984

1985

1986

1987

1988

1989

8.1

Total period of insurance under the Belgian social security scheme for employed persons — self-employed persons

+

notional additional days (*) 

8.2

Remarks:

(*) Equivalent periods for which no dates are specified.
(**) Additional insurance periods, early retirement pension (Article 5a, Royal Decree No 50)

3

8a

Admissible periods of service for the purpose of calculating pension under a special pension scheme in the public sector

Period

Number of months of
effective service (18)

Number of months of
other admissible 
periods (19)

Occupation

Increment (20)

Remarks (21)

E 205

B

General remarks

Total

Total

9

An insured person showing proof that he has completed an insurance period of less than one year
M may receive
a pension under national legislation (Art. 48.1 of Reg. 1408/71)

M may not receive

10

Institution completing the form

10.1 Name

10.2

Address (2) 
...................................................................................................................................................................................................................

...............................................................................................................................................................................
...............................................................................................................................................................................

10.3

Stamp

10.4

10.5

Date

Signature

.........................................................................

...................................................................................................

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.

NOTES

*

EEA Agreement on the European Economic Area, Annex VI, Social Security: for the purposes of this Agreement the present form shall also
apply to Iceland, Liechtenstein and Norway.
Symbol of the country to which the institution completing the form belongs B = Belgium.
Street, number, post code, town, country, telephone number.

(1)
(2)
(3) — For surname please state usual surname or surname acquired by marriage.

— The surname at birth must always be given; if same as current surname, put ‘IDEM’.
— Expressions such as ‘called …’ or ‘alias …’ and prefixes to surnames must be written in full in the order in which they appear on the

birth certificate.

— 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.

Give all forenames in the order in which they appear on  the birth certificate.
To be stated particularly in the case of adoption or in the case of other names in current use; expressions such as ‘called …’ or ‘alias …’
and prefixes to surnames must be written in full in the order in which they appear on the birth certificate.
Put M for male and F for female.
This information is required when the worker is a Spanish national, or when the form is to be sent to a French institution, regardless of the
worker’s nationality.
For workers subject to Belgian legislation, State worker’s national social security number (NISS).

(7a)
(8) Where appropriate indicate the date of naturalisation.
(8a)

In the case of Spanish nationals over 16 years of age, state the Número de Identificación Fiscal (N.I.F.). Failing this, indicate the number of
the Documento Nacional de Identidad (D.N.I.) or passport, even if they are out of date. If the aforementioned documents do not exist, state
‘none’.
The day and the month should be shown by two digits each and the year by four digits (example: 1 August 1921 = 01.08.1921).
For French towns comprising several arrondissements, please give the number of the arrondissement (example: Paris 14). In the case of
Portuguese districts state also the parish and the local authority. 

(11)  Must be stated for insured persons of Spanish, French or Italian nationality. Here, the territorial area or district in which the place of birth
is located should be stated (example: in the case of France if the place (commune) of birth is Lille, the department of birth should be shown
as ‘Nord’ followed by the area code if known to the insured person; in this case: 59. The complete entry should therefore read: ‘Nord 59’).
In the case of persons born in Spain, state only the province.
The symbol of the insured person’s country of birth in accordance with the international motor vehicle registration code.

(12)
(13) Complete where appropriate.
(14)
(15)
(16)
(17)

In 8.2 indicate the nature of the periods treated as periods of employment.
In the case of persons who were employed in mines or in undertakings treated as such, add an E 206 form.
For Greek and Spanish institutions, specify where possible the type of work in question.
For Spanish institutions, in the case of seamen a photocopy of the sailor’s book or books of the country issuing the certificate should be
enclosed.
For part-time work, the time to be indicated is the reduced time.

(18)
(19) Other periods actually taken into account in calculating the pension (including imputed periods for study and military service and periods

counting for more than their simple duration.
Increment: the denominator of the fraction assigned per year of service. The usual increment is 1/60 per year of service.
Any information which may be of interest to the foreign institution and which is not apparent from the other columns.

(20)
(21)

4

(4)
(5)

(6)
(7)

(9)
(10)

EUROPEAN COMMUNITIES
Social Security Regulations
EEA*

See ‘Instructions’ on page 3

E 205        DK     (1)

CERTIFICATE CONCERNING PERIODS OF INSURANCE AND PERIODS OF RESIDENCE IN DENMARK

Reg. 1408/71; Art. 38; Art. 43a; Art. 45; Art. 48; Art. 51a; Art. 57.5
Reg. 574/72; Art. 42.1; Art. 43.1 to 3; Art. 69

To be drawn up by the investigating institution for insurance periods completed under the legislation which it administers; where appropriate,
to be attached to form E 202, E 203 or E 204. Each institution concerned should draw up a form for the periods completed under the legislation
which it administers and send it to the investigating institution.

1

Institution to which the form is addressed (institution concerned or investigating institution, as applicable)

1.1

1.2

Name

Address (2) 

.............................................................................................................................................................................

.............................................................................................................................................................................

...................................................................................................................................................................................................................

...................................................................................................................................................................................................................

Information concerning insured persons

2

2.1
2.2

2.3

2.4

2.5

2.6

2.7

3

4

4.1

4.2

4.3

4.4

Surname (3)
Surname at birth (3)

Forenames (4)

Previous names (5)

Sex (6)

...............................................................................................................................................................

...............................................................................................................................................................

...............................................................................................................................................................

...............................................................................................................................................................

...............................................................................................................................................................

Father’s surname and forenames (7)

.........................................................................................................................................

Mother’s surname and forenames (7)

.........................................................................................................................................

Nationality (8)

............................................................................................ D.N.I. (8a) 

.............................

Details of birth

Date of birth (9)

Place of birth (10)

...............................................................................................................................................................

...............................................................................................................................................................

Province, department, county (11)

................................................................................................................................................

Country (12)

...............................................................................................................................................................

5

Address (2)

....................................................................................................................................................................................................................

....................................................................................................................................................................................................................

6

6.1

6.2

6.3

Insurance No at the investigating institution

Reference No of file at the investigating institution

Reference No of file at the institution concerned

....................................................................

....................................................................

....................................................................

7

Rightful claimant (13)

7.1

Surname (3)
...................................................................................................................................................................................................................

7.2

Forenames

Surname at birth

Place of birth (10)

...................................................................

...............................................................

...................................................................

7.3

Date of birth

Sex

Nationality

D.N.I. (8a)

...................................................................

......................................

...................................................

...................................

7.4

Address (2)

............................................................................................................................................................................................

...................................................................................................................................................................................................................

1

E 205

DK

8

Periods during which periods of residence and periods treated
as such were completed under the law on social pensions

Periods of residence

Year

from

to

Years

Months

Days

....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
...............................................................................................................................

....................................................................................................................................................................................................................................

....................................................................................................................................................................................................................................

....................................................................................................................................................................................................................................

....................................................................................................................................................................................................................................

....................................................................................................................................................................................................................................

....................................................................................................................................................................................................................................

....................................................................................................................................................................................................................................

....................................................................................................................................................................................................................................

....................................................................................................................................................................................................................................

...............................................................................................................................

.....................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................

.....................................................................................................

8.1

Total length of period of insurance under Danish social security schemes

8.2

...................................................................................................................................................................................................................
Remarks (14) 
...................................................................................................................................................................................................................

..........................................................................................................................................................................

2

E 205

DK

9

An insured person giving proof that he has completed an insurance period of less than one year

M may receive

M may not receive

a pension under national legislation (Art. 48.1 of Reg. 1408/71)

10

Institution completing the form

10.1 Name

10.2

Address (2)

............................................................................................................................................................................

............................................................................................................................................................................

...................................................................................................................................................................................................................

10.3

Stamp

10.4

10.5

Date

Signature

................................................

..........................................................................

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.

INSTRUCTIONS

NOTES

*

EEA Agreement on the European Economic Area, Annex VI, Social Security: for the purposes of this Agreement the present form shall
also apply to Iceland, Liechtenstein and Norway.
Symbol of the country to which the institution completing the form belongs DK = Denmark.
Street, number, post code, town, country, telephone number.

(1)
(2)
(3) — For surname please state usual surname or surname acquired by marriage.

— The surname at birth must always be given; if same as current surname, put ‘IDEM’.
— Expressions such as ‘called …’ or ‘alias …’ and prefixes to surnames must be written in full in the order in which they appear on the

birth certificate.

— 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.

(4)
(5)

(6)
(7)

Give all forenames in the order in which they appear on the birth certificate.
To be stated particularly in the case of adoption or in the case of other names in current use; expressions such as ‘called …’ or ‘alias …’
and prefixes to surnames must be written in full in the order in which they appear on the birth certificate.
Put M for male and F for female.
This information is required when the worker is a Spanish national, or when the form is to be sent to a French institution, regard-
less of the worker’s nationality.

(8) Where appropriate, indicate the date of naturalisation.
(8a)

In the case of Spanish nationals over 16 years of age, state the Número de Identificación Fiscal (N.I.F.). Failing this, indicate the
number of the Documento Nacional de Identidad (D.N.I.) or passport, even if they are out of date. If the aforementioned documents
do not exist, state ‘none’.
The day and the month should be shown by two digits each and the year by four digits (example: 1 August 1921 = 01.08.1921).
For French towns comprising several arrondissements, please give the number of the arrondissement (example: Paris 14). In the
case of Portuguese districts state also the parish and the local authority. 

(9)
(10)

(11)  Must be stated for insured persons of Spanish, French or Italian nationality. Here, the territorial area or district in which the place
of birth is located should be stated (example: in the case of France if the place (commune) of birth is Lille, the department of birth
should be shown as ‘Nord’ followed by the area code if known to the insured person; in this case: 59. The complete entry should
therefore read: ‘Nord 59’). In the case of persons born in Spain, state only the province.
The symbol of the insured person’s country of birth in accordance with the international motor vehicle registration code.

For  Spanish  institutions,  in  the  case  of  seamen  a  photocopy  of  the  sailor’s  book  or  books  of  the  country  issuing  the  certificate
should be enclosed.

(12)
(13) Complete where appropriate.
(14)

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
EUROPEAN COMMUNITIES
Social Security Regulations
EEA*

See ‘Instructions’ on page 3

E 205         D     (1)

CERTIFICATE CONCERNING INSURANCE HISTORY IN GERMANY

Reg. 1408/71; Art. 38; Art. 43a; Art. 45; Art. 48; Art. 51a; Art. 57.5
Reg. 574/72; Art. 42.1; Art. 43.1 to 3; Art. 69

To be drawn up by the investigating institution for insurance periods completed under the legislation which it administers; where appropriate,
to be attached to form E 202, E 203 or E 204. Each institution concerned should draw up a form for the periods completed under the legislation
which it administers and send it to the investigating institution.

1

Institution to which the form is addressed (institution concerned or investigating institution, as applicable)

1.1

1.2

Name

Address (2) 

.............................................................................................................................................................................

.............................................................................................................................................................................

...................................................................................................................................................................................................................

...................................................................................................................................................................................................................

Information concerning insured persons (2a)

2

2.1
2.2

2.3

2.4

2.5

2.6

2.7

3

4

4.1

4.2

4.3

4.4

Surname (3)
Surname at birth (3)

Forenames (4)

Previous names (5)

Sex (6)

...............................................................................................................................................................

...............................................................................................................................................................

...............................................................................................................................................................

...............................................................................................................................................................

...............................................................................................................................................................

Father’s surname and forenames (7)

.........................................................................................................................................

Mother’s surname and forenames (7)

.........................................................................................................................................

Nationality (8)

............................................................................................ D.N.I. (8a) 

.............................

Details of birth

Date of birth (9)

Place of birth (10)

...............................................................................................................................................................

...............................................................................................................................................................

Province, department, county (11)

................................................................................................................................................

Country (12)

...............................................................................................................................................................

5

Address (2)

....................................................................................................................................................................................................................

....................................................................................................................................................................................................................

6

6.1

6.2

6.3

Insurance No at the investigating institution

Reference No of file at the investigating institution

Reference No of file at the institution concerned

....................................................................

....................................................................

....................................................................

7

Rightful claimant (13)

7.1

Surname (3)
...................................................................................................................................................................................................................

7.2

Forenames

Surname at birth

Place of birth (10)

...................................................................

...............................................................

...................................................................

7.3

Date of birth

Sex

Nationality

D.N.I. (8a)

...................................................................

......................................

...................................................

...................................

7.4

Address (2)

............................................................................................................................................................................................

...................................................................................................................................................................................................................

1

8

Completed insurance periods
and periods treated as such

Insurance periods (14)

Periods treated as such (15)

Scheme

E 205

D

Occupation
(16) (17) (18)

Year

from

to

Years

Months

Days

Years

Months

Days

Employees

Self- 

Civil

employed servants

....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
...............................................................................................................................

...............................................................................................................................

...............................................................................................................................

....................................................................................................................................................................................................................................

....................................................................................................................................................................................................................................

....................................................................................................................................................................................................................................

....................................................................................................................................................................................................................................

....................................................................................................................................................................................................................................

.....................................................................................................

....................................................................................................................................................................................................................................

....................................................................................................................................................................................................................................

....................................................................................................................................................................................................................................

....................................................................................................................................................................................................................................

.....................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................

.....................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................

Total insurance period

8.1 — for the acquisition of entitlement to all types of pension

.............. Months

.............. Years

.............. Days

— plus only for the acquisition of entitlement to early

retirement pensions for the long-term insured

.............. Months

.............. Years

.............. Days

8.2 — for pension calculation

.............. Months

.............. Years

.............. Days

2

E 205

D

9

An insured person showing proof that he has completed an insurance period of less than one year

M may receive

M may not receive

a pension under national legislation (Art. 48.1 of Reg. 1408/71).

10

Institution completing the form

10.1 Name

10.2

Address (2)

...........................................................................................................................................................................

...........................................................................................................................................................................

...................................................................................................................................................................................................................

10.3

Stamp

10.4

10.5

Date

Signature

................................................

..........................................................................

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.

INSTRUCTIONS

NOTES

*

(1)
(2)
(2a)

EEA Agreement on the European Economic Area, Annex VI, Social Security: for the purposes of this Agreement the present form shall
also apply to Iceland, Liechtenstein and Norway.
Symbol of the country to which the institution completing the form belongs D = Germany.
Street, number, post code, town, country, telephone number.
The  term  ‘insured  persons’  encompasses  individuals  insured  under  the  general  social  security  scheme  as  well  as  civil  servants  and
individuals treated as such who are insured under a special scheme. The term ‘pension’ is considered to encompass pensions for civil
servants.

(3) — For surname please state usual surname or surname acquired by marriage.

— The surname at birth must always be given; if same as current surname, put ‘IDEM’.
— Expressions such as ‘called …’ or ‘alias …’ and prefixes to surnames must be written in full in the order in which they appear on the

birth certificate.

— 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.

(4)
(5)

(6)
(7)

Give all forenames in the order in which they appear on the birth certificate.
To be stated particularly in the case of adoption or in the case of other names in current use; expressions such as ‘called …’ or ‘alias …’
and prefixes to surnames must be written in full in the order in which they appear on the birth certificate.
Put M for male and F for female.
This information is required when the worker is a Spanish national, or when the form is to be sent to a French institution, regardless of the
worker’s nationality.

(8) Where appropriate, indicate the date of naturalisation.
(8a)

In the case of Spanish nationals over 16 years of age, state the Número de Identificación Fiscal (N.I.F.). Failing this, indicate the number
of the Documento Nacional de Identidad (D.N.I.) or passport, even if they are out of date. If the aforementioned documents do not exist,
state ‘none’.
The day and the month should be shown by two digits each and the year by four digits (example: 1 August 1921 = 01.08.1921).
For French towns comprising several arrondissements, please give the number of the arrondissement (example: Paris 14). In the case of
Portuguese districts state also the parish and the local authority. 

(11)  Must be stated for insured persons of Spanish, French or Italian nationality. Here, the territorial area or district in which the place of birth
is located should be stated (example: in the case of France if the place (commune) of birth is Lille, the department of birth should be shown
as ‘Nord’ followed by the area code if known to the insured person; in this case: 59. The complete entry should therefore read: ‘Nord 59’).
In the case of persons born in Spain, state only the province.
The symbol of the insured person’s country of birth in accordance with the international motor vehicle registration code.

(12)
(13) Complete where appropriate.
(14)

After the number of insurance months put ‘F’ (voluntary) for periods of voluntary insurance in order to avoid any confusion with compulsory
insurance.
After  the  number  of  months  treated  as  such  put  ‘A’  for  periods  of  interruption  which  are  taken  into  account  for  the  calculation  of  the
amount of the benefit but not for the acquisition of the right.
In the case of workers who were employed in mines or in undertakings treated as such, add an E 206 form.
For Greek and Spanish institutions, specify where possible the type of work in question.
For Spanish institutions, in the case of seamen a photocopy of the sailor’s book or books of the country issuing the certificate should be
enclosed.

(9)
(10)

(15)

(16)
(17)
(18)

3

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
EUROPEAN COMMUNITIES
Social Security Regulations
EEA*

See ‘Instructions’ on page 3

E 205

GR     (1)

CERTIFICATE CONCERNING INSURANCE HISTORY IN GREECE

Reg. 1408/71; Art. 38; Art. 43a; Art. 45; Art. 48; Art. 51a; Art. 57.5
Reg. 574/72; Art. 42.1; Art. 43.1 to 3; Art. 69

To be drawn up by the investigating institution for insurance periods completed under the legislation which it administers; where appropriate,
to be attached to form E 202, E 203 or E 204. Each institution concerned should draw up a form for the periods completed under the legislation
which it administers and send it to the investigating institution.

1

Institution to which the form is addressed (institution concerned or investigating institution, as applicable)

1.1

1.2

Name

Address (2) 

.............................................................................................................................................................................

.............................................................................................................................................................................

...................................................................................................................................................................................................................

...................................................................................................................................................................................................................

Information concerning insured persons

2

2.1
2.2

2.3

2.4

2.5

2.6

2.7

3

4

4.1

4.2

4.3

4.4

Surname (3)
Surname at birth (3)

Forenames (4)

Previous names (5)

Sex (6)

...............................................................................................................................................................

...............................................................................................................................................................

...............................................................................................................................................................

...............................................................................................................................................................

...............................................................................................................................................................

Father’s surname and forenames (7)

.........................................................................................................................................

Mother’s surname and forenames (7)

.........................................................................................................................................

Nationality (8)

............................................................................................ D.N.I. (8a) 

.............................

Details of birth

Date of birth (9)

Place of birth (10)

...............................................................................................................................................................

...............................................................................................................................................................

Province, department, county (11)

................................................................................................................................................

Country (12)

...............................................................................................................................................................

5

Address (2)

....................................................................................................................................................................................................................

....................................................................................................................................................................................................................

6

6.1

6.2

6.3

Insurance No at the investigating institution

Reference No of file at the investigating institution

Reference No of file at the institution concerned

....................................................................

....................................................................

....................................................................

7

Rightful claimant (13)

7.1

Surname (3)
...................................................................................................................................................................................................................

7.2

Forenames

Surname at birth

Place of birth (10)

...................................................................

...............................................................

...................................................................

7.3

Date of birth

Sex

Nationality

D.N.I. (8a)

...................................................................

......................................

...................................................

...................................

7.4

Address (2)

............................................................................................................................................................................................

...................................................................................................................................................................................................................

1

E 205

GR

8

Periods during which periods of
insurance and periods treated
as such were completed 

Periods of insurance (14)

Periods treated as
periods of insurance (15)

Occupation — type of work
(16) (17) (18)

Year

from

to

Years

Months

Days

Years

Months

Days

....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................

8.1

Total length of period of insurance under Greek social security schemes:

.................

years

................... months

...................

days; of which

— periods to be taken into account for the acquisition of entitlement:

.................

years

................... months

...................

days; 

— periods to be taken into account for the calculation of benefits:

.................

years

................... months

...................

days.

8.2

Remarks (15)
...................................................................................................................................................................................................................

.............................................................................................................................................................................

2

E 205

GR

9

An insured person showing proof that he has completed an insurance period of less than one year

M may receive

M may not receive

a pension under national legislation (Art. 48.1 of Reg. 1408/71)

10

Institution completing the form

10.1 Name

...............................................................................................................................................................................

10.2

Address (2)

...............................................................................................................................................................................

...................................................................................................................................................................................................................

10.3

Stamp

10.4

10.5

Date

....................................................

Signature

..........................................................................

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.

INSTRUCTIONS

NOTES

*

EEA Agreement on the European Economic Area, Annex VI, Social Security: for the purposes of this Agreement the present form shall
also apply to Iceland, Liechtenstein and Norway.
Symbol of the country to which the institution completing the form belongs GR = Greece.
Street, number, post code, town, country, telephone number.

(1)
(2)
(3) —  For surname please state usual surname or surname acquired by marriage.

—  The surname at birth must always be given; if same as current surname, put ‘IDEM’.
—  Expressions such as ‘called …’ or ‘alias …’ and prefixes to surnames must be written in full in the order in which they appear on the

birth certificate.

—  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.

(4)
(5)

(6)
(7)

Give all forenames in the order in which they appear on  the birth certificate.
To be stated particularly in the case of adoption or in the case of other names in current use; expressions such as ‘called …’ or ‘alias …’
and prefixes to surnames must be written in full in the order in which they appear on the birth certificate.
Put M for male and F for female.
This information is required when the worker is a Spanish national, or when the form is to be sent to a French institution, regardless of the
worker’s nationality.

(8) Where appropriate, indicate the date of naturalisation.
(8a)

In the case of Spanish nationals over 16 years of age, state the Número de Identificación Fiscal (N.I.F.). Failing this, indicate the number
of the Documento Nacional de Identidad (D.N.I.) or passport, even if they are out of date. If the aforementioned documents do not exist,
state ‘none’.
The day and the month should be shown by two digits each and the year by four digits (example: 1 August 1921 = 01.08.1921).
For French towns comprising several arrondissements, please give the number of the arrondissement (example: Paris 14). In the case of
Portuguese districts state also the parish and the local authority. 

