2005/376/EC: Decision No 201 of 15 December 2004 on model forms necessary for the application of Council Regulations (EEC) No 1408/71 and (EEC) No 574/72 (E 400 series) (Text with EEA relevance and for the EU/Switzerland Agreement)
Date: 2004-12-15
Institutions: European Commission
Subjects: enlargement of the Union, form, migrant worker, social security, social-security benefit

23.5.2005

EN

Official Journal of the European Union

L 129/1

II

(Acts whose publication is not obligatory)

COMMISSION

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

DECISION No 201

of 15 December 2004

on model forms necessary for the application of Council Regulations (EEC) No 1408/71 and (EEC)
No 574/72 (E 400 series)

(Text with EEA