(9)
(10)

(11)  Must be stated for insured persons of Spanish, French or Italian nationality. Here, the territorial area or district in which the place of birth
is located should be stated (example: in the case of France if the place (commune) of birth is Lille, the department of birth should be shown
as ‘Nord’ followed by the area code if known to the insured person; in this case: 59. The complete entry should therefore read: ‘Nord 59’).
In the case of persons born in Spain, state only the province.
The symbol of the insured person’s country of birth in accordance with the international motor vehicle registration code.

(12)
(13) Complete where appropriate.
(14)
(15)
(16)
(17)
(18)

After the period of voluntary insurance, put ‘V’ for voluntary insurance in order to avoid any confusion with compulsory insurance.
In 8.2 indicate the nature of the periods treated as insurance periods.
In the case of workers who were employed in mines or in undertakings treated as such, add an E 206 form.
Specify the type of work and indicate the category.
For Spanish institutions, in the case of seamen a photocopy of the sailor’s book or books of the country issuing the certificate should be
enclosed.

3

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
EUROPEAN COMMUNITIES
Social Security Regulations
EEA*

See ‘Instructions’ on page 3

E 205         E     (1)

CERTIFICATE CONCERNING INSURANCE HISTORY IN SPAIN

Reg. 1408/71; Art. 38; Art. 43a; Art. 45; Art. 48; Art. 51a; Art. 57.5
Reg. 574/72; Art. 42.1; Art. 43.1 to 3; Art. 69

To be drawn up by the investigating institution for insurance periods completed under the legislation which it administers; where appropriate,
to be attached to form E 202, E 203 or E 204. Each institution concerned should draw up a form for the periods completed under the legislation
which it administers and send it to the investigating institution.

1

Institution to which the form is addressed (institution concerned or investigating institution, as applicable)

1.1

1.2

Name

Address (2) 

.............................................................................................................................................................................

.............................................................................................................................................................................

...................................................................................................................................................................................................................

...................................................................................................................................................................................................................

Information concerning insured persons

2

2.1
2.2

2.3

2.4

2.5

2.6

2.7

3

4

4.1

4.2

4.3

4.4

Surname (3)
Surname at birth (3)

Forenames (4)

Previous names (5)

Sex (6)

...............................................................................................................................................................

...............................................................................................................................................................

...............................................................................................................................................................

...............................................................................................................................................................

...............................................................................................................................................................

Father’s surname and forenames (7)

.........................................................................................................................................

Mother’s surname and forenames (7)

.........................................................................................................................................

Nationality (8)

....................................................

D.N.I. or passport/N.I.F. (tax identity number) (8a)  .......................

Details of birth

Date of birth (9)

Place of birth (10)

...............................................................................................................................................................

...............................................................................................................................................................

Province, department, county (11)

................................................................................................................................................

Country (12)

...............................................................................................................................................................

5

Address (2)

....................................................................................................................................................................................................................

....................................................................................................................................................................................................................

6

6.1

6.2

6.3

Insurance No at the investigating institution

Reference No of file at the investigating institution

Reference No of file at the institution concerned

....................................................................

....................................................................

....................................................................

7

Rightful claimant (13)

7.1

Surname (3)
...................................................................................................................................................................................................................

7.2

Forenames

Surname at birth

Place of birth (10)

...................................................................

...............................................................

...................................................................

7.3

Date of birth

Sex

Nationality

D.N.I. (8a)

...................................................................

......................................

...................................................

...................................

7.4

Address (2)

............................................................................................................................................................................................

...................................................................................................................................................................................................................

1

E 205

E

8

Periods during which insurance
periods and periods treated as
such were completed

Insurance
periods (14)

Periods treated
as insurance
periods (15)

Occupation (16) (17) (18)

Year

from

to

Years

Months

Days

Years

Months

Days

....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................

8.1

Total length of period of insurance under Spanish social security schemes for employed persons:

– periods to be taken into account for the acquisition of entitlement and for calculation of benefits:

years

.....................

days

......................

– periods to be taken into account only for the acquisition of entitlement:

years

.....................

days

......................

8.2

Total length of period of insurance under Spanish social security schemes for self-employed persons:

– periods to be taken into account for the acquisition of entitlement and for calculation of benefits:

years

.....................

days

......................

– periods to be taken into account only for the acqusition of entitlement:

.....................

years
Remarks (15)
...................................................................................................................................................................................................................

...............................................................................................................................................................................

......................

days

8.3

2

E 205

E

9

An insured person showing proof that he has completed an insurance period of less than one year

M may receive

M may not receive

a pension under national legislation (Art. 48.1 of Reg. 1408/71)

10

Institution completing the form

10.1 Name

.............................................................................................................................................................................

10.2

Address (2)

.............................................................................................................................................................................

...................................................................................................................................................................................................................

10.3

Stamp

10.4

10.5

Date

Signature

................................................

..........................................................................

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.

INSTRUCTIONS

NOTES

*

EEA Agreement on the European Economic Area, Annex VI, Social Security: for the purposes of this Agreement the present form shall
also apply to Iceland, Liechtenstein and Norway.
Symbol of the country to which the institution completing the form belongs E = Spain.
Street, number, post code, town, country, telephone number.

(1)
(2)
(3) — For surname please state usual surname or surname acquired by marriage.

— The surname at birth must always be given; if same as current surname, put ‘IDEM’.
— Expressions such as ‘called …’ or ‘alias …’ and prefixes to surnames must be written in full in the order in which they appear on the

birth certificate.

— 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.

(4)
(5)

(6)
(7)

Give all forenames in the order in which they appear on the birth certificate.
To be stated particularly in the case of adoption or in the case of other names in current use; expressions such as ‘called …’ or ‘alias …’
and prefixes to surnames must be written in full in the order in which they appear on the birth certificate.
Put M for male and F for female.
This information is required when the worker is a Spanish national, or when the form is to be sent to a French institution, regardless of the
worker’s nationality.

(8) Where appropriate, indicate the date of naturalisation.
(8a)

In the case of Spanish nationals over 16 years of age, state the Número de Identificación Fiscal (N.I.F.). Failing this, indicate the number
of the Documento Nacional de Identidad (D.N.I.) or passport, even if they are out of date. If the aforementioned documents do not exist,
state ‘none’.
The day and the month should be shown by two digits each and the year by four digits (example: 1 August 1921 = 01.08.1921).
For French towns comprising several arrondissements, please give the number of the arrondissement (example: Paris 14). In the case of
Portuguese districts state also the parish and the local authority. 

(9)
(10)

(11)  Must be stated for insured persons of Spanish, French or Italian nationality. Here, the territorial area or district in which the place of birth
is located should be stated (example: in the case of France if the place (commune) of birth is Lille, the department of birth should be shown
as ‘Nord’ followed by the area code if known to the insured person; in this case: 59. The complete entry should therefore read: ‘Nord 59’).
In the case of persons born in Spain, state only the province.
The symbol of the insured person’s country of birth in accordance with the international motor vehicle registration code.

(12)
(13) Complete where appropriate.
(14)
(15)
(16)
(17)
(18)

After the number of voluntary insurance years or days put ‘V’ in order to avoid any confusion with compulsory insurance.
In point 8.3 indicate only the insurance periods taken into account for the pension calculation.
In the case of workers who were employed in mines or in undertakings treated as such, add an E 206 form.
For Greek institutions, specify where possible the type of work in question.
For Spanish institutions, in the case of seamen a photocopy of the sailor’s book or books of the country issuing the certificate should be
enclosed.

3

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
EUROPEAN COMMUNITIES
Social Security Regulations
EEA*

See ‘Instructions’ on page 3

E 205

F     (1)

CERTIFICATE CONCERNING INSURANCE HISTORY IN FRANCE

Reg. 1408/71; Art. 38; Art. 43a; Art. 45; Art. 48; Art. 51a; Art. 57.5
Reg. 574/72; Art. 42.1; Art. 43.1 to 3; Art. 69

To be drawn up by the investigating institution for insurance periods completed under the legislation which it administers; where appropriate,
to be attached to form E 202, E 203 or E 204. Each institution concerned should draw up a form for the periods completed under the legislation
which it administers and send it to the investigating institution.

1

Institution to which the form is addressed (institution concerned or investigating institution, as applicable)

1.1

1.2

Name

Address (2) 

.............................................................................................................................................................................

.............................................................................................................................................................................

...................................................................................................................................................................................................................

...................................................................................................................................................................................................................

Information concerning insured persons

2

2.1
2.2

2.3

2.4

2.5

2.6

2.7

3

4

4.1

4.2

4.3

4.4

Surname (3)
Surname at birth (3)

Forenames (4)

Previous names (5)

Sex (6)

...............................................................................................................................................................

...............................................................................................................................................................

...............................................................................................................................................................

...............................................................................................................................................................

...............................................................................................................................................................

Father’s surname and forenames (7)

.........................................................................................................................................

Mother’s surname and forenames (7)

.........................................................................................................................................

Nationality (8)

............................................................................................ D.N.I. (8a) 

.............................

Details of birth

Date of birth (9)

Place of birth (10)

...............................................................................................................................................................

...............................................................................................................................................................

Province, department, county (11)

................................................................................................................................................

Country (12)

...............................................................................................................................................................

5

Address (2)

....................................................................................................................................................................................................................

....................................................................................................................................................................................................................

6

6.1

6.2

6.3

Insurance No at the investigating institution

Reference No of file at the investigating institution

Reference No of file at the institution concerned

....................................................................

....................................................................

....................................................................

7

Rightful claimant (13)

7.1

Surname (3)
...................................................................................................................................................................................................................

7.2

Forenames

Surname at birth

Place of birth (10)

...................................................................

...............................................................

...................................................................

7.3

Date of birth

Sex

Nationality

D.N.I. (8a)

...................................................................

......................................

...................................................

...................................

7.4

Address (2)

............................................................................................................................................................................................

...................................................................................................................................................................................................................

1

E 205

F

8

Periods during which insurance periods and
periods treated as such were completed

Insurance 
periods (14)

Periods treated as
insurance periods (15)

Insurance schemes

Occupation (16) (17) (18)

Year

from

to

(quarters)

(quarters)

Employed 
person

Self-employed
person

....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................
....................................................................................................................................................................
....................................................................................................................................................................
....................................................................................................................................................................
....................................................................................................................................................................
....................................................................................................................................................................
....................................................................................................................................................................
....................................................................................................................................................................
....................................................................................................................................................................
....................................................................................................................................................................

Benefit increase for mothers

8.1

Total length of period of insurance under French social security schemes for employed and self-employed persons

...................................................................................................................................................................................................................

8.2

Comments

................................................................................................................................................................................

...................................................................................................................................................................................................................

...................................................................................................................................................................................................................

2

E 205

F

9

An insured person showing proof that he has completed an insurance period of less than one year

M may receive

M may not receive

a pension under national legislation (Art. 48.1 of Reg. 1408/71)

10

Institution completing the form

10.1 Name

10.2

Address (2)

............................................................................................................................................................................

............................................................................................................................................................................

...................................................................................................................................................................................................................

10.3

Stamp

10.4

10.5

Date

Signature

................................................

..........................................................................

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.

INSTRUCTIONS

NOTES

*

EEA Agreement on the European Economic Area, Annex VI, Social Security: for the purposes of this Agreement the present form shall
also apply to Iceland, Liechtenstein and Norway.
Symbol of the country to which the institution completing the form belongs F = France.
Street, number, post code, town, country, telephone number.

(1)
(2)
(3) — For surname please state usual surname or surname acquired by marriage.

— The surname at birth must always be given; if same as current surname, put ‘IDEM’.
— Expressions such as ‘called …’ or ‘alias …’ and prefixes to surnames must be written in full in the order in which they appear on the

birth certificate.

— 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.

(4)
(5)

(6)
(7)

Give all forenames in the order in which they appear on the birth certificate.
To be stated particularly in the case of adoption or in the case of other names in current use; expressions such as ‘called …’ or ‘alias …’
and prefixes to surnames must be written in full in the order in which they appear on the birth certificate.
Put M for male and F for female.
This information is required when the worker is a Spanish national, or when the form is to be sent to a French institution, regardless of the
worker’s nationality.

(8) Where appropriate, indicate the date of naturalisation.
(8a)

In the case of Spanish nationals over 16 years of age, state the Número de Identificación Fiscal (N.I.F.). Failing this, indicate the number
of the Documento Nacional de Identidad (D.N.I.) or passport, even if they are out of date. If the aforementioned documents do not exist,
state ‘none’.
The day and the month should be shown by two digits each and the year by four digits (example: 1 August 1921 = 01.08.1921).
For French towns comprising several arrondissements, please give the number of the arrondissement (example: Paris 14). In the case of
Portuguese districts state also the parish and the local authority. 

(11)  Must be stated for insured persons of Spanish, French or Italian nationality. Here, the territorial area or district in which the place of birth
is located should be stated (example: in the case of France if the place (commune) of birth is Lille, the department of birth should be shown
as ‘Nord’ followed by the area code if known to the insured person; in this case: 59. The complete entry should therefore read: ‘Nord 59’).
In the case of persons born in Spain, state only the province.
The symbol of the insured person’s country of birth in accordance with the international motor vehicle registration code.

(12)
(13) Complete where appropriate.
(14)

After the periods of voluntary insurance, put ‘V’ for voluntary insurance in order to avoid any confusion with compulsory insurance. After
periods referred to in Article 15(2) of Regulation 574/72 put ‘S’.
In 8.2 indicate the nature of the periods treated as insurance periods.
In the case of workers who were employed in mines or in undertakings treated as such, add an E 206 form.
For Greek institutions, specify where possible the type of work in question.
For Spanish institutions, in the case of seamen a photocopy of the sailor’s book or books of the country issuing the certificate should be
enclosed.

(9)
(10)

(15)
(16)
(17)
(18)

3

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
EUROPEAN COMMUNITIES
Social Security Regulations
EEA*

See ‘Instructions’ on page 3

E 205

IRL     (1)

CERTIFICATE CONCERNING INSURANCE HISTORY IN IRELAND

Reg. 1408/71; Art. 38; Art. 43a; Art. 45; Art. 48; Art. 51a; Art. 57.5
Reg. 574/72; Art. 42.1; Art. 43.1 to 3; Art. 69

To be drawn up by the investigating institution for insurance periods completed under the legislation which it administers; where appropriate,
to be attached to form E 202, E 203 or E 204. Each institution concerned should draw up a form for the periods completed under the legislation
which it administers and send it to the investigating institution.

1

Institution to which the form is addressed (institution concerned or investigating institution, as applicable)

1.1

1.2

Name

Address (2) 

.............................................................................................................................................................................

.............................................................................................................................................................................

...................................................................................................................................................................................................................

...................................................................................................................................................................................................................

Information concerning insured persons

2

Names

2.1
2.2

2.3

2.4

2.5

2.6

2.7

3

4

4.1
4.2

4.3

4.4

Surname (3)
Surname at birth (3)

Forenames (4)

Previous names (5)

Sex (6)

...............................................................................................................................................................

...............................................................................................................................................................

...............................................................................................................................................................

...............................................................................................................................................................

...............................................................................................................................................................

Father’s surname and forenames (7)

.........................................................................................................................................

Mother’s surname and forenames (7)

.........................................................................................................................................

Nationality (8)

............................................................................................ D.N.I. (8a) 

.............................

Details of birth

Date of birth (9)
Place of birth (10)

...............................................................................................................................................................

...............................................................................................................................................................

Province, department, county (11)

................................................................................................................................................

Country (12)

...............................................................................................................................................................

5

Address (2)

....................................................................................................................................................................................................................

....................................................................................................................................................................................................................

6

6.1

6.2

6.3

Insurance No at the investigating institution

Reference No of file at the investigating institution

Reference No of file at the institution concerned

....................................................................

....................................................................

....................................................................

7

Rightful claimant (13)

7.1

Surname (3)
...................................................................................................................................................................................................................

7.2

Forenames

Surname at birth

Place of birth (10)

...................................................................

...............................................................

...................................................................

7.3

Date of birth

Sex

Nationality

D.N.I. (8a)

...................................................................

......................................

...................................................

...................................

7.4

Address (2)

............................................................................................................................................................................................

...................................................................................................................................................................................................................

1

E 205

IRL

8

Periods during which insurance periods and
periods treated as such were completed

Insurance 
periods (14)

Periods treated as
insurance period

Year

from

to

(weeks)

(weeks)

Reason for
treating these
periods as insu-
rance periods (15)

Occupation (16) (17) (18)

....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................

8.1

Total length of period of insurance under the Irish social security shemes for employed persons

...................................................................................................................................................................................................................

8.2

Comments

...............................................................................................................................................................................

...................................................................................................................................................................................................................

...................................................................................................................................................................................................................

2

E 205

IRL

9

An insured person showing proof that he has completed an insurance period of less than one year

M may receive

M may not receive

a pension under national legislation (Art. 48.1 of Reg. 1408/71)

10

Institution completing the form

10.1 Name

10.2

Address (2)

............................................................................................................................................................................

............................................................................................................................................................................

...................................................................................................................................................................................................................

10.3

Stamp

10.4

10.5

Date

Signature

................................................

..........................................................................

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.

INSTRUCTIONS

NOTES

*

EEA Agreement on the European Economic Area, Annex VI, Social Security: for the purposes of this Agreement the present form shall
also apply to Iceland, Liechtenstein and Norway.
Symbol of the country to which the institution completing the form belongs IRL = Ireland.
Street, number, post code, town, country, telephone number.

(1)
(2)
(3) — For surname please state usual surname or surname acquired by marriage.

— The surname at birth must always be given; if same as current surname, put ‘IDEM’.
— Expressions such as ‘called …’ or ‘alias …’ and prefixes to surnames must be written in full in the order in which they appear on the

birth certificate.

— 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.

(4)
(5)

(6)
(7)

Give all forenames in the order in which they appear on the birth certificate.
To be stated particularly in the case of adoption or in the case of other names in current use; expressions such as ‘called …’ or ‘alias …’
and prefixes to surnames must be written in full in the order in which they appear on the birth certificate.
Put M for male and F for female.
This information is required when the worker is a Spanish national, or when the form is to be sent to a French institution, regardless of the
worker’s nationality.

(8) Where appropriate, indicate the date of naturalisation.
(8a)

In the case of Spanish nationals over 16 years of age, state the Número de Identificación Fiscal (N.I.F.). Failing this, indicate the number
of the Documento Nacional de Identidad (D.N.I.) or passport, even if they are out of date. If the aforementioned documents do not exist,
state ‘none’.
The day and the month should be shown by two digits each and the year by four digits (example: 1 August 1921 = 01.08.1921).
For French towns comprising several arrondissements, please give the number of the arrondissement (example: Paris 14). In the case of
Portuguese districts state also the parish and the local authority. 

(11)  Must be stated for insured persons of Spanish, French or Italian nationality. Here, the territorial area or district in which the place of birth
is located should be stated (example: in the case of France if the place (commune) of birth is Lille, the department of birth should be shown
as ‘Nord’ followed by the area code if known to the insured person; in this case: 59. The complete entry should therefore read: ‘Nord 59’).
In the case of persons born in Spain, state only the province.
The symbol of the insured person’s country of birth in accordance with the international motor vehicle registration code.

(12)
(13) Complete where appropriate.
(14)
(15)
(16)

After the number of weeks put ‘V’ where the periods in question are periods of voluntary insurance.
Indicate whether the period in question are periods of illness, unemployment, etc.
In the case of insured persons who were employed in mines or in undertakings treated as such, add an E 206 form. These data may be
issued only on the basis of information supplied by the employee.
For Greek and Spanish institutions, specify where possible the type of work in question.
For Spanish institutions, in the case of seamen a photocopy of the sailor’s book or books of the country issuing the certificate should be
enclosed.

(9)
(10)

(17)
(18)

3

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
EUROPEAN COMMUNITIES
Social Security Regulations
EEA*

See ‘Instructions’ on page 3

E 205

I     (1)

CERTIFICATE CONCERNING INSURANCE HISTORY IN ITALY

Reg. 1408/71; Art. 38; Art. 43a; Art. 45; Art. 48; Art. 51a; Art. 57.5
Reg. 574/72; Art. 42.1; Art. 43.1 to 3; Art. 69

To be drawn up by the investigating institution for insurance periods completed under the legislation which it administers; where appropriate,
to be attached to form E 202, E 203 or E 204. Each institution concerned should draw up a form for the periods completed under the legislation
which it administers and send it to the investigating institution.

1

Institution to which the form is addressed (institution concerned or investigating institution, as applicable)

1.1

1.2

Name

Address (2) 

.............................................................................................................................................................................

.............................................................................................................................................................................

...................................................................................................................................................................................................................

...................................................................................................................................................................................................................

Information concerning insured persons

2

Names

2.1
2.2

2.3

2.4

2.5

2.6

2.7

3

4

4.1
4.2

4.3

4.4

Surname (3)
Surname at birth (3)

Forenames (4)

Previous names (5)

Sex (6)

...............................................................................................................................................................

...............................................................................................................................................................

...............................................................................................................................................................

...............................................................................................................................................................

...............................................................................................................................................................

Father’s surname and forenames (7)

.........................................................................................................................................

Mother’s surname and forenames (7)

.........................................................................................................................................

Nationality (8)

............................................................................................ D.N.I. (8a) 

.............................

Details of birth

Date of birth (9)
Place of birth (10)

...............................................................................................................................................................

...............................................................................................................................................................

Province, department, county (11)

................................................................................................................................................

Country (12)

...............................................................................................................................................................

5

Address (2)

....................................................................................................................................................................................................................

....................................................................................................................................................................................................................

6

6.1

6.2

6.3

Insurance No at the investigating institution

Reference No of file at the investigating institution

Reference No of file at the institution concerned

....................................................................

....................................................................

....................................................................

7

Rightful claimant (13)

7.1

Surname (3)
...................................................................................................................................................................................................................

7.2

Forenames

Surname at birth

Place of birth (10)

...................................................................

...............................................................

...................................................................

7.3

Date of birth

Sex

Nationality

D.N.I. (8a)

...................................................................

......................................

...................................................

...................................

7.4

Address (2)

............................................................................................................................................................................................

...................................................................................................................................................................................................................

1

E 205

I

8

Periods during
which insurance periods and periods
treated as such were completed

Insurance
periods (14)

Periods treated 
as insurance
periods (15)

Year

from

to

Weeks

Months

Weeks

Months

Insurance scheme

Employed
persons

Self-employed
persons

Occupation (16) (17) (18)

....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................

8.1

Total length of period of insurance under Italian social security schemes for employed persons and self-employed persons treated as such:

— periods to be taken into account for the acquisition of entitlement and for calculation of benefits:

weeks

...................

months ...................

— periods to be taken into account only for the calculation of benefits:

weeks

...................

months ...................

— periods to be taken into account only for the acquisition of entitlement to benefits:

weeks

...................

months ...................

The period of

........................

up to .........................

are converted into benefits with effect from .........................

8.2

Comments (15) 

................................................................................................................................................................................

...................................................................................................................................................................................................................

2

E 205

I

9

An insured person showing proof that he has completed an insurance period of less than one year

M may receive

M may not receive

a pension under national legislation (Art. 48.1 of Reg. 1408/71)

10

Institution completing the form

10.1 Name

10.2

Address (2)

............................................................................................................................................................................

............................................................................................................................................................................

...................................................................................................................................................................................................................

10.3

Stamp

10.4

10.5

Date

Signature

................................................

..........................................................................

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.

INSTRUCTIONS

NOTES

*

EEA Agreement on the European Economic Area, Annex VI, Social Security: for the purposes of this Agreement the present form shall
also apply to Iceland, Liechtenstein and Norway.
Symbol of the country to which the institution completing the form belongs I = Italy.
Street, number, post code, town, country, telephone number.

(1)
(2)
(3) — For surname please state usual surname or surname acquired by marriage.

— The surname at birth must always be given; if same as current surname, put ‘IDEM’.
— Expressions such as ‘called …’ or ‘alias …’ and prefixes to surnames must be written in full in the order in which they appear on the

birth certificate.

— 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.

(4)
(5)

(6)
(7)

Give all forenames in the order in which they appear on the birth certificate.
To be stated particularly in the case of adoption or in the case of other names in current use; expressions such as ‘called …’ or ‘alias …’
and prefixes to surnames must be written in full in the order in which they appear on the birth certificate.
Put M for male and F for female.
This information is required when the worker is a Spanish national, or when the form is to be sent to a French institution, regardless of the
worker’s nationality.

(8) Where appropriate, indicate the date of naturalisation.
(8a)

In the case of Spanish nationals over 16 years of age, state the Número de Identificación Fiscal (N.I.F.). Failing this, indicate the number
of the Documento Nacional de Identidad (D.N.I.) or passport, even if they are out of date. In case the aforementioned documents do not
exist, state ‘none’.
The day and the month should be shown by two digits each and the year by four digits (example: 1 August 1921 = 01.08.1921).
For French towns comprising several arrondissements, please give the number of the arrondissement (example: Paris 14). In the case of
Portuguese districts state also the parish and the local authority. 

(11)  Must be stated for insured persons of Spanish, French or Italian nationality. Here, the territorial area or district in which the place of birth
is located should be stated (example: in the case of France if the place (commune) of birth is Lille, the department of birth should be shown
as ‘Nord’ followed by the area code if known to the insured person; in this case: 59. The complete entry should therefore read: ‘Nord 59’).
In the case of persons born in Spain, state only the province.
The symbol of the insured person’s country of birth in accordance with the international motor vehicle registration code.

(12)
(13) Complete where appropriate.
(14)

After the number of weeks or months put ‘P’ for periods of compulsory insurance in order to avoid any confusion with periods of voluntary
insurance.
In 8.2 indicate the nature of the periods treated as insurance periods.
In the case of workers who were employed in mines or in undertakings treated as such, add an E 206 form.
For Greek and Spanish institutions, specify where possible the type of work in question.
For Spanish institutions, in the case of seamen a photocopy of the sailor’s book or books of the country issuing the certificate should be
enclosed.

(9)
(10)

(15)
(16)
(17)
(18)

3

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
EUROPEAN COMMUNITIES
Social Security Regulations
EEA*

See ‘Instructions’ on page 3

E 205

L     (1)

CERTIFICATE CONCERNING INSURANCE HISTORY IN LUXEMBOURG

Reg. 1408/71; Art. 38; Art. 43a; Art. 45; Art. 48; Art. 51a; Art. 57.5
Reg. 574/72; Art. 42.1; Art. 43.1 to 3; Art. 69

To be drawn up by the investigating institution for insurance periods completed under the legislation which it administers; where appropriate,
to be attached to form E 202, E 203 or E 204. Each institution concerned should draw up a form for the periods completed under the legislation
which it administers and send it to the investigating institution.

1

Institution to which the form is addressed (institution concerned or investigating institution, as applicable)

1.1

1.2

Name

Address (2) 

.............................................................................................................................................................................

.............................................................................................................................................................................

...................................................................................................................................................................................................................

...................................................................................................................................................................................................................

Information concerning the insured persons

2

Names

2.1
2.2

2.3

2.4

2.5

2.6

2.7

3

4

4.1
4.2

4.3

4.4

Surname (3)
Surname at birth (3)

Forenames (4)

Previous names (5)

Sex (6)

...............................................................................................................................................................

...............................................................................................................................................................

...............................................................................................................................................................

...............................................................................................................................................................

...............................................................................................................................................................

Father’s surname and forenames (7)

.........................................................................................................................................

Mother’s surname and forenames (7)

.........................................................................................................................................

Nationality (8)

............................................................................................ D.N.I. (8a) 

.............................

Details of birth

Date of birth (9)
Place of birth (10)

...............................................................................................................................................................

...............................................................................................................................................................

Province, department, county (11)

................................................................................................................................................

Country (12)

...............................................................................................................................................................

5

Address (2)

....................................................................................................................................................................................................................

....................................................................................................................................................................................................................

6

6.1

6.2

6.3

Insurance No at the investigating institution

Reference No of file at the investigating institution

Reference No of file at the institution concerned

....................................................................

....................................................................

....................................................................

7

Rightful claimant (13)

7.1

Surname (3)
...................................................................................................................................................................................................................

7.2

Forenames

Surname at birth

Place of birth (10)

...................................................................

...............................................................

...................................................................

7.3

Date of birth

Sex

Nationality

D.N.I. (8a)

...................................................................

......................................

...................................................

...................................

7.4

Address (2)

............................................................................................................................................................................................

...................................................................................................................................................................................................................

1

E 205

L

8

Periods during
which insurance periods and periods
treated as such were completed

Insurance
periods

Periods treated
as insurance
periods (14)

Year

from

to

Days Months

Days Months

Insurance
scheme

Occupation (15) (16) (17)

....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................

8.1

Total length of period of insurance under Luxembourg social security schemes

8.2

...................................................................................................................................................................................................................
Comments (14) 
...................................................................................................................................................................................................................

...............................................................................................................................................................................

2

E 205

L

9

An insured person showing proof that he has completed an insurance period of less than one year

M may receive

M may not receive

a pension under national legislation (Art. 48.1 of Reg. 1408/71)

10

Institution completing the form

10.1 Name

10.2

Address (2)

............................................................................................................................................................................

............................................................................................................................................................................

...................................................................................................................................................................................................................

10.3

Stamp

10.4

10.5

Date

Signature

................................................

..........................................................................

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.

INSTRUCTIONS

NOTES

*

EEA Agreement on the European Economic Area, Annex VI, Social Security: for the purposes of this Agreement the present form shall
also apply to Iceland, Liechtenstein and Norway.
Symbol of the country to which the institution completing the form belongs: L = Luxembourg.
Street, number, post code, town, country, telephone number.

(1)
(2)
(3) — For surname please state usual surname or surname acquired by marriage.

— The surname at birth must always be given; if same as current surname, put ‘IDEM’.
— Expressions such as ‘called …’ or ‘alias …’ and prefixes to surnames must be written in full in the order in which they appear on the

birth certificate.

— 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.

(4)
(5)

(6)
(7)

Give all forenames in the order in which they appear on the birth certificate.
To be stated particularly in the case of adoption or in the case of other names in current use; expressions such as ‘called …’ or ‘alias …’
and prefixes to surnames must be written in full in the order in which they appear on the birth certificate.
Put M for male and F for female.
This information is required when the worker is a Spanish national, or when the form is to be sent to a French institution, regardless of the
worker’s nationality.

(8) Where appropriate, indicate the date of naturalisation.
(8a)

In the case of Spanish nationals over 16 years of age, state the Número de Identificación Fiscal (N.I.F.). Failing this, indicate the number
of the Documento Nacional de Identidad (D.N.I.) or passport, even if they are out of date. If the aforementioned documents do not exist,
state ‘none’.
The day and the month should be shown by two digits each and the year by four digits (example: 1 August 1921 = 01.08.1921).
For French towns comprising several arrondissements, please give the number of the arrondissement (example: Paris 14). In the case of
Portuguese districts state also the parish and the local authority. 

(9)
(10)

(11)  Must be stated for insured persons of Spanish, French or Italian nationality. Here, the territorial area or district in which the place of birth
is located should be stated (example: in the case of France if the place (commune) of birth is Lille, the department of birth should be shown
as ‘Nord’ followed by the area code if known to the insured person; in this case: 59. The complete entry should therefore read: ‘Nord 59’).
In the case of persons born in Spain, state only the province.
The symbol of the insured person’s country of birth in accordance with the international motor vehicle registration code.

(12)
(13) Complete where appropriate.
(14)
(15)
(16)
(17)

In 8.2 indicate the nature of the periods treated as periods of employment.
In the case of persons who were employed in mines or in undertakings treated as such, add an E 206 form.
For Greek and Spanish institutions, specify where possible the type of work in question.
For Spanish institutions, in the case of seamen a photocopy of the sailor’s book or books of the country issuing the certificate should be
enclosed.

3

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
EUROPEAN COMMUNITIES
Social Security Regulations
EEA*

See ‘Instructions’ on page 4

E 205        NL     (1)

CERTIFICATE CONCERNING INSURANCE HISTORY IN THE NETHERLANDS

Reg. 1408/71; Art. 38; Art. 43a; Art. 45; Art. 48; Art. 51a; Art. 57.5
Reg. 574/72; Art. 42.1; Art. 43.1 to 3; Art. 69

To be drawn up by the investigating institution for insurance periods completed under the legislation which it administers; where appropriate,
to be attached to form E 202, E 203 or E 204. Each institution concerned should draw up a form for the periods completed under the legislation
which it administers and send it to the investigating institution.

1

Institution to which the form is addressed (institution concerned or investigating institution, as applicable)

1.1

1.2

Name

Address (2) 

.............................................................................................................................................................................

.............................................................................................................................................................................

...................................................................................................................................................................................................................

...................................................................................................................................................................................................................

Information concerning insured persons

2

Names

2.1
2.2

2.3

2.4

2.5

2.6

2.7

3

4

4.1
4.2

4.3

4.4

Surname (3)
Surname at birth (3)

Forenames (4)

Previous names (5)

Sex (6)

...............................................................................................................................................................

...............................................................................................................................................................

...............................................................................................................................................................

...............................................................................................................................................................

...............................................................................................................................................................

Father’s surname and forenames (7)

.........................................................................................................................................

Mother’s surname and forenames (7)

.........................................................................................................................................

Nationality (8)

............................................................................................ D.N.I. (8a)

.............................

Details of birth

Date of birth (9)
Place of birth (10)

...............................................................................................................................................................

...............................................................................................................................................................

Province, department, county (11)

................................................................................................................................................

Country (12)

...............................................................................................................................................................

5

Address (2)

....................................................................................................................................................................................................................

....................................................................................................................................................................................................................

6

6.1

6.2

6.3

Insurance No at the investigating institution

Reference No of file at the investigating institution

Reference No of file at the institution concerned

....................................................................

....................................................................

....................................................................

7

Rightful claimant (13)

7.1

Surname (3)
...................................................................................................................................................................................................................

7.2

Forenames

Surname at birth

Place of birth (10)

...................................................................

...............................................................

...................................................................

7.3

Date of birth

Sex

Nationality

D.N.I. (8a)

...................................................................

......................................

...................................................

...................................

7.4

Address (2)

............................................................................................................................................................................................

...................................................................................................................................................................................................................

1

E 205

NL

8

Insurance 
periods under
AOW/ANW (14)

Insurance periods
under WAO/AAW/WAZ (14)

Number of

Type (15) (16) (17)

from

to

from

to

Years

Months

Days

....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
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....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................

Total length of period of insurance in the Netherlands (17) under
................................................... years,

................................................. months,

.......................................... days.

h AOW

h ANW

h WAO/AAW/WAZ

8.1

2

E 205

NL

9

An insured person showing proof that he has completed an insurance period of less than one year

M may receive

M may not receive

a pension under national legislation (Art. 48.1 of Reg. 1408/71)

10

Institution completing the form

10.1 Name

10.2

Address (2)

............................................................................................................................................................................

............................................................................................................................................................................

...................................................................................................................................................................................................................

10.3

Stamp

10.4

10.5

Date

Signature

................................................

..........................................................................

3

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.

INSTRUCTIONS

NOTES

E 205

NL

*

EEA Agreement on the European Economic Area, Annex VI, Social Security: for the purposes of this Agreement the present form shall
also apply to Iceland, Liechtenstein and Norway.
Symbol of the country to which the institution completing the form belongs: NL = the Netherlands.
Street, number, post code, town, country, telephone number.

(1)
(2)
(3) — For surname please state usual surname of surname acquired by marriage.

— The surname at birth must always be given; if same as current surname, put ‘IDEM’.
— Expressions such as ‘called …’ or ‘alias …’ and prefixes to surnames must be written in full in the order in which they appear on the

birth certificate.

— 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.

(4)
(5)

(6)
(7)

Give all forenames in the order in which they appear on the birth certificate.
To be stated particularly in the case of adoption or in the case of other names in current use; expressions such as ‘called …’ or ‘alias …’
and prefixes to surnames must be written in full in the order in which they appear on the birth certificate.
Put M for male and F for female.
This information is required when the worker is a Spanish national, or when the form is to be sent to a French institution, regardless of the
worker’s nationality.

(8) Where appropriate, indicate the date of naturalisation.
(8a)

In the case of Spanish nationals over 16 years of age, state the Número de Identificación Fiscal (N.I.F.). Failing this, indicate the number
of the Documento Nacional de Identidad (D.N.I.) or passport, even if they are out of date. If the aforementioned documents do not exist,
state ‘none’.
The day and the month should be shown by two digits each and the year by four digits (example: 1 August 1921 = 01.08.1921).
For French towns comprising several arrondissements, please give the number of the arrondissement (example: Paris 14). In the case of
Portuguese districts state also the parish and the local authority. 

(9)
(10)

(11)  Must be stated for insured persons of Spanish, French or Italian nationality. Here, the territorial area or district in which the place of birth
is located should be stated (example: in the case of France if the place (commune) of birth is Lille, the department of birth should be shown
as ‘Nord’ followed by the area code if known to the insured person; in this case: 59. The complete entry should therefore read: ‘Nord 59’).
In the case of persons born in Spain state only the province.
The symbol of the insured person’s country of birth in accordance with the international motor vehicle registration code.

(12)
(13) Complete where appropriate.
(14)

AOW = law on general old-age insurance
ANW = the General Surviving Dependants’ Insurance Act
WAO = law on insurance against incapacity for work for employed persons
AAW = law on general incapacity for work
WAZ = the Invalidity Insurance (self-employed persons) Act

(15) Use the following symbols in order to indicate the type of insurance period

P = compulsory insurance
V = voluntary insurance
G = periods treated as periods of insurance
For Greek and Spanish institutions, specify where possible the type of work in question.
Since the Netherlands insurance scheme does not provide for registration of the insured person, it may happen that our statistics may
contain references to periods in respect of which it can only be assumed that the person concerned was insured in the Netherlands. In
the case where it is established that the person concerned was insured during the period of insurance stated by us in the Netherlands
under the legislation of your country, you should, without consulting us, deduct the periods in question from the total number of periods
of insurance stated in point 8.1 of this form.
For Spanish institutions, in the case of seamen a photocopy of the sailor’s book or books of the country issuing the certificate should be
enclosed.

(16)
(17)

(18)

4

EUROPEAN COMMUNITIES
Social Security Regulations
EEA*

See ‘Instructions’ on page 3

E 205         A     (1)

CERTIFICATE CONCERNING INSURANCE HISTORY IN AUSTRIA

Reg. 1408/71; Art. 38; Art. 43a; Art. 45; Art. 48; Art. 51a; Art. 57.5
Reg. 574/72; Art. 42.1; Art. 43.1 to 3; Art. 69

To be drawn up by the investigating institution for insurance periods completed under the legislation which it administers; where appropriate,
to be attached to form E 202, E 203 or E 204. Each institution concerned should draw up a form for the periods completed under the legislation
which it administers and send it to the investigating institution.

1

Institution to which the form is addressed (institution concerned or investigating institution, as applicable)

1.1

1.2

Name

Address (2) 

.............................................................................................................................................................................

.............................................................................................................................................................................

...................................................................................................................................................................................................................

...................................................................................................................................................................................................................

Information concerning insured persons

2

2.1
2.2

2.3

2.4

2.5

2.6

2.7

3

4

4.1

4.2

4.3

4.4

Surname (3)
Surname at birth (3)

Forenames (4)

Previous names (5)

Sex (6)

...............................................................................................................................................................

...............................................................................................................................................................

...............................................................................................................................................................

...............................................................................................................................................................

...............................................................................................................................................................

Father’s surname and forenames (7)

.........................................................................................................................................

Mother’s surname and forenames (7)

.........................................................................................................................................

Nationality (8)

............................................................................................ D.N.I. (8a)

.............................

Details of birth

Date of birth (9):

Place of birth (10):

...............................................................................................................................................................

...............................................................................................................................................................

Province, department, county (11):

................................................................................................................................................

Country (12):

...............................................................................................................................................................

5

Address (2)

....................................................................................................................................................................................................................

....................................................................................................................................................................................................................

6

6.1

6.2

6.3

Insurance No at the investigating institution

Reference No of file at the investigating institution

Reference No of file at the institution concerned

....................................................................

....................................................................

....................................................................

7

Rightful claimant (13)

7.1

Surname (3)
...................................................................................................................................................................................................................

7.2

Forenames

Surname at birth

Place of birth (10)

...................................................................

...............................................................

...................................................................

7.3

Date of birth

Sex

Nationality

D.N.I. (8a)

...................................................................

......................................

...................................................

...................................

7.4

Address (2)

............................................................................................................................................................................................

...................................................................................................................................................................................................................

1

E 205

A

8

Periods during which insurance periods and
periods treated as such were completed

Insurance
periods (14)

Periods treated as
insurance periods (14)

Insurance schemes

Year

from

to

Years Months

Days

Years Months

Days

Employed
person

Self-
employed
person

Civil
servants

Occupation
(16) (17) (18)

....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
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Sum total of periods

8.1

Total length of period of insurance under the social security schemes for employed and for self-employed persons and civil servants in Austria:

— periods to be taken into account only for the acquisition of entitlement of benefits:

..............................

years

.............................. months

..............................

days

— periods to be taken into account only for calculation of benefits:

..............................

years

.............................. months

..............................

days

8.2

Remarks (15)

...............................................................................................................................................................................

...................................................................................................................................................................................................................

2

E 205

A

9

An insured person showing proof that he has completed an insurance period of less than one year

M may receive

M may not receive

a pension under national legislation (Art. 48.1 of Reg. 1408/71)

10

Institution completing the form

10.1 Name

10.2

Address (2)

............................................................................................................................................................................

............................................................................................................................................................................

...................................................................................................................................................................................................................

10.3

Stamp

10.4

10.5

Date

Signature

................................................

..........................................................................

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.

INSTRUCTIONS

NOTES

*

EEA Agreement on the European Economic Area, Annex VI, Social Security: for the purposes of this Agreement the present form shall
also apply to Iceland, Liechtenstein and Norway.
Symbol of the country to which the institution completing the form belongs: A = Austria.
Street, number, post code, town, country, telephone number.

(1)
(2)
(3) — For surname please state usual surname or surname acquired by marriage.

— The surname at birth must always be given; if same as current surname, put ‘IDEM’.
— Expressions such as ‘called …’ or ‘alias …’ and prefixes to surnames must be written in full in the order in which they appear on the

birth certificate.

— 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.

(4)
(5)

(6)
(7)

Give all forenames in the order in which they appear on the birth certificate.
To be stated particularly in the case of adoption or in the case of other names in current use; expressions such as ‘called …’ or ‘alias …’
and prefixes to surnames must be written in full in the order in which they appear on the birth certificate.
Put M for male and F for female.
This information is required when the worker is a Spanish national, or when the form is to be sent to a French institution, regardless of the
worker’s nationality.

(8) Where appropriate, indicate the date of naturalisation.
(8a)

In the case of Spanish nationals over 16 years of age, state the Número de Identificación Fiscal (N.I.F.). Failing this, indicate the number
of the Documento Nacional de Identidad (D.N.I.) or passport, even if they are out of date. If the aforementioned documents do not exist,
state ‘none’.
The day and the month should be shown by two digits each and the year by four digits (example: 1 August 1921 = 01.08.1921).
For French towns comprising several arrondissements, please give the number of the arrondissement (example: Paris 14). In the case of
Portuguese districts state also the parish and the local authority. 

(11)  Must be stated for insured persons of Spanish, French or Italian nationality. Here, the territorial area or district in which the place of birth
is located should be stated (example: in the case of France if the place (commune) of birth is Lille, the department of birth should be shown
as ‘Nord’ followed by the area code if known to the insured person; in this case: 59. The complete entry should therefore read: ‘Nord 59’).
In the case of persons born in Spain state only the province.
The symbol of the insured person’s country of birth in accordance with the international motor vehicle registration code.

(12)
(13) Complete where appropriate.
(14)

After the number of insurance months put ‘F’ (voluntary) for periods of voluntary insurance in order to avoid any confusion with compulsory
insurance.
Furthermore, put ‘FS’ for periods of self-insurance, which are taken into account for the calculation of the amount of the benefit, but not
for the acquisition of the right.
After  the  number  of  months  treated  a  such  put  ‘E’  for  periods  treated  as  periods  of  insurance  which  are  taken  into  account  for  the
acquisition of the right, but not for the calculation of the amount of the benefit. Furthermore, the nature of the periods treated as such
(Ersatzzeiten) must be indicated in 8.2 (‘Remarks’).
In the case of workers who were employed in mines or in undertakings treated as such, add an E 206 form.
For Greek and Spanish institutions, specify where possible the type of work in question.
For Spanish institutions, in the case of seamen a photocopy of the sailor’s book or books of the country issuing the certificate should be
enclosed.

(9)
(10)

(15)

(16)
(17)
(18)

3

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
EUROPEAN COMMUNITIES
Social Security Regulations
EEA*

See ‘Instructions’ on page 3

E 205

P     (1)

CERTIFICATE CONCERNING INSURANCE HISTORY IN PORTUGAL

Reg. 1408/71; Art. 38; Art. 43a; Art. 45; Art. 48; Art. 51a; Art. 57.5
Reg. 574/72; Art. 42.1; Art. 43.1 to 3; Art. 69

To be drawn up by the investigating institution for insurance periods completed under the legislation which it administers; where appropriate,
to be attached to form E 202, E 203 or E 204. Each institution concerned should draw up a form for the periods completed under the legislation
which it administers and send it to the investigating institution.

1

Institution to which the form is addressed (institution concerned or investigating institution, as applicable)

1.1

1.2

Name

Address (2) 

.............................................................................................................................................................................

.............................................................................................................................................................................

...................................................................................................................................................................................................................

...................................................................................................................................................................................................................

Information concerning insured persons

2

2.1
2.2

2.3

2.4

2.5

2.6

2.7

3

4

4.1

4.2

4.3

4.4

Surname (3)
Surname at birth (3)

Forenames (4)

Previous names (5)

Sex (6)

...............................................................................................................................................................

...............................................................................................................................................................

...............................................................................................................................................................

...............................................................................................................................................................

...............................................................................................................................................................

Father’s surname and forenames (7)

.........................................................................................................................................

Mother’s surname and forenames (7)

.........................................................................................................................................

Nationality (8)

............................................................................................ D.N.I. (8a) 

.............................

Details of birth

Date of birth (9)

Place of birth (10)

...............................................................................................................................................................

...............................................................................................................................................................

Province, department, county (11)

................................................................................................................................................

Country (12)

...............................................................................................................................................................

5

Address (2)

....................................................................................................................................................................................................................

....................................................................................................................................................................................................................

6

6.1

6.2

6.3

Insurance No at the investigating institution

Reference No of file at the investigating institution

Reference No of file at the institution concerned

....................................................................

....................................................................

....................................................................

7

Rightful claimant (13)

7.1

Surname (3)
...................................................................................................................................................................................................................

7.2

Forenames

Surname at birth

Place of birth (10)

...................................................................

...............................................................

...................................................................

7.3

Date of birth

Sex

Nationality

D.N.I. (8a)

...................................................................

......................................

...................................................

...................................

7.4

Address (2)

............................................................................................................................................................................................

...................................................................................................................................................................................................................

1

E 205

P

8

Periods of insurance and
periods treated as such

Insurance
periods to 
31.12.1993

(14b)

Periods
treated as
insurance
periods to
31.12.1993 (14)

Insurance
periods
from
1.1.1994
(14b)

Periods
treated as 
insurance
periods from
1.1.1994 (14)

Occupation (14a) (15) (16) (17)

Year

from

to

Months

Months

Days

Days

....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
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8.1

Length of periods of insurance under Portuguese social security schemes:

...................................................................................................................................................................................................................

until 31. 12. 1993:

from 1. 1. 1994:

...................................................................................................................................................................

...................................................................................................................................................................

8.2

Comments:

...............................................................................................................................................................................

...................................................................................................................................................................................................................

2

E 205

P

9

An insured person showing proof that he has completed an insurance period of less than one year

M may receive

M may not receive

a pension under national legislation (Art. 48.1 of Reg. 1408/71)

10

Institution completing the form

10.1 Name

10.2

Address (2)

............................................................................................................................................................................

............................................................................................................................................................................

...................................................................................................................................................................................................................

10.3

Stamp

10.4

10.5

Date

Signature

................................................

..........................................................................

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.

INSTRUCTIONS

NOTES

*

EEA Agreement on the European Economic Area, Annex VI, Social Security: for the purposes of this Agreement the present form shall
also apply to Iceland, Liechtenstein and Norway.
Symbol of the country to which the institution completing the form belongs: P = Portugal.
Street, number, post code, town, country, telephone number.

(1)
(2)
(3) — For surname please state usual surname or surname acquired by marriage.

— The surname at birth must always be given; if same as current surname, put ‘IDEM’.
— Expressions such as ‘called …’ or ‘alias …’ and prefixes to surnames must be written in full in the order in which they appear on the

birth certificate.

— 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.

(4)
(5)

(6)
(7)

Give all forenames in the order in which they appear on the birth certificate.
To be stated particularly in the case of adoption or in the case of other names in current use; expressions such as ‘called …’ or ‘alias …’
and prefixes to surnames must be written in full in the order in which they appear on the birth certificate.
Put M for male and F for female.
This information is required when the worker is a Spanish national, or when the form is to be sent to a French institution, regardless of the
worker’s nationality.

(8) Where appropriate, indicate the date of naturalisation.
(8a)

In the case of Spanish nationals over 16 years of age, state the Número de Identificación Fiscal (N.I.F.). Failing this, indicate the number
of the Documento Nacional de Identidad (D.N.I.) or passport, even if they are out of date. If the aforementioned documents do not exist,
state ‘none’.
The day and the month should be shown by two digits each and the year by four digits (example: 1 August 1921 = 01.08.1921).
For French towns comprising several arrondissements, please give the number of the arrondissement (example: Paris 14). In the case of
Portuguese districts state also the parish and the local authority. 

(9)
(10)

(11)  Must be stated for insured persons of Spanish, French or Italian nationality. Here, the territorial area or district in which the place of birth
is located should be stated (example: in the case of France if the place (commune) of birth is Lille, the department of birth should be shown
as ‘Nord’ followed by the area code if known to the insured person; in this case: 59. The complete entry should therefore read: ‘Nord 59’).
In the case of persons born in Spain state only the province.
The symbol of the insured person’s country of birth in accordance with the international motor vehicle registration code.

(12)
(13) Complete where appropriate.
(14)
In 8.2 indicate the nature of the periods treated as periods of employment.
(14a) This information is given on the basis of particulars provided by the worker.
(14b) After periods referred to in Art. 15.2 of Reg. 574/72 put ‘S’.
(15)
(16)
(17)

In the case of workers who were employed in mines or in undertakings treated as such, add an E 206 form.
For Greek and Spanish institutions, specify where possible the type of work in question.
For Spanish institutions, in the case of seamen a photocopy of the sailor’s book or books of the country issuing the certificate should be
enclosed.

3

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
EUROPEAN COMMUNITIES
Social Security Regulations
EEA*

See ‘Instructions’ on pages 3 and 4

E 205

FIN     (1)

CERTIFICATE CONCERNING INSURANCE HISTORY IN FINLAND

Reg. 1408/71; Art. 38; Art. 43a; Art. 45; Art. 48; Art. 51a; Art. 57.5
Reg. 574/72; Art. 42.1; Art. 43.1 to 3; Art. 69

To be drawn up by the investigating institution for insurance periods completed under the legislation which it administers; where appropriate,
to be attached to form E 202, E 203 or E 204. Each institution concerned should draw up a form for the periods completed under the legislation
which it administers and send it to the investigating institution.

1

Institution to which the form is addressed (institution concerned or investigating institution, as applicable)

1.1

1.2

Name

Address (2) 

.............................................................................................................................................................................

.............................................................................................................................................................................

...................................................................................................................................................................................................................

...................................................................................................................................................................................................................

Information concerning insured persons

2

2.1
2.2

2.3

2.4

2.5

2.6

2.7

3

4

4.1

4.2

4.3

4.4

Surname (3)
Surname at birth (3)

Forenames (4)

Previous names (5)

Sex (6)

...............................................................................................................................................................

...............................................................................................................................................................

...............................................................................................................................................................

...............................................................................................................................................................

...............................................................................................................................................................

Father’s surname and forenames (7)

.........................................................................................................................................

Mother’s surname and forenames (7)

.........................................................................................................................................

Nationality (8)

............................................................................................ D.N.I. (8a)

.............................

Details of birth

Date of birth (9)

Place of birth (10)

...............................................................................................................................................................

...............................................................................................................................................................

Province, department, county (11)

................................................................................................................................................

Country (12)

...............................................................................................................................................................

5

Address (2)

....................................................................................................................................................................................................................

....................................................................................................................................................................................................................

6

6.1

6.2

6.3

Insurance No at the investigating institution

Reference No of file at the investigating institution

Reference No of file at the institution concerned

....................................................................

....................................................................

....................................................................

7

Rightful claimant (13)

7.1

Surname (3)
...................................................................................................................................................................................................................

7.2

Forenames

Surname at birth

Place of birth (10)

...................................................................

...............................................................

...................................................................

7.3

Date of birth

Sex

Nationality

D.N.I. (8a)

...................................................................

......................................

...................................................

...................................

7.4

Address (2)

............................................................................................................................................................................................

...................................................................................................................................................................................................................

1

E 205

FIN

8

Periods of insurance

Kind of period (15)

Remarks

Year

From

To

Years Quarters Months Weeks

Days

Type  
20

Nature  
21

Scheme 
22

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8.1

Totals by contribution type (15)

Years

Quarters

Months

Weeks

Days

8.2

Remarks (14)

2

E 205

FIN

9

An insured person showing proof that he has completed an insurance period of less than one year

M may receive

M may not receive

a pension under national legislation (Art. 48.1 of Reg. 1408/71)

10

Institution completing the form

10.1 Name

10.2

Address

............................................................................................................................................................................

............................................................................................................................................................................

...................................................................................................................................................................................................................

10.3

Stamp

10.4

10.5

Date

Signature

................................................

..........................................................................

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.

INSTRUCTIONS

NOTES

*

EEA Agreement on the European Economic Area, Annex VI, Social Security: for the purposes of this Agreement the present form shall
also apply to Iceland, Liechtenstein and Norway.
Symbol of the country to which the institution completing the form belongs: FIN = Finland.
Street, number, post code, town, country, telephone number.

(1)
(2)
(3) — For surname please state usual surname or surname acquired by marriage.

— The surname at birth must always be given; if same as current surname, put ‘IDEM’.
— Expressions such as ‘called …’ or ‘alias …’ and prefixes to surnames must be written in full in the order in which they appear on the

birth certificate.

— 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.

(4)
(5)

(6)
(7)

Give all forenames in the order in which they appear on the birth certificate.
To be stated particularly in the case of adoption or in the case of other names in current use; expressions such as ‘called …’ or ‘alias …’
and prefixes to surnames must be written in full in the order in which they appear on the birth certificate.
Put M for male and F for female.
This information is required when the worker is a Spanish national, or when the form is to be sent to a French institution, regardless of the
worker’s nationality.

(8) Where appropriate, indicate the date of naturalisation.
(8a)

In the case of Spanish nationals over 16 years of age, state the Número de Identificación Fiscal (N.I.F.). Failing this, indicate the number
of the Documento Nacional de Identidad (D.N.I.) or passport, even if they are out of date. If the aforementioned documents do not exist,
state ‘none’.
The day and the month should be shown by two digits each and the year by four digits (example: 1 August 1921 = 01.08.1921).
For French towns comprising several arrondissements, please give the number of the arrondissement (example: Paris 14). In the case of
Portuguese districts state also the parish and the local authority. 

(11)  Must be stated for insured persons of Spanish, French or Italian nationality. Here, the territorial area or district in which the place of birth
is located should be stated (example: in the case of France if the place (commune) of birth is Lille, the department of birth should be shown
as ‘Nord’ followed by the area code if known to the insured person; in this case: 59. The complete entry should therefore read: ‘Nord 59’).
In the case of persons born in Spain state only the province.
The symbol of the insured person’s country of birth in accordance with the international motor vehicle registration code.

(12)
(13) Complete where appropriate.
(14)

For Spanish institutions, in the case of seamen a photocopy of the sailor’s book or books of the country issuing the certificate should be
enclosed.
The classification variables for the insurance periods as expressed in the note CA.SS.TM 186/87 and in its later updates, and, as regards
the total amount, in the specification of entry ‘contribution type 5049’ in the code list for message SSRECH used in the technical data
exchange.

Key to contribution codes used in form E 205

COLUMN 20 - TYPE OF PERIOD
00
03
40

Period of compulsory in insurance (for the acquisition of entitlement and the calculation)
Equivalent period (for the acquisition of entitlement and the calculation)
Period of compulsory insurance (for the purposes of acquiring entitlement)

COLUMN 21 - NATURE
00
10
30
40
50
70

Period of insurance based on residence
Period of employment
Period of unemployment
Period of rehabilitation
Period of vocational training for adults
The projected period to old-age pension

3

(9)
(10)

(15)

E 205

FIN

COLUMN 22 - TYPE OF INSURANCE SCHEME
00
10
20
90

The pension schemes for residence based pension
The pension schemes for employed pensions
The pension schemes for self-employed persons
The pension schemes for employed persons as well as self-employed persons

TOTALS BY CONTRIBUTION TYPE
107
108
109
111

Periods of residence for calculation and entitlement
Periods of residence for entitlement only
Periods of employment for calculation and entitlement
Periods of employment for entitlement only

4

EUROPEAN COMMUNITIES
Social Security Regulations
EEA*

See ‘Instructions’ on page 3

E 205

S     (1)

CERTIFICATE CONCERNING INSURANCE HISTORY IN SWEDEN

Reg. 1408/71; Art. 38; Art. 43a; Art. 45; Art. 48; Art. 51a; Art. 57.5
Reg. 574/72; Art. 42.1; Art. 43.1 to 3; Art. 69

To be drawn up by the investigating institution for insurance periods completed under the legislation which it administers; where appropriate,
to be attached to form E 202, E 203 or E 204. Each institution concerned should draw up a form for the periods completed under the legislation
which it administers and send it to the investigating institution.

1

Institution to which the form is addressed (institution concerned or investigating institution, as applicable)

1.1

1.2

Name

Address (2) 

.............................................................................................................................................................................

.............................................................................................................................................................................

...................................................................................................................................................................................................................

...................................................................................................................................................................................................................

Information concerning insured persons

2

2.1
2.2

2.3

2.4

2.5

2.6

2.7

3

4

4.1

4.2

4.3

4.4

Surname (3)
Surname at birth (3)

Forenames (4)

Previous names (5)

Sex (6)

...............................................................................................................................................................

...............................................................................................................................................................

...............................................................................................................................................................

...............................................................................................................................................................

...............................................................................................................................................................

Father’s surname and forenames (7)

.........................................................................................................................................

Mother’s surname and forenames (7)

.........................................................................................................................................

Nationality (8)

............................................................................................ D.N.I. (8a) 

.............................

Details of birth

Date of birth (9)

Place of birth (10)

...............................................................................................................................................................

...............................................................................................................................................................

Province, department, county (11)

................................................................................................................................................

Country (12)

...............................................................................................................................................................

5

Address (2)

....................................................................................................................................................................................................................

....................................................................................................................................................................................................................

6

6.1

6.2

6.3

Insurance No at the investigating institution

Reference No of file at the investigating institution

Reference No of file at the institution concerned

....................................................................

....................................................................

....................................................................

7

Rightful claimant (13)

7.1

Surname (3)
...................................................................................................................................................................................................................

7.2

Forenames

Surname at birth

Place of birth (10)

...................................................................

...............................................................

...................................................................

7.3

Date of birth

Sex

Nationality

D.N.I. (8a)

...................................................................

......................................

...................................................

...................................

7.4

Address (2)

............................................................................................................................................................................................

...................................................................................................................................................................................................................

1

E 205

S

8

1. Periods under employment 2. Periods equal with years with 
pension scheme establishing
right to supplementary 
pension (ATP)

pension points establishing
right to basic pension

3. Periods of residence
establishing right
to basic pension

Number of

from

to

from

to

from

to

Years

Months

Days

....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
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8.1-2 Total length of period under employment pension scheme in Sweden

.................

years

8.3

Total length of periods of residence in Sweden

.................

years

................... months

...................

days

8.4

Remarks (14) 
...................................................................................................................................................................................................................

...............................................................................................................................................................................

2

E 205

S

9

An insured person showing proof that he has completed an insurance period of less than one year

M may receive

M may not receive

a pension under national legislation (Art. 48.1 of Reg. 1408/71)

10

Institution completing the form

10.1 Name

10.2

Address (2)

............................................................................................................................................................................

............................................................................................................................................................................

...................................................................................................................................................................................................................

10.3

Stamp

10.4

10.5

Date

Signature

................................................

..........................................................................

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.

INSTRUCTIONS

NOTES

*

EEA Agreement on the European Economic Area, Annex VI, Social Security: for the purposes of this Agreement the present form shall
also apply to Iceland, Liechtenstein and Norway.
Symbol of the country to which the institution completing the form belongs S = Sweden.
Street, number, post code, town, country, telephone number.

(1)
(2)
(3) — For surname please state usual surname or surname acquired by marriage.

— The surname at birth must always be given; if same as current surname, put ‘IDEM’.
— Expressions such as ‘called …’ or ‘alias …’ and prefixes to surnames must be written in full in the order in which they appear on the

birth certificate.

— 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.

(4)
(5)

(6)
(7)

Give all forenames in the order in which they appear on  birth certificate.
To be stated particularly in the case of adoption or in the case of other names in current use; expressions such as ‘called …’ or ‘alias …’
and prefixes to surnames must be written in full in the order in which they appear on the birth certificate.
Put M for male and F for female.
This information is required when the worker is a Spanish national, or when the form is to be sent to a French institution, regardless of the
worker’s nationality.

(8) Where appropriate, indicate the date of naturalisation.
(8a)

In the case of Spanish nationals over 16 years of age, state the Número de Identificación Fiscal (N.I.F.). Failing this, indicate the number
of the Documento Nacional de Identidad (D.N.I.) or passport, even if they are out of date. If the aforementioned documents do not exist,
state ‘none’.
The day and the month should be shown by two digits each and the year by four digits (example: 1 August 1921 = 01.08.1921).
For French towns comprising several arrondissements, please give the number of the arrondissement (example: Paris 14). In the case of
Portuguese districts state also the parish and the local authority. 

(9)
(10)

(11)  Must be stated for insured persons of Spanish, French or Italian nationality. Here, the territorial area or district in which the place of birth
is located should be stated (example: in the case of France if the place (commune) of birth is Lille, the department of birth should be shown
as ‘Nord’ followed by the area code if known to the insured person; in this case: 59. The complete entry should therefore read: ‘Nord 59’).
In the case of persons born in Spain, state only the province.
The symbol of the insured person’s country of birth in accordance with the international motor vehicle registration code.

For Spanish institutions, in the case of seamen a photocopy of the sailor’s book or books of the country issuing the certificate should be
enclosed.

(12)
(13) Complete where appropriate.
(14)

3

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
EUROPEAN COMMUNITIES
Social Security Regulations
EEA*

See ‘Instructions’ on page 3

E 205

GB     (1)

CERTIFICATE CONCERNING INSURANCE HISTORY IN THE UNITED KINGDOM

Reg. 1408/71; Art. 38; Art. 43a; Art. 45; Art. 48; Art. 51a; Art. 57.5
Reg. 574/72; Art. 42.1; Art. 43.1 to 3; Art. 69

To be drawn up by the investigating institution for insurance periods completed under the legislation which it administers; where appropriate,
to be attached to form E 202, E 203 or E 204. Each institution concerned should draw up a form for the periods completed under the legislation
which it administers and send it to the investigating institution.

1

Institution to which the form is addressed (institution concerned or investigating institution, as applicable)

1.1

1.2

Name

Address (2) 

.............................................................................................................................................................................

.............................................................................................................................................................................

...................................................................................................................................................................................................................

...................................................................................................................................................................................................................

Information concerning insured persons

2

Names

2.1
2.2

2.3

2.4

2.5

2.6

2.7

3

4

4.1
4.2

4.3

4.4

Surname (3)
Surname at birth (3)

Forenames (4)

Previous names (5)

Sex (6)

...............................................................................................................................................................

...............................................................................................................................................................

...............................................................................................................................................................

...............................................................................................................................................................

...............................................................................................................................................................

Father’s surname and forenames (7)

.........................................................................................................................................

Mother’s surname and forenames (7)

.........................................................................................................................................

Nationality (8)

............................................................................................ D.N.I. (8a)

.............................

Details of birth

Date of birth (9)
Place of birth (10)

...............................................................................................................................................................

...............................................................................................................................................................

Province, department, county (11)

................................................................................................................................................

Country (12)

...............................................................................................................................................................

5

Address (2)

....................................................................................................................................................................................................................

....................................................................................................................................................................................................................

6

6.1

6.2

6.3

Insurance No at the investigating institution

Reference No of file at the investigating institution

Reference No of file at the institution concerned

....................................................................

....................................................................

....................................................................

7

Rightful claimant (13)

7.1

Surname (3)
...................................................................................................................................................................................................................

7.2

Forenames

Surname at birth

Place of birth (10)

...................................................................

...............................................................

...................................................................

7.3

Date of birth

Sex

Nationality

D.N.I. (8a)

...................................................................

......................................

...................................................

...................................

7.4

Address (2)

............................................................................................................................................................................................

...................................................................................................................................................................................................................

1

E 205

GB

8

Periods during which insurance periods and
periods treated as such were completed

Insurance 
periods (14)

Employed
persons

Self-employed
persons

Voluntary 
insurance

Periods
treated
as insurance
periods (15)

Occupation (16) (17) (18)

Year

from

to

Weeks

Weeks

Weeks

Weeks

....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
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8.1

Total length of period of insurance under the United Kingdom social security scheme for employed and self-employed persons

...................................................................................................................................................................................................................

8.2

Comments 

...............................................................................................................................................................................

...................................................................................................................................................................................................................

2

E 205

GB

9

An insured person showing proof that he has completed an insurance period of less than one year

M may receive

M may not receive

a pension under national legislation (Art. 48.1 of Reg. 1408/71)

10

Institution completing the form

10.1 Name

10.2

Address (2)

............................................................................................................................................................................

............................................................................................................................................................................

...................................................................................................................................................................................................................

10.3

Stamp

10.4

10.5

Date

Signature

................................................

..........................................................................

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.

INSTRUCTIONS

NOTES

*

EEA Agreement on the European Economic Area, Annex VI, Social Security: for the purposes of this Agreement the present form shall
also apply to Iceland, Liechtenstein and Norway.
Symbol of the country to which the institution completing the form belongs GB = United Kingdom.
Street, number, post code, town, country, telephone number.

(1)
(2)
(3) — For surname please state usual surname or surname acquired by marriage.

— The surname at birth must always be given; if same as current surname, put ‘IDEM’.
— Expressions such as ‘called …’ or ‘alias …’ and prefixes to surnames must be written in full in the order in which they appear on the

birth certificate.

— 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.

(4)
(5)

(6)
(7)

Give all forenames in the order in which they appear on  birth certificate.
To be stated particularly in the case of adoption or in the case of other names in current use; expressions such as ‘called …’ or ‘alias …’
and prefixes to surnames must be written in full in the order in which they appear on the birth certificate.
Put M for male and F for female.
This information is required when the worker is a Spanish national, or when the form is to be sent to a French institution, regardless of the
worker’s nationality.

(8) Where appropriate, indicate the date of naturalisation.
(8a)

In the case of Spanish nationals over 16 years of age, state the Número de Identificación Fiscal (N.I.F.). Failing this, indicate the number
of the Documento Nacional de Identidad (D.N.I.) or passport, even if they are out of date. If the aforementioned documents do not exist,
state ‘none’.
The day and the month should be shown by two digits each and the year by four digits (example: 1 August 1921 = 01.08.1921).
For French towns comprising several arrondissements, please give the number of the arrondissement (example: Paris 14). In the case of
Portuguese districts state also the parish and the local authority. 

(11)  Must be stated for insured persons of Spanish, French or Italian nationality. Here, the territorial area or district in which the place of birth
is located should be stated (example: in the case of France if the place (commune) of birth is Lille, the department of birth should be shown
as ‘Nord’ followed by the area code if known to the insured person; in this case: 59. The complete entry should therefore read: ‘Nord 59’).
In the case of persons born in Spain, state only the province.
The symbol of the insured person’s country of birth in accordance with the international motor vehicle registration code.

(12)
(13) Complete where appropriate.
(14)
(15)
(16)

Indicate the period of voluntary insurance in the next column.
Indicate whether the period in question are periods of illness, unemployment, etc.
In the case of workers who were employed in mines or in undertakings treated as such, add an E 206 form. These data may be issued
only on the basis of information supplied by the employee.
For Greek and Spanish institutions, specify where possible the type of work in question.
For Spanish institutions, in the case of seamen a photocopy of the sailor’s book or books of the country issuing the certificate should be
enclosed.

(9)
(10)

(17)
(18)

3

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
EUROPEAN COMMUNITIES
Social Security Regulations
EEA*

See ‘Instructions’ on page 3

E 205         IS     (1)

CERTIFICATE CONCERNING INSURANCE HISTORY IN ICELAND

Reg. 1408/71; Art. 38; Art. 43a; Art. 45; Art. 48; Art. 51a; Art. 57.5
Reg. 574/72; Art. 42.1; Art. 43.1 to 3; Art. 69

To be drawn up by the investigating institution for insurance periods completed under the legislation which it administers; where appropriate,
to be attached to form E 202, E 203 or E 204. Each institution concerned should draw up a form for the periods completed under the legislation
which it administers and send it to the investigating institution.

1

Institution to which the form is addressed (institution concerned or investigating institution, as applicable)

1.1

1.2

Name

Address (2)

.............................................................................................................................................................................

.............................................................................................................................................................................

...................................................................................................................................................................................................................

...................................................................................................................................................................................................................

Information concerning insured persons

2

2.1
2.2

2.3

2.4

2.5

2.6

2.7

3

4

4.1

4.2

4.3

4.4

Surname (3)
Surname at birth (3)

Forenames (4)

Previous names (5)

Sex (6)

...............................................................................................................................................................

...............................................................................................................................................................

...............................................................................................................................................................

...............................................................................................................................................................

...............................................................................................................................................................

Father’s surname and forenames (7)

.........................................................................................................................................

Mother’s surname and forenames (7)

.........................................................................................................................................

Nationality (8)

............................................................................................ D.N.I. (8a) 

.............................

Details of birth

Date of birth (9)

Place of birth (10)

...............................................................................................................................................................

...............................................................................................................................................................

Province, department, county (11)

................................................................................................................................................

Country (12)

...............................................................................................................................................................

5

Address (2)

....................................................................................................................................................................................................................

....................................................................................................................................................................................................................

6

6.1

6.2

6.3

Insurance No at the investigating institution

Reference No of file at the investigating institution

Reference No of file at the institution concerned

....................................................................

....................................................................

....................................................................

7

Rightful claimant (13)

7.1

Surname (3)
...................................................................................................................................................................................................................

7.2

Forenames

Surname at birth

Place of birth (10)

...................................................................

...............................................................

...................................................................

7.3

Date of birth

Sex

Nationality

D.N.I. (8a)

...................................................................

......................................

...................................................

...................................

7.4

Address (2)

............................................................................................................................................................................................

...................................................................................................................................................................................................................

1

E 205

IS

8

1. Periods under employment
pension schemes establishing
right to supplementary penions

2. Periods of residence
establishing right
to basic pension

3. Sum of periods
of
employment

4. Sum of
periods
of residence

From

To

From

To

Years

Months

Days

Years

Months

Days

....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................

8.1

Total length of periods under employment pension schemes

.................

years

................... months

...................

days

8.2

Total length of periods of residence

.................

years

................... months

...................

days

8.3

Remarks (14) 
...................................................................................................................................................................................................................

...............................................................................................................................................................................

2

E 205

IS

9

An insured person showing proof that he has completed an insurance period of less than one year

M may receive

M may not receive

a pension under national legislation (Art. 48.1 of Reg. 1408/71)

10

Institution completing the form

10.1 Name

10.2

Address (2)

............................................................................................................................................................................

............................................................................................................................................................................

...................................................................................................................................................................................................................

10.3

Stamp

10.4

10.5

Date

Signature

................................................

..........................................................................

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.

INSTRUCTIONS

NOTES

*

EEA Agreement on the European Economic Area, Annex VI, Social Security: for the purposes of this Agreement the present form shall
also apply to Iceland, Liechtenstein and Norway.
Symbol of the country to which the institution completing the form belongs: IS = Iceland.
Street, number, post code, town, country, telephone number.

(1)
(2)
(3) — For surname please state usual surname or surname acquired by marriage.

— The surname at birth must always be given; if same as current surname, put ‘IDEM’.
— Expressions such as ‘called …’ or ‘alias …’ and prefixes to surnames must be written in full in the order in which they appear on the

birth certificate.

— 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.

(4)
(5)

(6)
(7)

Give all forenames in the order in which they appear on  birth certificate.
To be stated particularly in the case of adoption or in the case of other names in current use; expressions such as ‘called …’ or ‘alias …’
and prefixes to surnames must be written in full in the order in which they appear on the birth certificate.
Put M for male and F for female.
This information is required when the worker is a Spanish national, or when the form is to be sent to a French institution, regardless of the
worker’s nationality.

(8) Where appropriate, indicate the date of naturalisation.
(8a)

In the case of Spanish nationals over 16 years of age, state the Número de Identificación Fiscal (N.I.F.). Failing this, indicate the number
of the Documento Nacional de Identidad (D.N.I.) or passport, even if they are out of date. If the aforementioned documents do not exist,
state ‘none’.
The day and the month should be shown by two digits each and the year by four digits (example: 1 August 1921 = 01.08.1921).
For French towns comprising several arrondissements, please give the number of the arrondissement (example: Paris 14). In the case of
Portuguese districts state also the parish and the local authority. 

(9)
(10)

(11)  Must be stated for insured persons of Spanish, French or Italian nationality. Here, the territorial area or district in which the place of birth
is located should be stated (example: in the case of France if the place (commune) of birth is Lille, the department of birth should be shown
as ‘Nord’ followed by the area code if known to the insured person; in this case: 59. The complete entry should therefore read: ‘Nord 59’).
In the case of persons born in Spain, state only the province.
The symbol of the insured person’s country of birth in accordance with the international motor vehicle registration code.

For Spanish institutions, in the case of seamen a photocopy of the sailor’s book or books of the country issuing the certificate should be
enclosed.

(12)
(13) Complete where appropriate.
(14)

3

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
EUROPEAN COMMUNITIES
Social Security Regulations
EEA*

See ‘Instructions’ on page 4

E 205        FL     (1)

CERTIFICATE CONCERNING INSURANCE HISTORY IN LIECHTENSTEIN

Reg. 1408/71; Art. 38; Art. 43a; Art. 45; Art. 48; Art. 51a; Art. 57.5
Reg. 574/72; Art. 42.1; Art. 43.1 to 3; Art. 69

To be drawn up by the investigating institution for insurance periods completed under the legislation which it administers; where appropriate,
to be attached to form E 202, E 203 or E 204. Each institution concerned should draw up a form for the periods completed under the legislation
which it administers and send it to the investigating institution.

1

Institution to which the form is addressed (institution concerned or investigating institution, as applicable)

1.1

1.2

Name

Address (2) 

.............................................................................................................................................................................

.............................................................................................................................................................................

...................................................................................................................................................................................................................

...................................................................................................................................................................................................................

Information concerning insured persons

2

2.1
2.2

2.3

2.4

2.5

2.6

2.7

3

4

4.1

4.2

4.3

4.4

Surname (3)
Surname at birth (3)

Forenames (4)

Previous names (5)

Sex (6)

...............................................................................................................................................................

...............................................................................................................................................................

...............................................................................................................................................................

...............................................................................................................................................................

...............................................................................................................................................................

Father’s surname and forenames (7)

.........................................................................................................................................

Mother’s surname and forenames (7)

.........................................................................................................................................

Nationality (8)

............................................................................................ D.N.I. (8a) 

.............................

Details of birth

Date of birth (9)

Place of birth (10)

...............................................................................................................................................................

...............................................................................................................................................................

Province, department, county (11)

................................................................................................................................................

Country (12)

...............................................................................................................................................................

5

Address (2)

....................................................................................................................................................................................................................

....................................................................................................................................................................................................................

6

6.1

6.2

6.3

Insurance No at the investigating institution

Reference No of file at the investigating institution

Reference No of file at the institution concerned

....................................................................

....................................................................

....................................................................

7

Rightful claimant (13)

7.1

Surname (3)
...................................................................................................................................................................................................................

7.2

Forenames

Surname at birth

Place of birth (10)

...................................................................

...............................................................

...................................................................

7.3

Date of birth

Sex

Nationality

D.N.I. (8a)

...................................................................

......................................

...................................................

...................................

7.4

Address (2)

............................................................................................................................................................................................

...................................................................................................................................................................................................................

1

E 205

FL

8

Year from
1 January
to 31 December

1954

Number of months

Type of insurance periods

Type of contributions (15)

Remarks (17)

...................................................................................................................................................................................................................................

1955

...................................................................................................................................................................................................................................

1956

...................................................................................................................................................................................................................................

1957

...................................................................................................................................................................................................................................

1958

...................................................................................................................................................................................................................................

1959

...................................................................................................................................................................................................................................

1960

...................................................................................................................................................................................................................................

1961

...................................................................................................................................................................................................................................

1962

...................................................................................................................................................................................................................................

1963

...................................................................................................................................................................................................................................

1964

...................................................................................................................................................................................................................................

1965

...................................................................................................................................................................................................................................

1966

...................................................................................................................................................................................................................................

1967

...................................................................................................................................................................................................................................

1968

...................................................................................................................................................................................................................................

1969

...................................................................................................................................................................................................................................

1970

...................................................................................................................................................................................................................................

1971

...................................................................................................................................................................................................................................

1972

...................................................................................................................................................................................................................................

1973

...................................................................................................................................................................................................................................

1974

...................................................................................................................................................................................................................................

1975

...................................................................................................................................................................................................................................

1976

...................................................................................................................................................................................................................................

1977

...................................................................................................................................................................................................................................

1978

...................................................................................................................................................................................................................................

1979

...................................................................................................................................................................................................................................

1980

...................................................................................................................................................................................................................................

1981

...................................................................................................................................................................................................................................

1982

...................................................................................................................................................................................................................................

1983

...................................................................................................................................................................................................................................

1984

...................................................................................................................................................................................................................................

1985

...................................................................................................................................................................................................................................

2

E 205

FL

8

(continued)

Year from
1 January
to 31 December

1986

Number of months

Type of insurance periods

Type of contributions (15)

Remarks (17)

...................................................................................................................................................................................................................................

1987

...................................................................................................................................................................................................................................

1988

...................................................................................................................................................................................................................................

1989

...................................................................................................................................................................................................................................

1990

...................................................................................................................................................................................................................................

1991

...................................................................................................................................................................................................................................

1992

...................................................................................................................................................................................................................................

1993

...................................................................................................................................................................................................................................

1994

...................................................................................................................................................................................................................................

1995

...................................................................................................................................................................................................................................

1996

...................................................................................................................................................................................................................................

1997

...................................................................................................................................................................................................................................

1998

...................................................................................................................................................................................................................................

1999

...................................................................................................................................................................................................................................

2000

...................................................................................................................................................................................................................................

2001

...................................................................................................................................................................................................................................

2002

...................................................................................................................................................................................................................................

2003

...................................................................................................................................................................................................................................

2004

...................................................................................................................................................................................................................................

2005

...................................................................................................................................................................................................................................

2006

...................................................................................................................................................................................................................................

2007

...................................................................................................................................................................................................................................

2008

...................................................................................................................................................................................................................................

2009

...................................................................................................................................................................................................................................

2010

...................................................................................................................................................................................................................................

2011

...................................................................................................................................................................................................................................

2012

...................................................................................................................................................................................................................................

2013

...................................................................................................................................................................................................................................

2014

...................................................................................................................................................................................................................................

2015

...................................................................................................................................................................................................................................

2016

...................................................................................................................................................................................................................................

8.1

8.2

Total period of insurance

......................... months

Remarks 

...............................................................................................................................................................................

3

E 205

FL

9

An insured person showing proof that he has completed an insurance period of less than one year

M may receive

M may not receive

a pension under national legislation (Art. 48.1 of Reg. 1408/71)

10

Institution completing the form

10.1 Name

10.2

Address (2)

............................................................................................................................................................................

............................................................................................................................................................................

...................................................................................................................................................................................................................

10.3

Stamp

10.4

10.5

Date

Signature

................................................

..........................................................................

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.

INSTRUCTIONS

NOTES

*

EEA Agreement on the European Economic Area, Annex VI, Social Security: for the purposes of this Agreement the present form shall
also apply to Iceland, Liechtenstein and Norway.
Symbol of the country to which the institution completing the form belongs: FL = Liechtenstein.
Street, number, post code, town, country, telephone number.

(1)
(2)
(3) — For surname please state usual surname or surname acquired by marriage.

— The surname at birth must always be given; if same as current surname, put ‘IDEM’.
— Expressions such as ‘called …’ or ‘alias …’ and prefixes to surnames must be written in full in the order in which they appear on the

birth certificate.

— 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.

(4)
(5)

(6)
(7)

Give all forenames in the order in which they appear on  birth certificate.
To be stated particularly in the case of adoption or in the case of other names in current use; expressions such as ‘called …’ or ‘alias …’
and prefixes to surnames must be written in full in the order in which they appear on the birth certificate.
Put M for male and F for female.
This information is required when the worker is a Spanish national, or when the form is to be sent to a French institution, regardless of the
worker’s nationality.

(8) Where appropriate, indicate the date of naturalisation.
(8a)

In the case of Spanish nationals over 16 years of age, state the Número de Identificación Fiscal (N.I.F.). Failing this, indicate the number
of the Documento Nacional de Identidad (D.N.I.) or passport, even if they are out of date. If the aforementioned documents do not exist,
state ‘none’.
The day and the month should be shown by two digits each and the year by four digits (example: 1 August 1921 = 01.08.1921).
For French towns comprising several arrondissements, please give the number of the arrondissement (example: Paris 14). In the case of
Portuguese districts state also the parish and the local authority. 

(9)
(10)

(11)  Must be stated for insured persons of Spanish, French or Italian nationality. Here, the territorial area or district in which the place of birth
is located should be stated (example: in the case of France if the place (commune) of birth is Lille, the department of birth should be shown
as ‘Nord’ followed by the area code if known to the insured person; in this case: 59. The complete entry should therefore read: ‘Nord 59’).
In the case of persons born in Spain, state only the province.
The symbol of the insured person’s country of birth in accordance with the international motor vehicle registration code.

(12)
(13) Complete where appropriate.
(14)
(15)

In 8.2 indicate the nature of the periods treated as periods of employment.
Kind of insurance periods/kind of contribution:
1 — contributions from employment
2 — contributions from a voluntary-insured person
3 — contributions from self-employment
4 — contributions from non-active persons
10 — periods of insurance without contribution obligation
For Greek and Spanish institutions, specify where possible the type of work in question.
For Spanish institutions, in the case of seamen a photocopy of the sailor’s book or books of the country issuing the certificate should be
enclosed.

(16)
(17)

4

EUROPEAN COMMUNITIES
Social Security Regulations
EEA*

See ‘Instructions’ on page 3

E 205

N     (1)

CERTIFICATE CONCERNING INSURANCE HISTORY IN NORWAY

Reg. 1408/71; Art. 38; Art. 43a; Art. 45; Art. 48; Art. 51a; Art. 57.5
Reg. 574/72; Art. 42.1; Art. 43.1 to 3; Art. 69

To be drawn up by the investigating institution for insurance periods completed under the legislation which it administers; where appropriate,
to be attached to form E 202, E 203 or E 204. Each institution concerned should draw up a form for the periods completed under the legislation
which it administers and send it to the investigating institution.

1

Institution to which the form is addressed (institution concerned or investigating institution, as applicable)

1.1

1.2

Name

Address (2) 

.............................................................................................................................................................................

.............................................................................................................................................................................

...................................................................................................................................................................................................................

...................................................................................................................................................................................................................

Information concerning insured persons

2

2.1
2.2

2.3

2.4

2.5

2.6

2.7

3

4

4.1

4.2

4.3

4.4

Surname (3)
Surname at birth (3)

Forenames (4)

Previous names (5)

Sex (6)

...............................................................................................................................................................

...............................................................................................................................................................

...............................................................................................................................................................

...............................................................................................................................................................

...............................................................................................................................................................

Father’s surname and forenames (7)

.........................................................................................................................................

Mother’s surname and forenames (7)

.........................................................................................................................................

Nationality (8)

............................................................................................ D.N.I. (8a)

.............................

Details of birth

Date of birth (9)

Place of birth (10)

...............................................................................................................................................................

...............................................................................................................................................................

Province, department, county (11)

................................................................................................................................................

Country (12)

...............................................................................................................................................................

5

Address (2)

....................................................................................................................................................................................................................

....................................................................................................................................................................................................................

6

6.1

6.2

6.3

Insurance No at the investigating institution

Reference No of file at the investigating institution

Reference No of file at the institution concerned

....................................................................

....................................................................

....................................................................

7

Rightful claimant (13)

7.1

Surname (3)
...................................................................................................................................................................................................................

7.2

Forenames

Surname at birth

Place of birth (10)

...................................................................

...............................................................

...................................................................

7.3

Date of birth

Sex

Nationality

D.N.I. (8a)

...................................................................

......................................

...................................................

...................................

7.4

Address (2)

............................................................................................................................................................................................

...................................................................................................................................................................................................................

1

E 205

N

8

Insurance periods based on residence
and periods treated as such

Insurance years with income as
employed or self-employed, giving

points for supplementary pension

Sum of each
insurance period

Year

from

to

Year

Months

Days

....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................

8.1

Total number of insurance years as employed or self-employed, counting,

as basis for calculation of supplementary pension

....................

years

8.2

Total insurance period under the pension scheme in Norway

Total insurance period, according to Norwegian legislation

8.3

Remarks (14)
...................................................................................................................................................................................................................

...............................................................................................................................................................................

2

E 205

N

9

An insured person showing proof that he has completed an insurance period of less than one year

M may receive

M may not receive

a pension under national legislation (Art. 48.1 of Reg. 1408/71)

10

Institution completing the form

10.1 Name

10.2

Address (2)

............................................................................................................................................................................

............................................................................................................................................................................

...................................................................................................................................................................................................................

10.3

Stamp

10.4

10.5

Date

Signature

................................................

..........................................................................

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.

INSTRUCTIONS

NOTES

*

EEA Agreement on the European Economic Area, Annex VI, Social Security: for the purposes of this Agreement the present form shall
also apply to Iceland, Liechtenstein and Norway.
Symbol of the country to which the institution completing the form belongs N = Norway.
Street, number, post code, town, country, telephone number.

(1)
(2)
(3) — For surname please state usual surname or surname acquired by marriage.

— The surname at birth must always be given; if same as current surname, put ‘IDEM’.
— Expressions such as ‘called …’ or ‘alias …’ and prefixes to surnames must be written in full in the order in which they appear on the

birth certificate.

— 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.

(4)
(5)

(6)
(7)

Give all forenames in the order in which they appear on  the birth certificate.
To be stated particularly in the case of adoption or in the case of other names in current use; expressions such as ‘called …’ or ‘alias …’
and prefixes to surnames must be written in full in the order in which they appear on the birth certificate.
Put M for male and F for female.
This information is required when the worker is a Spanish national, or when the form is to be sent to a French institution, regardless of the
worker’s nationality.

(8) Where appropriate, indicate the date of naturalisation.
(8a)

In the case of Spanish nationals over 16 years of age, state the Número de Identificación Fiscal (N.I.F.). Failing this, indicate the number
of the Documento Nacional de Identidad (D.N.I.) or passport, even if they are out of date. If the aforementioned documents do not exist,
state ‘none’.
The day and the month should be shown by two digits each and the year by four digits (example: 1 August 1921 = 01.08.1921).
For French towns comprising several arrondissements, please give the number of the arrondissement (example: Paris 14). In the case of
Portuguese districts state also the parish and the local authority. 

(9)
(10)

(11)  Must be stated for insured persons of Spanish, French or Italian nationality. Here, the territorial area or district in which the place of birth
is located should be stated (example: in the case of France if the place (commune) of birth is Lille, the department of birth should be shown
as ‘Nord’ followed by the area code if known to the insured person; in this case: 59. The complete entry should therefore read: ‘Nord 59’).
In the case of persons born in Spain, state only the province.
The symbol of the insured person’s country of birth in accordance with the international motor vehicle registration code.

For Spanish institutions, in the case of seamen a photocopy of the sailor’s book or books of the country issuing the certificate should be
enclosed.

(12)
(13) Complete where appropriate.
(14)

3

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
EUROPEAN COMMUNITIES
Social Security Regulations
EEA*

See ‘Instructions’ on page 4

E 206                (1)

CERTIFICATE CONCERNING PERIODS OF EMPLOYMENT IN MINES AND SIMILAIR UNDERTAKINGS

Reg. 1408/71: Art. 38; Art. 43a; Art. 45; Art. 48; Art. 51a; Art. 57.5
Reg. 574/72: Art. 42.1; Art. 43.1 to 3; Art. 69

This form should be completed by each institution concerning the periods of insurance completed under the legislation administered by it.

1

Institution to which the form is addressed (institution concerned or investigating institution, as applicable)

1.1

1.2

Name

Address (2) 

.............................................................................................................................................................................

.............................................................................................................................................................................

...................................................................................................................................................................................................................

...................................................................................................................................................................................................................

Information concerning insured persons

2

2.1
2.2

2.3

2.4

2.5

2.6

2.7

3

4

4.1

4.2

4.3

4.4

Surname (3)
Surname at birth (3)

Forenames (4)

Previous names (5)

Sex (6)

...............................................................................................................................................................

...............................................................................................................................................................

...............................................................................................................................................................

...............................................................................................................................................................

...............................................................................................................................................................

Father’s surname and forenames (7)

.........................................................................................................................................

Mother’s surname and forenames (7)

.........................................................................................................................................

Nationality (8)

............................................................................................ D.N.I. (8a)

.............................

Details of birth

Date of birth (9)

Place of birth (10)

...............................................................................................................................................................

...............................................................................................................................................................

Province, department, county (11)

.........................................................................................................................................

Country (12)

...............................................................................................................................................................

5

Address (2)

....................................................................................................................................................................................................................

....................................................................................................................................................................................................................

6

6.1

6.2

6.3

Insurance No at the investigating institution

Reference No of file at the investigating institution

Reference No of file at the institution concerned

....................................................................

....................................................................

....................................................................

7

Rightful claimant (13)

7.1

7.2

Surname (3)
...................................................................................................................................................................................................................
Forenames

Place of birth (10)

Previous names

...................................................................

...............................................................

...................................................................

7.3

Date of birth

Sex

Nationality

D.N.I. (8a)

...................................................................

......................................

...................................................

...................................

7.4

Address (2)

............................................................................................................................................................................................

...................................................................................................................................................................................................................

1

E 206

8

Undertakings
(14)

Type of
work
performed (15)

Periods of employment or

periods treated as such

Length of each period

overall

underground work

from

to

Years

Months

Days

Years

Months

Days

....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
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....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................

8.1

2

Total

E 206

9

The periods of employment shown in item 8 were interrupted as follows (16)

Periods of interruption

from

to

Day/month/year

Day/month/year

Reason for interruption (sickness, leave, military service, 

active service, unemployment, medical treatment, 

rehabilitation, unpaid leave, etc.)

....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................

10

Institution completing the form

10.1 Name

.............................................................................................................................................................................

10.2

Address (2)

.............................................................................................................................................................................

...................................................................................................................................................................................................................

10.3

Stamp

10.4

10.5

Date

................................................

Signature
..........................................................................

3

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.

INSTRUCTIONS

NOTES

E 206

*

(1)

EEA Agreement on the European Economic Area, Annex VI, Social Security: for the purposes of this Agreement the present form shall
also apply to Iceland, Liechtenstein and Norway.
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;  A  =  Austria;  P  =  Portugal;  FIN  =  Finland;
S = Sweden; GB = United Kingdom; IS = Iceland; FL = Liechtenstein; N = Norway.
Street, number, post code, town, country, telephone number.

(2)
(3) — For surname please state usual surname or surname acquired by marriage. If the form is being completed by a Netherlands institution
in cases where the insured person or the rightful claimant is a married woman or a woman who was married before, put the present
or last husband’s surname for current surname.

— The surname at birth must always be given; if same as current surname, put ‘IDEM’. If the form is being completed by a Netherlands
institution in cases where the insured person or the rightful claimant is a married woman or a woman who was married before, put
maiden name for surname at birth.

— Expressions such as ‘called …’ or ‘alias …’ and all prefixes to surnames must be written in full in the order in which they appear on

the birth certificate.

— 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.

(4)
(5)

(6)
(7)

Give all forenames in the order in which they appear on the birth certificate.
To be stated particularly in the case of adoption or in the case of other names in current use; expressions such as ‘called …’ or ‘alias …’
and prefixes to surnames must be written in full in the order in which they appear on the birth certificate.
Put M for male and F for female.
This information is required when the worker is a Spanish national, or when the form is to be sent to a French institution, regardless of the
worker’s nationality.

(8) Where appropriate, indicate the date of naturalisation.
(8a)

In the case of Spanish nationals over 16 years of age, state the Número de Identificación Fiscal (N.I.F.). Failing this, indicate the number
of the Documento Nacional de Identidad (D.N.I.) or passport, even if they are out of date. If the aforementioned documents do not exist,
state ‘none’.
The day and the month should be shown by two digits each and the year by four digits (example: 1 August 1921 = 01.08.1921).
For French towns comprising several arrondissements, please give the number of the arrondissement (example: Paris 14). In the case of
Portuguese districts state also the parish and the local authority. 

(9)
(10)

(11)  Must be stated for insured persons of Spanish, French or Italian nationality. Here, the territorial area or district in which the place of birth
is located should be stated (example: in the case of France if the place (commune) of birth is Lille, the department of birth should be shown
as ‘Nord’ followed by the area code if known to the insured person; in this case: 59. The complete entry should therefore read: ‘Nord 59’).
In the case of persons born in Spain state only the province.
The symbol of the insured person’s country of birth in accordance with the international motor vehicle registration code.

(12)
(13) Complete where appropriate.
(14)
(15)

Indicate the undertakings in which the person concerned was employed and the substance extracted or processed.
Specify type of work and indicate whether performed on the surface or underground, or whether it concerns periods treated as periods
of employment.

(16) Complete only if the form is to be sent to German, Spanish and Austrian institutions.

4

EUROPEAN COMMUNITIES
Social Security Regulations
EEA*

See ‘Instructions’ on page 3

E 207

(1)

CERTIFICATE CONCERNING THE INSURED PERSON’S INSURANCE HISTORY

Reg. 1408/71; Art. 38; Art. 43a; Art. 45; Art. 48; Art. 51a; Art. 57.5
Reg. 574/72; Art. 42.1; Art. 43.1 to 3; Art. 69

To be completed by the investigating institution and to be attached to forms E 202, E 203 and E 204.
The information in box 7 has been obtained from the person concerned and will be sent to the institution concerned.

Information concerning insured persons (2)

1

1.1

1.2

1.3

1.4
1.5

1.6

1.7

1.8

2

3

1.1

1.2

1.3

1.4

Surname (3)

Surname at birth (3)

Forenames (4)
Previous names (5)
Sex (6)

...............................................................................................................................................................

...............................................................................................................................................................

...............................................................................................................................................................
...............................................................................................................................................................

...............................................................................................................................................................

Father’s surname and forenames (7)

.........................................................................................................................................

Mother’s surname and forenames (7)

.........................................................................................................................................

National social security number (NISS) (7a)

Nationality (8)

............................................................................................ D.N.I. (8a)

.............................

Details of birth

Date of birth (9)
Place of birth (10)

...............................................................................................................................................................

...............................................................................................................................................................

Province, department, county (11)

................................................................................................................................................

Country (12)

...............................................................................................................................................................

4

Address (13)(14)

....................................................................................................................................................................................................................

....................................................................................................................................................................................................................

5

6

Insurance No at the registering institution  (15)  

...........................................................................

Investigating institution

6.1

6.2

Name

Address (13)

.............................................................................................................................................................................

.............................................................................................................................................................................

...................................................................................................................................................................................................................

6.3

Stamp

6.4

6.5

Date

Signature

................................................

..........................................................................

1

2

E 207

7

Information relating to all periods completed (periods as civil servant or periods of employment, self-employment, residence and training) (16)

Period (17)

from

1

to

2

Type 
of period (18)

Name of employer and place of
registered office or type of activity
carried out as self-employed person

Place and country
where activity is
carried out (19)

(a) Insurance institution or scheme (15)
(b) Insurance number (20)
(c) Type of insurance (21)

Place of residence
during period
of employment (22)

3

4

5

6

7

1

2

3

4

5

6

7

8

.......................................
Date 

.................................................................... (23)
Signature

(a)  ...................................................................
(b)  ...................................................................
(c)  ...................................................................

(a)  ...................................................................
(b)  ...................................................................
(c)  ...................................................................

(a)  ...................................................................
(b)  ...................................................................
(c)  ...................................................................

(a)  ...................................................................
(b)  ...................................................................
(c)  ...................................................................

(a)  ...................................................................
(b)  ...................................................................
(c)  ...................................................................

(a)  ...................................................................
(b)  ...................................................................
(c)  ...................................................................

(a)  ...................................................................
(b)  ...................................................................
(c)  ...................................................................

(a)  ...................................................................
(b)  ...................................................................
(c)  ...................................................................

E 207

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. If the space provided on page 2 is not sufficient to indicate all stages of the
insurance history of the person concerned, insert one or more identical pages, changing the numbers at the extreme left-hand side
(substituting 9, 10, 11 … for 1, 2, 3 …)

INSTRUCTIONS

NOTES

*

(1)

(2)

EEA Agreement on the European Economic Area, Annex VI, Social Security: for the purposes of this Agreement the present form shall
also apply to Iceland, Liechtenstein and Norway.
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;  A  =  Austria;  P  =  Portugal;  FIN  =  Finland;
S = Sweden; GB = United Kingdom; IS = Iceland; FL = Liechtenstein; N = Norway.
For Germany and Austria, the term ‘insured persons’ encompasses individuals insured under the general social security scheme as well
as civil servants and individuals treated as such who are insured under a special scheme. If the form is being sent to a Swedish institution
please complete additional page No 1.

(3) — For surname please state usual surname or surname acquired by marriage. If the form is being completed by a Netherlands institution
in cases where the insured person or the rightful claimant is a married woman or a woman who was married before, put the present
or last husband’s surname for current surname.

— The surname at birth must always be given; if same as current surname, put ‘IDEM’. If the form is being completed by a Netherlands
institution in cases where the insured person or the rightful claimant is a married woman or a woman who was married before, put
the maiden name for surname at birth.

— Expressions such as ‘called …’ or ‘alias …’ and prefixes to surnames must be written in full in the order in which they appear on the

birth certificate.

— 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.

(4)
(5)

(6)
(7)

(7a)

Give all forenames in the order in which they appear on the birth certificate.
To be stated particularly in the case of adoption or in the case of other names in current use; expressions such as ‘called …’ or ‘alias …’
and prefixes to surnames must be written in full in the order in which they appear on the birth certificate.
Put M for male and F for female.
This information is required when the worker is a Spanish national, or when the form is to be sent to a French institution, regardless of the
worker’s nationality.
For  workers  subject  to  Belgian  legislation,  state  worker’s  national  social  security  number  (NISS);  for  the  purposes  of  the  Netherlands’
institutions state the Sofi number.

(8) Where appropriate, indicate the date of naturalisation.
(8a)

In the case of Spanish nationals over 16 years of age, state the Número de Identificación Fiscal (N.I.F.). Failing this, indicate the number
of the Documento Nacional de Identidad (D.N.I.) or passport, even if they are out of date. If the aforementioned documents do not exist,
state ‘none’.
The day and the month should be shown by two digits each and the year by four digits (example: 1 August 1921 = 01.08.1921).
For French towns comprising several arrondissements, please give the number of the arrondissement (example: Paris 14). In the case of
Portuguese districts state also the parish and the local authority. 

(9)
(10)

(16)
(17)

(12)
(13)
(14)
(15)

(11)  Must be stated for insured persons of Spanish, French or Italian nationality. Here, the territorial area or district in which the place of birth
is located should be stated (example: in the case of France if the place (commune) of birth is Lille, the department of birth should be shown
as ‘Nord’ followed by the area code if known to the insured person; in this case: 59. The complete entry should therefore read: ‘Nord 59’).
In the case of persons born in Spain, state only the province.
The symbol of the insured person’s country of birth in accordance with the international motor vehicle registration code.
Street, number, post code, town, country, telephone number.
For the purposes of Norwegian institutions, please state actual address and last address in Norway with date of emigration.
For Spanish institutions enclose a photocopy of the Spanish sailor’s book or books if the relevant institution is the ISM (Instituto Nacional
de la Marina/Mariners’ Social Institute) or if the relevant scheme is the Special Scheme for Mariners.
Attach certified copies of documentary evidence for each period (e.g. pension cards, salary slips, contribution vouchers).
If the form is being sent to a Danish, Netherlands, Finnish, Icelandic, Liechtenstein or Norwegian institution, indicate also all periods of
residence completed by the worker in Denmark, the Netherlands, Finland, Iceland, Liechtenstein or Norway. For this purpose, give the
exact address in the corresponding State.
Indicate the type of work performed (employed or self-employed), e.g. mechanic, shop assistant, self-employed farmer. Where applicable:
school  or  vocational  training:  (specify  type  of  course  and  diplomas  obtained);  periods  without  paid  employment  (e.g.  housewife,
unemployed, sickness, etc.); military service (country). If the person concerned served in the Spanish armed forces, enclose a copy of the
service record book (cartilla militar) with form E 207. Failing this, provide the following information: year of conscription, service branch,
function, province of recruitment and place of residence immediately after discharge. If the person concerned served in the armed forces
in Italy, a copy of his service book (‘foglio matricolare’) or of his service record (‘stato di servizio’) should be enclosed where possible with
the E 207 form.

(18)

(19) Where the activity is carried out in France, give the name of the department.
(20)
If the form is to be sent to a Danish institution, indicate the CPR number.
Where the form is to be sent to an Icelandic institution, the Icelandic personal identification number must be indicated.
If the form is to be sent to a Liechtenstein institution, insert the AHV insurance number.
Specify whether compulsory insurance, voluntary insurance, optional continued insurance or period uninsured.
For Greece, indicate the commune and department where the person concerned is insured with OGA.
If page 2 is completed by the claimant him/herself the claimant’s signature and date must be given. In the case of Ireland, a copy of the
national form completed by the claimant will be attached.

(21)
(22)
(23)

3

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
E 207 additional page No 1

ADDITIONAL INFORMATION FOR SWEDISH INSTITUTIONS

Periods of residence
between 16 and 65

Periods under employment
pension scheme

Number of

Addresses in Sweden

from

to

from

to

years

months

days

....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................

In case of a survivor’s pension the abovementioned periods refer to the deceased.

If the claimant/the deceased as employed/self-employed in Sweden before 1960 proof of employment should be enclosed if possible.

1

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
EUROPEAN COMMUNITIES
Social Security Regulations
EEA*

E 210

Symbol
of the country

NOTIFICATION OF DECISION CONCERNING A CLAIM FOR A PENSION
Application of Reg. 1408/71 and Reg. 574/72

for

M old age

M invalidity

M survivor

Award or rejection

Each  of  the  institutions  concerned  should  complete  this  form  and  send  it  to  the  investigating  institution  together  with  a  copy  of  the  formal
decision. One extra copy should be added for any additional institution concerned.

1

Investigating institution to which the form is addressed

1.1

1.2

Name: 

Address: 

...............................................................................................................................................................................

...............................................................................................................................................................................

...................................................................................................................................................................................................................

1.3

Number of insured person/reference number of file:  ...............................................................................................................................

2

Information concerning the insured person

2.1

2.2

2.3

2.4

2.5

2.6

Surname:

Surname at birth:

Forenames:

Previous names:

Date of birth:

Identification No:

...............................................................................................................................................................

...............................................................................................................................................................

...............................................................................................................................................................

...............................................................................................................................................................

...............................................................................................................................................................

.........................................................................................................................................

3

Information concerning the entitled person

3.1

3.2

3.3

3.4

3.5

3.6

Surname:

Surname at birth:

Forenames:

Previous names:

Date of birth:

...............................................................................................................................................................

...............................................................................................................................................................

...............................................................................................................................................................

...............................................................................................................................................................

...............................................................................................................................................................

Family relationship or other connection with the deceased insured person (box 2):

...............................................................

4

Address

M of insured person

M of entitled person

....................................................................................................................................................................................................................

....................................................................................................................................................................................................................

....................................................................................................................................................................................................................

....................................................................................................................................................................................................................

5

The claim is rejected

Reasons:

............................................................................................................................................................................................

............................................................................................................................................................................................

............................................................................................................................................................................................

............................................................................................................................................................................................

............................................................................................................................................................................................

............................................................................................................................................................................................

............................................................................................................................................................................................

1

E 210

6.

A pension is awarded

6.1

This benefit is awarded pursuant to:

M Art. 46.1.a.i. of Reg. 1408/71 (national)

M Art. 46.1.a.ii of Reg. 1408/71 (pro rata)

M Art. 46.2 of Reg. 1408/71 (pro rata)

M Art. 51a.2 of Reg. 1408/71

6.2

For the award of the benefit, a rule against overlapping was applied from 

................................... taking account of:

M benefit of the same kind

..................................................................................................................................................

(state type of benefit)

M benefit of a different kind

..................................................................................................................................................

(state type of benefit)

M other sources of income

M   professionnal or trade activity / activity as a civil servant

M   other (state the income concerned)

.............................................................................................................................................................................................................

6.3

The effect of the rule against overlapping was limited by the application of provisions of:

M Art. 46a.3.d of Reg. 1408/71

M Art. 46c of Reg. 1408/71 because one or more institutions took account of:

M   a benefit of a different kind

M   other sources of income

M   professional trade or activity / activity as a civil servant

M   other (please specify)

.............................................................................................................................................................................................................

M Art. 7.1 of Reg. 574/72

2

E 210

6.4

Number of monthly payments per year

M 12

M 13

M 14

6.5

From  .........................................................................................

6.6 Monthly  amount,  where  appropriate,  for  the  application  of
Art. 46a.3.d,  Art.  46c  of  Reg.  1408/71,  or  Art.  7.1  of
Reg. 574/72

6.7

Part  of  the  amount  awarded  on  the  basis  of  voluntary
insurance (Art. 46a.3.c of Reg. 1408/71) (to be completed only
at the request of the investigating institution)

6.8 Monthly amount before deduction of taxes, etc. (Art. 46a.3.b
of Reg. 1408/71), where appropriate, following application of
Art. 46c of Reg. 1408/71 or of Art. 7.1 of Reg. 574/72

6.9 Monthly amount due (amount paid after deduction of taxes,

etc.)

6.10 To be filled in by Swedish institutions

Monthly amount from the basic pension scheme

.........................................................................

Monthly amount from the supplementary pension scheme

.........................................................................

7

Institution concerned

7.1

7.2

7.3

4.4

Name:   

Address:   

.............................................................................................................................................................................

.............................................................................................................................................................................

...................................................................................................................................................................................................................

Number of insured person/reference number of file:

Stamp:

7.5 Date:

7.6 Signature:

................................................

.............................................................................

3

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
EUROPEAN COMMUNITIES
Social Security Regulations
EEA*

See ‘Instructions’ overleaf

E 211

(1)

SUMMARY OF DECISION

Reg. 574/72: Art. 48

The investigating institution should complete this form and send a copy to the claimant in his own language attaching a copy of each of the
formal decisions, together with a notice of appeals and periods allowed for appeals (an E 212 form). The investigating institution should also
send a copy of an E 211 form to each of the institutions concerned, attaching a copy of its own decision and of the decisions of the other
institutions concerned.

1

Claimant

1.1

Surname (2)

...................................................................................................................................................................................................................

1.2

Forenames

Previous names (2)

Place of birth (3)

...................................................................

...............................................................

...................................................................

1.3

Date of birth

Sex

Nationality

D.N.I. (4)

...................................................................

......................................

...................................................

...................................

1.4

Address (5)

............................................................................................................................................................................................

...................................................................................................................................................................................................................

Your claim for a pension for

2
2.1 M old age
2.2

has been examined by the following institutions

M invalidity

M survivor

3

Institutions concerned

3.1

3.2

3.3

3.4

3.5

4

5

5.1

Country

Institution

File reference

.........................................................................

......................................................................

......................................................

.........................................................................

......................................................................

......................................................

.........................................................................

......................................................................

......................................................

.........................................................................

......................................................................

......................................................

.........................................................................

......................................................................

......................................................

These institutions have taken the following decisions (see original decisions attached)

Your claim has been rejected

Concerning (6) 
Reason

............................................................................................................................................................

............................................................................................................................................................

..................................................................................................................................................................................................................

..................................................................................................................................................................................................................

..................................................................................................................................................................................................................

5.2

Concerning (6)

............................................................................................................................................................

Reason

............................................................................................................................................................

..................................................................................................................................................................................................................

..................................................................................................................................................................................................................

..................................................................................................................................................................................................................

6

A pension (7) has been awarded to you

Concerning (6)

Annual amount in currency of country 

Payable from (date)

responsible for payment (8) (9)

6.1

6.2

6.3

6.4

6.5

.........................................................................

......................................................................

......................................................

.........................................................................

......................................................................

......................................................

.........................................................................

......................................................................

......................................................

.........................................................................

......................................................................

......................................................

.........................................................................

......................................................................

......................................................

7

If you wish to appeal against the decisions given in your case by one or more of these institutions, you may do so in accordance with

the procedures and within the time limits indicated on form E 212.

1

E 211

8

Investigating institution

8.1

8.2

Name

Address (5)

.............................................................................................................................................................................

..............................................................................................................................................................................

...................................................................................................................................................................................................................

8.3

Stamp

8.4 Date

8.5 Signature

................................................

...............................................................................

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

INSTRUCTIONS

NOTES

*

(1)

(2)

(3)

(4)

(5)

(6)

(7)

EEA Agreement on the European Economic Area, Annex VI, Social Security: for the purposes of this Agreement the present form shall
also apply to Iceland, Liechtenstein and Norway.

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;  A  =  Austria;  P  =  Portugal;  FIN  =  Finland;
S = Sweden; GB = United Kingdom; IS = Iceland; FL = Liechtenstein; N = Norway.

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.

In the case of Portuguese districts state also the parish and the local authority.

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, state ‘None’.

Street, number, post code, town, country.

Indicate country and where necessary the scheme concerned.

Or cash compensation in Liechtenstein.

(8) Where rates of pensions are upgraded by virtue of national legislation, the amount indicated above will be changed. The new amount will

not be communicated to any other institution.

(9)

It is possible that this amount is reduced by taxes and contributions payable by the pensioner.

2

EUROPEAN COMMUNITIES
Social Security Regulations
EEA*

See ‘Instructions’ on page 3

E 212

(1)

APPEALS AND PERIODS ALLOWED FOR APPEALS

Reg. 574/72; Art. 48

A — If you do not agree with the decision or decisions taken, you may appeal. For this purpose you should, for each contested decision:

1.

State in writing the grounds for your appeal.

2. State the references on the notification relating to the contested decision. Attach a copy of this decision.

3. Sign the letter. If you cannot sign, make a cross and have the letter of appeal signed by two adult persons, giving their surnames,

forenames and addresses (2) (3).

4. Ensure that, within the period mentioned in the notification of the contested decision, this letter is in the possession of the institution

with which you lodge an appeal against the decision.

NB: This period starts on the date of the notification; under Art. 86 of Reg. 1408/71 any claim, declaration or appeal which should
have been submitted, in order to comply with the legislation of one State, within a specified period to an authority, institution
or court of that State shall be admissible if it is submitted within the same period to a corresponding authority, institution or
court of another State.

To obtain the name and address of this authority, institution or court, enquire at the pension insurance institution of your place
of residence.

B — 1. An  appeal  against  a  Belgian decision  should,  within  one  month  of  the  date  on  which  the  decision  is  received,  either  be  sent  by

registered letter, or delivered to the office of the clerk of the labour court in the area of jurisdiction:

(1) where you reside, if you are resident in Belgium (labour court of

...........................................................................................................................................................................................................);

(2) of your or the insured person’s last domicile or residence in Belgium, if you are resident abroad;

(3) of the place where the insured person was last occupied in Belgium, if you and the insured person have never been domiciled

or resident in Belgium.

2. An appeal against a Danish decision relating to entitlement to a pension should be lodged, within a period of four weeks of the date
on which the decision is received, with the authority that took the decision. The authority will forward the appeal to the appropriate
body.

An appeal against a Danish decision relating to entitlement to a pension under the legislation on supplementary pensions for employed
persons (ATP) should be lodged, within a period of four weeks of the date on which the decision is received, with the ‘Ankenævnet
for  Arbejdsmarkedets  Tillægspension’  (ATP  Appeals  Board),  Ministry  of  Labour,  Copenhagen. Address:  Laksegade,  19,  1063
Copenhagen K (Denmark).

3. A protest against a decision taken by a German institution for pension insurance may be lodged within a period of one month of the

date of notification of the decision.

The protest must be made in writing to .....................................................................................................................................................

....................................................................................................................................................................................................................

(Address of German insurance institution from which the decision is received).

You may also personally go to the institution and have your appeal recorded in writing there.

4. An appeal against a decision by a Greek institution should be lodged with the following authority either directly or via the institution

of the place of residence within a period of .......... days of the date on which the decision is received: (name and address)

....................................................................................................................................................................................................................

5. An appeal against a decision by a Spanish institution must be sent within 30 working days of the date on which notification of the

decision was received to the following authority (name and address):

....................................................................................................................................................................................................................

....................................................................................................................................................................................................................

either directly or via the institution or your place of residence.

1

E 212

6. An appeal against a decision by a French institution should be lodged within a period of two months of the date on which it is received
(if it is an administrative decision) with the Chairman of the Appeals Board, the address of which is given below, or (if it is a medical
decision) to the Chairman of the Regional Technical Commission, the address of which is given below:

....................................................................................................................................................................................................................

....................................................................................................................................................................................................................

7. An appeal against an Irish decision should be sent to the Chief Appeals Officer, Social Welfare Appeals Office, D’Olier House, D’Olier

Street, Dublin 2, within a period of 21 days of the date of notification of the decision.

8. An appeal against an Italian decision of the INPS should be sent to the ‘Comitato provinciale’ attached to the provincial office of the

INPS in

....................................................................................................................................................................................................................

within 90 days of the date on which the Summary of Decisions (E 211 form) is received.

If no decision has been received at the end of the period of 90 days, the person concerned may, within three years of the end of the
said period, take legal action as provided for by law.

The above appeal procedures apply to claims for pensions which form the subject matter of a decision by the INPS in the context of
general compulsory invalidity, old-age and survivor’s insurance. Appeals against decisions taken in the context of special schemes of
the INPS or of the other institutions are subject to different procedures of which the insured person will be notified separately.

9. An  appeal  against  a  Luxembourg decision  should  be  sent  in  duplicate  to  the  ‘Conseil  arbitral  des  assurances  sociales’  in

Luxembourg, within a period of 40 days of the date on which the decision is received.

10. An appeal againts a Netherlands decision should be sent in duplicate to the ‘Arrondissementsrechtbank, Sector Bestuursrecht’:

....................................................................................................................................................................................................................

within six weeks of the date on which it is reasonably assumed you were aware of that decision.

Legal charges will have to be paid in connection with the dispute procedure; these charges will be reimbursed if the court finds in your
favour.  This  does  not  apply  to  notifications  concerning  pensions  under  the  special  scheme  for  miners.  These  notifications  include
instructions as to what you should do if you disagree with the calculation of the pension.

11. You can appeal against a decision of an Austrian pension insurance institution within a time limit of three months without extension
beginning with the delivery of the decision to the authority quoted in the decision under ‘Klagerecht’ (‘legal information’), at the county
court  of  your  place  of  residence  or  place  of  employment,  if  the  court  mentioned  in  the  decision  is  not  located  at  your  place  of
residence or place of employment or at the pension insurance institution which has issued the decision.

12. An appeal against a decision by a Portuguese institution must be sent:

— if permanent incapacity has not been recognised, to the National Pensions Centre (Centro Nacional de Pensoes), within 15 days
(or 45 days in case of residence outside Portugal) of the day on which the conclusions of the Supervisory Board on Permanent
Incapacity (Commissao de Verificaçao de Incapacidades Permanentes) were notified, 
or

— if a claim for cash benefits has been rejected on administrative grounds, to the locally competent Administrative Tribunal (Tribunal
Administrativo de Circulo) within two months (or four months in case of residence outside Portugal) of the day on which the notice
of the decision was received.

13. An appeal against a Finnish decision relating to a pension under the legislation on Finnish employment pensions should be sent within

a period of 30 days of the date on which the decision is received, to the address given below:

....................................................................................................................................................................................................................

An appeal against a Finnish decision relating to a pension under the legislation on national pensions should be sent, within a period
of 30 days of the date on which the decision was received, to ‘Kansaneläkalaitos’ (Social Insurance Institution), to the address given
below:

....................................................................................................................................................................................................................

14. An appeal against a decision by a Swedish social insurance office must be sent to the social insurance office for reconsideration

within two months of the date on which the decision was received.

15. An appeal against a decision of a United Kingdom institution should be sent, within a period of three months from the date shown
on the decision letter, to the Department of Social Security, Benefits Agency, Pensions and Overseas Benefits Directorate, Newcastle-
upon-Tyne or the Northern Ireland Social Security Agency, Overseas Branch, Belfast, as appropriate.

2

E 212

16. An appeal against an Icelandic decision relating to a pension under the legislation on social pension should be sent no later than

three months after a decision was reached to ‘Tryggingarad’ (The State Social Security Board), Reykjavik.

Address:  .....................................................................................................................................................................................................

....................................................................................................................................................................................................................

An appeal against an Icelandic decision relating to a pension under the legislation on supplementary pension (pension funds) should
be lodged within ‘gerdardomur lifeyrissjodsins’ (the court of arbitration of the relevant pension fund).

Address: ......................................................................................................................................................................................................

....................................................................................................................................................................................................................

17. An appeal against a decision of the Liechtenstein old-age, survivor’s or invalidity insurance must be sent by the applicant or all other
persons who are concerned by this decision to the Liechtenstein old-age, survivor’s or invalidity insurance, Vaduz, for reconsideration
within 30 days of the date on which the decision was received.

An appeal against a Liechtenstein decision relating to the occupational scheme must be brought into the Liechtenstein court within
three years in case of claims concerning periodical benefits.

18. An appeal against a Norwegian decision must be sent to the Norwegian social insurance office within six weeks of receiving notice

of the decision.

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

INSTRUCTIONS

NOTES

*

(1)

(2)
(3)

EEA Agreement on the European Economic Area, Annex VI, Social Security: for the purposes of this Agreement the present form shall
also apply to Iceland, Liechtenstein and Norway.
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;  A  =  Austria;  P  =  Portugal;  FIN  =  Finland;
S = Sweden; GB = United Kingdom; IS = Iceland; FL = Liechtenstein; N = Norway.
Street, number, post code, town, country, telephone number.
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.

3

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
EUROPEAN COMMUNITIES
Social Security Regulations
EEA*

See ‘Instructions’ on page 12

E 213                (1)

DETAILED MEDICAL REPORT

Reg. 1408/71: Art. 39 to 41; Art. 43a; Art. 87

1.1

Institution to which the report is addressed

1.1.1 Name 

......................................................................................................................................................................................

1.1.2 Address (2) 

......................................................................................................................................................................................

......................................................................................................................................................................................

......................................................................................................................................................................................

1.1.3 Reference 

......................................................................................................................................................................................

......................................................................................................................................................................................

1.2

Person examined

1.2.1 Surname (3)

...................................................................................................................................................................................................................

1.2.2 Forenames

Previous names (3)

Place of birth (4)

...................................................................................................................................................................................................................

1.2.3 Date of birth

Sex

Nationality

D.N.I. (5)

...................................................................................................................................................................................................................

1.2.4 Address (2)

...................................................................................................................................................................................................................

Last occupation (6)

1.2.5
1.2.6 M Insurance No
1.2.7 M Pension No
1.2.8 File No

.............................................................................................................................................................

...................................................................................................................................................

...................................................................................................................................................

..........................................................................................................................................................

1.2.9 Date of submission of pension claim 

.............................................................................................................................

1.2.10 Date of submission of request for review on grounds of aggravation

................................................................................................................

1.3

Doctor who drew up the report

1.3.1 Surname 
1.3.2 Address (2) 

...................................................................... Forenames

............................................................................................
......................................................................................................................................................................................

......................................................................................................................................................................................

1.3.3 Examining doctor of (7)  

...................................................................................................................................................................

1.4

Institution which requested the examination

1.4.1 Name 
1.4.2 Address (2) 

......................................................................................................................................................................................
......................................................................................................................................................................................
......................................................................................................................................................................................

1.4.3 Reference number of file

.....................................................................................................................................................

1.4.4 Stamp 

1.4.5  Date

.......................................................................

1.4.6  Signature

.......................................................................

1

Surname, Forenames

2.1

Opinion based on the own examination of:

2.2

Opinion based on medical report of:

3

Patient’s history 

E 213

Date

(date) 

(date) 

3.1

Medical history

...................................................................................................................................................................

.......................................................................................................................................................................................................................

.......................................................................................................................................................................................................................

.......................................................................................................................................................................................................................

.......................................................................................................................................................................................................................

.......................................................................................................................................................................................................................

.......................................................................................................................................................................................................................

.......................................................................................................................................................................................................................

.......................................................................................................................................................................................................................

.......................................................................................................................................................................................................................

3.2

Current chief complaints

...................................................................................................................................

.......................................................................................................................................................................................................................

.......................................................................................................................................................................................................................

.......................................................................................................................................................................................................................

.......................................................................................................................................................................................................................

.......................................................................................................................................................................................................................

.......................................................................................................................................................................................................................

.......................................................................................................................................................................................................................

3.2.1 Doctor currently treating the patient

............................................................................................................................

.......................................................................................................................................................................................................................

3.3

Current treatment

...............................................................................................................................................................................

.......................................................................................................................................................................................................................

.......................................................................................................................................................................................................................

.......................................................................................................................................................................................................................

.......................................................................................................................................................................................................................

3.4

Social and employment history (6)
.......................................................................................................................................................................................................................

.............................................................................................................................

.......................................................................................................................................................................................................................

.......................................................................................................................................................................................................................

.......................................................................................................................................................................................................................

.......................................................................................................................................................................................................................

.......................................................................................................................................................................................................................

3.4.1 Is the insured person currently gainfully employed?

M Yes
Type of actual employment

M No

M Number of working hours

................

...................................................................................................................................................................

.......................................................................................................................................................................................................................

3.4.2 Accidents at work/Occupational diseases 

.............................................................................................................................

.......................................................................................................................................................................................................................

.......................................................................................................................................................................................................................

3.4.3 Type of last employment 

.........................................................................................................................................

.......................................................................................................................................................................................................................

3.4.4 Unfit for work

Cessation of work

M since
M on

.........................................................................................................

.........................................................................................................

2

Surname, Forenames

4

Findings

4.1

General conditions

Height 

.............................................. cm

Weight 

................................... kg

E 213

Date

Nutritional condition:

Mucous membranes

Skin

M good
...................................................................................................................................................................

M underweight

M overweight

...................................................................................................................................................................

Mental status, mood

...................................................................................................................................................................

Remarks

...........................................................................................................................................................................................

.......................................................................................................................................................................................................................

.......................................................................................................................................................................................................................

.......................................................................................................................................................................................................................

4.2

Head

4.2.1 Vision

4.2.2 Hearing

.........................................................................................................................................................................

..................................................................................................................................................................................

..................................................................................................................................................................................

4.2.3 Other sensory organs  

......................................................................................................................................................

.......................................................................................................................................................................................................................

4.3

Neck (external findings)

.........................................................................................................................................

4.3.1 Review of thyroid gland

............................................................................................................................................................

4.3.2 Lymphatic nodes
4.3.3 Others  

...................................................................................................................................................................
.........................................................................................................................................................................

.......................................................................................................................................................................................................................

4.4

Respiratory organs

.......................................................................................................................................................................................................................

.......................................................................................................................................................................................................................

.......................................................................................................................................................................................................................

.......................................................................................................................................................................................................................

4.5

Circulatory system

4.5.1 Heart

4.5.2 Pulse

............................................................................................................................................................................................

...............................................................................................................................................................................

4.5.3 Blood pressure (at rest)

.........................................................................................................................................

4.5.4 Blood pressure (second measurement)  

.........................................................................................................................................

4.5.5 Peripheral blood vessels  

.............................................................................................................................................................

4.5.6 Oedema  

............................................................................................................................................................................................

4.5.7 ECG (at rest)  

..........................................................................................................

4.6

Abdomen 

.............................................................................................................................................................................................

4.6.1 Digestive system and linked intra-abdominal organs  

................................................................................................................

.......................................................................................................................................................................................................................

4.6.2 Liver   

..................................................................................................................................................................................................

4.6.3 Spleen  

..................................................................................................................................................................................................

4.6.4 Endocrine system  

...................................................................................................................................................................

4.7

Genito-urinary system

.......................................................................................................................................................................................................................

.......................................................................................................................................................................................................................

.......................................................................................................................................................................................................................

3

Surname, Forenames

Additional page for Neutral-0 method

4. Measurements of locomotor system (neutral-zero method)
Indicate only pathological findings or normal findings that should be specifically recorded.

Chin-sternum distance

Extension/Flexion
40-0-40°

Lumbar spinal 
mobility test
8-10-15 cm

SSppiinnee

Rotation R/L
60-0-60°

Rotation R/L
50-0-50°

Shoulder joint

Rotation ext./int.

50-0-95°

Elbow joint

Wrist joint

Abduction/Adduction
180-0-40°

Backward/Forward
40-0-160°

Extension/Flexion
10-0-150°

Supination/Pronation
85-0-85°

R
L

R
L

Hip joint

R
L

R
L
Knee joint

adduction

abduction

Int.
rot.

Ext.
rot.

E 213

Date

Lateral inclination
R/L
40-0-40°

Lateral inclination
R/L
30-0-30°

Extension/Flexion
50-0-50°

R
L
Abduction/Adduction
30-0-25°

R
L
Talocrural joint

Extension/Flexion
10-0-130°

Abduction/Adduction
50-0-25°

Ext./Int. Rot.
35-0-45°

Extension/Flexion
5-0-150°

Extension/Flexion
40-0-25°

R
L

R
L

R
L

R
L

Circumference in cm

Upper arm (15 cm above lateral
epic.)

D           G

Elbow joint

Forearm (10 cm below
lateral epic.)

Wrist

Metacarpus 
(without thumb)

Circumference in cm

Thigh 20 cm above medical knee-
joint space

Mid patella

Lower leg (15 cm below medial
joint space)

Lower leg 
(smallest circumference)

Malleolus

R
L

D           G

E 213

Surname, Forenames

Date

4.8

Locomotor system (if necessary use Neutral-0 method, page 4)

4.8.1 Spine

.....................................................................................................................................................................................................

.......................................................................................................................................................................................................................

.......................................................................................................................................................................................................................

.......................................................................................................................................................................................................................

.......................................................................................................................................................................................................................

.......................................................................................................................................................................................................................

4.8.2 Upper limbs

...............................................................................................................................................................................

.......................................................................................................................................................................................................................

.......................................................................................................................................................................................................................

.......................................................................................................................................................................................................................

.......................................................................................................................................................................................................................

.......................................................................................................................................................................................................................

.......................................................................................................................................................................................................................

.......................................................................................................................................................................................................................

.......................................................................................................................................................................................................................

4.8.3 Lower limbs

.........................................................................................................................................................................

.......................................................................................................................................................................................................................

.......................................................................................................................................................................................................................

.......................................................................................................................................................................................................................

.......................................................................................................................................................................................................................

.......................................................................................................................................................................................................................

.......................................................................................................................................................................................................................

4.9

Presence of lymphatic nodes ........................................................................................................................................................................

.......................................................................................................................................................................................................................

.......................................................................................................................................................................................................................

.......................................................................................................................................................................................................................

4.10 Neurologic findings 

...................................................................................................................................................................

Movement (power and tone):

M unremarkable

M stiff

M slowed

M weak

Gait:

M unremarkable

M ponderous

M impaired on right M impaired on left

.......................................................................................................................................................................................................................

.......................................................................................................................................................................................................................

Reflexes 

..................................................................................................................................................................................................

.......................................................................................................................................................................................................................

4.11 Psychoautonomic symptoms or psychologically determined physical symptoms

......................................................................................

.......................................................................................................................................................................................................................

.......................................................................................................................................................................................................................

.......................................................................................................................................................................................................................

.......................................................................................................................................................................................................................

.......................................................................................................................................................................................................................

4.12 Other (Allergies etc.)

................................................................................................................................................

.......................................................................................................................................................................................................................

.......................................................................................................................................................................................................................

.......................................................................................................................................................................................................................

.......................................................................................................................................................................................................................

.......................................................................................................................................................................................................................

5

E 213

Surname, Forenames

Date

5

Function and other tests (when necessary)

5.1

Lung function

.......................................................................................................................................................................................................................

.......................................................................................................................................................................................................................

.......................................................................................................................................................................................................................

.......................................................................................................................................................................................................................

.......................................................................................................................................................................................................................

5.2

Cardiac function/exercise ECG

.......................................................................................................................................................................................................................

.......................................................................................................................................................................................................................

.......................................................................................................................................................................................................................

5.3

Doppler ultrasonography (Heart and vessels)

.......................................................................................................................................................................................................................

.......................................................................................................................................................................................................................

.......................................................................................................................................................................................................................

5.4

Imaging studies (please specify date)

5.4.1 Findings in today’s X-ray examination

...............................................................................................................

.......................................................................................................................................................................................................................
.......................................................................................................................................................................................................................

.......................................................................................................................................................................................................................

.......................................................................................................................................................................................................................

.......................................................................................................................................................................................................................

5.4.2 Earlier finding/X-ray examinations done elsewhere 

...................................................................

.......................................................................................................................................................................................................................

.......................................................................................................................................................................................................................

.......................................................................................................................................................................................................................

.......................................................................................................................................................................................................................

.......................................................................................................................................................................................................................

5.4.3 Ultrasonography (abdomen, et al.)

.......................................................................................................................................................................................................................

.......................................................................................................................................................................................................................

.......................................................................................................................................................................................................................

.......................................................................................................................................................................................................................

5.4.4 MRI and special investigations

.......................................................................................................................................................................................................................

.......................................................................................................................................................................................................................

.......................................................................................................................................................................................................................

5.5

Laboratory results

.......................................................................................................................................................................................................................

.......................................................................................................................................................................................................................

.......................................................................................................................................................................................................................

5.6

Other tests

.......................................................................................................................................................................................................................

.......................................................................................................................................................................................................................

.......................................................................................................................................................................................................................

6

Surname, Forenames

Date

6

Additional sheet for further specialists’ findings (to be completed only if relevant)

E 213

7

Surname, Forenames

7

Diagnosis

E 213

Date

.......................................................................................................................................................................................................................

.......................................................................................................................................................................................................................

.......................................................................................................................................................................................................................

(ICD code recommended)

8

Summary

.......................................................................................................................................................................................................................

.......................................................................................................................................................................................................................

.......................................................................................................................................................................................................................

Course of disease

.......................................................................................................................................................................................................................

.......................................................................................................................................................................................................................

.......................................................................................................................................................................................................................
.......................................................................................................................................................................................................................

Damage to health

.......................................................................................................................................................................................................................

.......................................................................................................................................................................................................................

.......................................................................................................................................................................................................................

.......................................................................................................................................................................................................................

Functional deficits 

.......................................................................................................................................................................................................................

.......................................................................................................................................................................................................................

.......................................................................................................................................................................................................................

.......................................................................................................................................................................................................................

Compared with previous report (dated

...........................................),
Improvement  M 

worsening  M 

no change  M 

9

The insured person is still capable of regularly performing the following types of work

heavy

average

light

M 

M 

M 

8

E 213

M 
M 

M 

M 

M

Surname, Forenames

Date

10

The following restrictions should be taken into account

10.1 Work can only be performed without

Damp

Heat

Smoke, gases, vapours
Shifts

Frequent bending, lifting, carrying, objects

Climbing ramps, ladders or stairs

M
M
M
M
M

M

Cold

Noise

Nightshifts

Danger of falling

10.2 Work can only be performed under the following conditions

Only in seated position

Only indoors

Work with varying body posture

Work only without particular time pressure

M

M

M

M

Only with additional breaks

(in addition to the usual breaks)
number and length of breaks

.........................................................................................

Work varying between walking, standing, sitting

M

10.3

The work performance is reduced because the insured person is restricted in using

his/her sensory organs, hands, etc.

......................................................................................

.......................................................................................................................................................................................................................

is allergic to 

...................................................................................................................................................................

.......................................................................................................................................................................................................................

11

Additional questions

11.1 Can the insured person do video-screen work?

Yes M

No M 

If ‘No’, please specify the reason

...................................................................................................................................

.......................................................................................................................................................................................................................

11.2 Can the insured person work without the support of another person at the working place?

Yes M

No M 

If ‘No’, please specify the reason

...................................................................................................................................

.......................................................................................................................................................................................................................

11.3 Can the insured person work without the support of another person at home?

Yes M

No M 

If ‘No’, please specify the reason

...................................................................................................................................

.......................................................................................................................................................................................................................

9

E 213

Surname, Forenames

Date

11.4 Can the insured person work full time in his/her last occupation as

.................................................................................

.......................................................................................................................................................................................................................

Yes M

No M 

If ‘No’, please specify maximum working time (in hours or percentages of a working day)

.......................................................................................................................................................................................................................

11.5 Can adapted work be performed?

Yes M

No M 

If ‘Yes’, please indicate some examples of adapted work

.......................................................................................................................................................................................................................

11.6 Can adapted work be performed full time?

Yes M

No M 

If ‘No’, specify maximum working time (in hours or percentages of a working day)

.......................................................................................................................................................................................................................

11.7

The invalidity for the last occupation is, under the legislation of the country of residence,

M total

M partial

If partial, indicate the degree

(Does not concern Germany and the Netherlands)

11.8 Degree of invalidity for any other work with reference to the aptitudes of the person concerned under the legislation of the country of

residence

(Does not concern Germany, Ireland, Luxembourg and the Netherlands)

.......................................................................................................................................................................................................................

11.9 Category of invalidity under the legislation of the country of residence

(Complete only if the medical examination was carried out with a view to the decision to be taken on a disability or invalidity pension

claim)

(Does not concern Germany and the Netherlands)

.......................................................................................................................................................................................................................

11.10 The established restrictions

(a) have been permanent since

......................................................................................................................................................

(b) are temporary, from

..................................................

to

......................................................................................

11.11 Would it be possible to improve the present state of health?

Yes M

No M 

No answer possible M 

If ‘Yes’, indicate the measures

.......................................................................................................................................................................................................................

.......................................................................................................................................................................................................................

10

Surname, Forenames

Date

11.12 Are there possibilities to ameliorate the work capacity through

E 213

M medical training

M vocational training

Yes M

12

Is re-examination necessary in the future?

Yes M

If ‘Yes’, please state when

No M 

No M 

No answer possible M 

.......................................................................................................................................................................................................................

Doctor’s signature

Stamp

11

E 213

Please complete this form in block letters or typewriting. It consists of 12 pages, none of which may be left out even if it does not
contain any relevant information.

INSTRUCTIONS

NOTES

*

(1)

(2)
(3)

(4)
(5)

(6)

(7)

EEA Agreement on the European Economic Area, Annex VI, Social Security: for the purposes of this Agreement the present form shall
also apply to Iceland, Liechtenstein and Norway.
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;  A  =  Austria;  P  =  Portugal;  FIN  =  Finland;
S = Sweden; GB = United Kingdom; IS = Iceland; FL = Liechtenstein; N = Norway.
Street, number, post code, town, country, telephone number.
In the case of Spanish nationals state both names.
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.
In the case of Portuguese districts state also the parish and the local authority.
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, state ‘None’.
Please list as far as possible all the occupations in which the insured person has worked. This information is given after the statement of
the person concerned. Where necessary, insert extra pages.
Not relevant for Norway.

12

E 213 additional page No 1

ADDITIONAL INFORMATION FOR THE PURPOSES OF INSTITUTIONS IN THE NETHERLANDS

Questions

Answers

Can the person insured

No

Incidentally

Sometimes

Regularly

No limit

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

sit

stand

walk

kneel/crawl/squat

work with bent back

bow or twist back often

use the nape

hold the arms extended

hold the arms raised

use his/her hands/fingers

lift and carry ............... kg max.

12.

work under the following conditions:

— be exposed to sudden changes of temper-

ature

— stand high humidity (> 90 %)

— stand low humidity (< 35 %)

— stand strong changes of climate

13.

stand intensive (skin) contacts with solid and

liquid substances

stand vibrations

wear protective gear

maintain a demanding rhythm of work

stay doing nothing

handle conflicting demands arising from

his/her functions

handle conflicts

perform monotonous work

perform cyclical repeated work

bear responsibility

work alone

work with others

14.

15.

16.

17.

18.

19.

20.

21.

22.

23.

24.

1

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
E 213 additional page No 2

ADDITIONAL PAGE FOR THE PURPOSES OF THE UNITED KINGDOM INSTITUTIONS

A.

1.

B.

2.

Complete in all cases

Name and address of the doctor of the person named in item 1.2

.........................................................................................................................................................................................................................

.........................................................................................................................................................................................................................

Complete in cases where the person suffers from a mental health problem

Tick one of the boxes below if the person has any of the following illnesses or disabling conditions

M a psychiatric illness (if yes, please specify)
M a significant degree of personality disorder
M a severe learning disability
M alcohol or substance abuse
M inpairment of brain function consequent to organic disease or traumatic brain injury

........................................................................................................................

If any box in item 2 above is ticked, complete boxes 3 to 7

3.

Has the person exhibited paranoid features, delusions, hallucinations, or other frankly psychotic symptoms/behaviour at any time during

the past six months?

M Yes

M No

4.

Is  the  person  receiving  neuroleptic  drug  and/or  mood  altering  drugs  which  could  be  given  orally  or  as  depot  (long-term  injected

treatment)?

M Yes

M No

5.

Does the person need continual care or supervision because of the effects of the condition(s) ticked at item 2 above?

M Yes

M No

If ‘Yes’, is the person being looked after in home surroundings or in sheltered care?

M Home

M Sheltered care

6.

Is the person attending a day care centre (where constant qualified nursing care is available) for at least one day a week?

M Yes

M No

7.

Name and address of consultant psychiatrist

.........................................................................................................................................................................................................................

.........................................................................................................................................................................................................................

8. 

Add any comments which may assist in determining the severity of the person’s mental health problem even if none of the boxes in item

2 have been ticked:

.........................................................................................................................................................................................................................

.........................................................................................................................................................................................................................

.........................................................................................................................................................................................................................

.........................................................................................................................................................................................................................

1

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
E 213 additional page No 3

ADDITIONAL INFORMATION FOR THE PURPOSES OF NORWEGIAN INSTITUTIONS

1

If there are causes of incapacity for work other than illness, please give a brief description and the degree of contribution

.........................................................................................................................................................................................................................

.........................................................................................................................................................................................................................

.........................................................................................................................................................................................................................

.........................................................................................................................................................................................................................

.........................................................................................................................................................................................................................

2

During the period immediately preceding the present disability has the patient been partly occupied by domestic work and partly been

employed/self-employed?

M Yes

M No

3

Due to the illness and on a permanent basis does the patient have extra expenses for transport needs, dietary needs, etc., which are not

covered in full or in part by any social security scheme?

M Yes

M No

If ‘Yes’, state types and costs of extra expenses

.........................................................................................................................................................................................................................

.........................................................................................................................................................................................................................

.........................................................................................................................................................................................................................

.........................................................................................................................................................................................................................

.........................................................................................................................................................................................................................

.........................................................................................................................................................................................................................

.........................................................................................................................................................................................................................

1

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
EUROPEAN COMMUNITIES
Social Security Regulations
EEA*

See ‘Instructions’ on pages 4 and 5

E 215                  (1)

ADMINISTRATIVE REPORT ON THE POSITION OF A PENSIONER

Reg. 574/72 : Art. 40; Art. 51

1

Institution to which the form is addressed

1.1

1.2

Name

Address (2)

...............................................................................................................................................................................

...............................................................................................................................................................................

...................................................................................................................................................................................................................

...................................................................................................................................................................................................................

...................................................................................................................................................................................................................

2

Pensioner

2.1

2.2

2.3

2.4

2.5

2.6

2.7

2.8

Surname (3)

Surname at birth (3)
Forenames (4)
Previous names (5)

Sex (6)

...................................................................................................................................................................

...................................................................................................................................................................

...................................................................................................................................................................

...................................................................................................................................................................

...................................................................................................................................................................

Father’s surname and forenames (7)

.........................................................................................................................................

Mother’s surname and forenames (7)
M single

Civil status

.........................................................................................................................................

M divorced 

M separated from spouse

since ............................................

since .................................................

M married

M remarried (8)

M widower/widow

since ..........................

since ............................................

since .................................................

M cohabiting since

........................................................................................................... (9) (10) 

2.9

Insurance No at investigating institution:

............................................................................................................................

2.10

Insurance No at other institution concerned (11):

..........................................................................................

2.11

Type of pension

............................................................................................................................................................

3

4

4.1
4.2

4.3

4.4

Nationality (12)

.......................................................................................................

D.N.I. (13)

.............................

Details of birth 

Date of birth (14) (15)
Place of birth (16)

...............................................................................................................................................................................

...............................................................................................................................................................................

Province, department, county (17)

.........................................................................................................................................

Country (18)

...............................................................................................................................................................................

5

Address (2) (19)

.....................................................................................................................................................................................................................

.....................................................................................................................................................................................................................

1

6.3

6.4

6.5

6.6

6.7

6.8

6.9

6.10

6.11

6.12
6.13

6.14

6

Spouse/cohabiting partner (9)

6.1

Surname (3)

...................................................................................................................................................................................................................

6.2

Forenames (4)

Previous names (5)

E 215

..........................................................................

..............................................................

.................................................................

Date of birth (15)

Address (2) (20)

......................................

Place of birth (16)

.................................................................

...................................................................................................................................................................

...................................................................................................................................................................................................................

Date of marriage/cohabiting

The spouse/partner

M is

.........................................................................................
M is not pursuing a professional activity or trade

If in the affirmative, state amount of
M weekly earnings (21)
The spouse/partner

from a scheme for

If in the affirmative, indicate

Type of pension

Pension No (13)

...............................

M monthly earnings (22) ................ M annual earnings (23) .............................

M receives
M employed persons

M does not receive a pension
M self-employed persons M civil servants

...................................................................................................................................

...................................................................................................................................

Institution responsible for pension payment 

...................................................................................................................................

Amount
The spouse/partner (24)

M quarterly
M monthly
M receives other M does not receive other benefits

M annually

..................................

M unemployment
Date of commencement

benefits namely for

M sickness
..........................................

M invalidity

M other

Amount

6.15
6.16 Other known resources

M monthly
Type

Amount (25)

M quarterly
.......................................................................................................................

..................................

M annually

.......................................................................................................................

7

Children (26) 

7.1

Surname (3)

Forenames

Date of birth (15)

Relationship

1.

...................................................................

.......................................

............................

.............................................

...................................................................

.......................................

............................

.............................................

2.

...................................................................

.......................................

............................

.............................................

...................................................................

.......................................

............................

.............................................

3.

...................................................................

.......................................

............................

.............................................

...................................................................

.......................................

............................

.............................................

4.

...................................................................

.......................................

............................

.............................................

...................................................................

.......................................

............................

.............................................

5.

...................................................................

.......................................

............................

.............................................

...................................................................

.......................................

............................

.............................................

6.

...................................................................

.......................................

............................

.............................................

7.2

...................................................................

Address (2) (27)
..............................................................................................................................................................................................................

.............................................
........................................................................................................................................................................

.......................................

............................

7.3

Remarks (28) (29)

........................................................................................................................................................................

2

E 215   

8

Ascendants and other members of the household (30) 

8.1

Surname (3)

Forenames

Date of birth  (15)

Relationship

........................................................................

.......................................

............................

.............................................

........................................................................

.......................................

............................

.............................................

........................................................................

.......................................

............................

.............................................

........................................................................

.......................................

............................

.............................................

........................................................................

.......................................

............................

.............................................

........................................................................

.......................................

............................

.............................................

........................................................................

.......................................

............................

.............................................

........................................................................

.......................................

............................

.............................................

8.2

Address (27)

........................................................................................................................................................................

..............................................................................................................................................................................................................

8.3

Remarks

........................................................................................................................................................................

..............................................................................................................................................................................................................

9

Benefits

9.1

The pensioner

9.2
9.3

9.4

9.5

9.6

9.7

9.8

9.9

Continued wage or salary payments in case of illness
Sickness insurance cash benefits for incapacity for work

Rehabilitation allowance

Invalidity pension (31)

Old-age pension (31)

Survivor’s pension (31)

Pension for accident at work or occupational disease

Unemployment benefits

9.10

Institutions responsible for paying the benefits listed in 9.3 to 9.9

[name, address (2)]

has applied
for the following
benefits
M
M
M
M
M
M
M
M

and/or receives
the following
benefits
M
M
M
M
M
M
M
M

9 ....

9 ....

9 ....

9 ....

...................................................................................................................................................................................................

...................................................................................................................................................................................................

...................................................................................................................................................................................................

...................................................................................................................................................................................................

9.11

Additional information on the benefits listed in 9.3 to 9.9

Reference No

Period or date

Amount

9  ........

9  ........

9  ........

9  ........

M weekly
............................................................................................................. M monthly
M annual
...................................................................
M weekly
............................................................................................................. M monthly
M annual
...................................................................
M weekly
............................................................................................................. M monthly
M annual
...................................................................
M weekly
............................................................................................................. M monthly
M annual
...................................................................

3

E 215

10 

Activity pursued, if any

10.1

The pensioner
M is unemployed
M is engaged in paid employment
M is engaged in self-employment

M intends to pursue paid employment (32)
M intends to pursue self-employment (32)

Type of work

.......................................................................................................................................................

10.2

Date of commencement of present work

.......................................................................................

10.3 No of hours worked per week ...................................

10.4

Amount of

M daily

M weekly

M monthly earnings

......................

10.5

Earnings

M daily
of a healthy person employed in the same activity

M weekly

M monthly

......................

with a normal working period

....................................

of
M daily

hours
M weekly

M monthly

......................

10.6

Period in which the income mentioned in 10.4 was earned

...................................................................................................................................................................................................................

11

12

The pensioner died on

.......................................

Remarks, if any

..............................................................................................................................................................

...................................................................................................................................................................................................................

13

Institution which drafted the report

13.1 Name

.............................................................................................................................................................................

13.2

Address (2)
...................................................................................................................................................................................................................

.............................................................................................................................................................................

13.3

Stamp

13.4

13.5

Date

Signature

................................................

..........................................................................

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

INSTRUCTIONS

NOTES

*

(1)

EEA Agreement on the European Economic Area, Annex VI, Social Security: for the purposes of this Agreement the present form shall
also apply to Iceland, Liechtenstein and Norway.
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;  A  =  Austria;  P  =  Portugal;  FIN  =  Finland;
S = Sweden; GB = United Kingdom; IS = Iceland; FL = Liechtenstein; N = Norway.
Street, number, post code, town, country, telephone number.

(2)
(3) — For  surname  please  state  usual  surname  or  surname  acquired  by  marriage.  If  the  form  is  being    completed  by  a  Netherlands
institution, in cases where the insured person or the rightful claimant is a married woman or a woman who was married before, put
the present or last husband’s surname for current surname.

— The surname at birth must always be given; if same as current surname, put ‘IDEM’. If the form is being completed by a Netherlands
institution, in cases where the insured person or the rightful claimant is a married woman or a woman who was married before, put
the maiden name for surname at birth.

— Expressions such as ‘called …’ or ‘alias …’ and all prefixes to surnames must be written in full in the order in which they appear on

the birth certificate.

— 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.

4

E 215   

(4)
(5)

(6)
(7)
(8)

(9)
(10)
(11)

Give all forenames in the order in which they appear on birth certificate.
Previous names should be stated particularly in the case of adoption or in the case of other names in current use.
Expressions such as ‘called …’ or ‘alias …’ must be written in full in the order in which they appear on the birth certificate.
Put M for male and F for female.
This information is required for a Spanish national, or a French national born outside metropolitan France.
Complete  where  possible,  for  Belgian,  German,  French,  Italian,  Luxembourg,  Netherlands,  Austrian  and  Portuguese  institutions. If  this
information is not available from the investigating institution, the competent institution should contact the person concerned.
For the purposes of Belgian, Danish, Netherlands, Finnish, Icelandic and Norwegian institutions.
This information is based on a statement from the person concerned.
If the form is being sent to a Danish institution, indicate the CPR number.
If the form is being sent to an Icelandic institution, the Icelandic personal identification number must be indicated.

(12) Where appropriate, indicate the date of naturalisation.
(13)

In the case of Spanish nationals over 16 years of age, state the Número de Identificación Fiscal (N.I.F.). Failing this, indicate the number
of the Documento Nacional de Identidad (D.N.I.) or passport, even if they are out of date. If the aforementioned documents do not exist,
state ‘none’.
The day and the month should be shown by two digits each and the year by four digits (example: 1 August 1921 = 01.08.1921).

(14)
(15) Where the form is being sent to a Finnish institution give population register (identity) number where applicable.
(16)

For French towns comprising several arrondissements, please give the number of the arrondissement (example: Paris 14). In the case of
Portuguese districts state also the parish and the local authority. 

(17)  Must be stated for insured persons of Spanish, French or Italian nationality. Here, the territorial area or district in which the place of birth
is located should be stated (example: in the case of France if the place (commune) of birth is Lille, the department of birth should be shown
as ‘Nord’ followed by the area code if known to the insured person; in this case: 59. The complete entry should therefore read: ‘Nord 59’).
In the case of persons born in Spain, state only the province.
The symbol of the insured person’s country of birth in accordance with the international motor vehicle registration code.
If the form is being sent to a Danish, Finnish, Icelandic or Norwegian institution, give the claimant’s last address in the corresponding
country in the box below.

(18)
(19)

Address (2)

....................................................................................................................................................................................

.....................................................................................................................................................................................................................

(20) Complete only if the form is being sent to a Danish, Icelandic or Norwegian institution.
(21) Complete only if the form is being sent to an Irish, United Kingdom or Austrian institution.
(22) Complete if the form is being sent to a Belgian institution.
(23) Complete  if  the  form  is  being  sent  to  a  Danish,  Spanish,  French,  Italian,  Luxembourg,  Netherlands,  Austrian,  Portuguese,  Icelandic  or

Norwegian institution.

(24) Does not apply to Luxembourg institutions.
(25) Complete for Belgian, German, Italian, Austrian or Portuguese (monthly amount), French (quarterly amount), Danish, Spanish, Netherlands,

Icelandic or Norwegian (annual amount) institutions.
For the purposes of Norwegian institutions, complete also form E 215/additional page No 1.
Indicate the common address, if one of the children or ascendants lives at a different address, indicate in the box below.

(26)
(27)

Surname and forenames ....................................................................................................................................................................................
Address (2)
....................................................................................................................................................................................
.....................................................................................................................................................................................................................

(28)
(29)

Indicate if the child is married, an invalid, deceased (date of death), an apprentice or a student.
For the purposes of Spanish and Norwegian institutions state whether the invalid child receives an invalidity pension in his or her own
right.

(30) Complete if the form is being sent to a Belgian, German, French or Austrian institution.
(31)
(32)

For the purposes of Liechtenstein institutions, indicate also if the person applied for or received the pension as cash compensation.
For the purposes of Spanish institutions state whether this occupation entails compulsory pension insurance cover.

5

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
E 215 additional page No 1

ADDITIONAL INFORMATION FOR THE PURPOSES OF NORWEGIAN INSTITUTIONS

1

Children

1.1

Name

..................................................... Forename

.......................................... Date of birth

............................

Income per year (All kinds)

...............................................................................................................................

1.2

Name

..................................................... Forename

.......................................... Date of birth

............................

Income per year (All kinds)

...............................................................................................................................

1.3

Name

..................................................... Forename

.......................................... Date of birth

............................

Income per year (All kinds)

...............................................................................................................................

1.4

Name

..................................................... Forename

.......................................... Date of birth

............................

Income per year (All kinds)

...............................................................................................................................

1.5

Name

..................................................... Forename

.......................................... Date of birth

............................

Income per year (All kinds)

...............................................................................................................................

1.6

Name

..................................................... Forename

.......................................... Date of birth

............................

Income per year (All kinds)

...............................................................................................................................

2

Does the child share the household with both parents?

M Yes

M No

If ‘No’, state which of the children, if not all children are concerned.

.........................................................................................................................................................................................................................

.........................................................................................................................................................................................................................

.........................................................................................................................................................................................................................

3

If the parents are not married and the child (children) shares the household with both parents, give information about the other parent

Name

.............................................................................................................................................................................

Date of birth

.............................................................................................................................................................................

Income per year (All kinds. Specify)

.............................................................................................................

.........................................................................................................................................................................................................................

Name of the child (children) if not all children are concerned

.............................................................................................................

.........................................................................................................................................................................................................................

.........................................................................................................................................................................................................................

.........................................................................................................................................................................................................................

4

Cohabitant

4.1

Has the pensioner previously been married to the cohabitant?

M Yes

M No

4.1

Does the pensioner have or has she/he had children by the cohabitant?

M Yes

M No

1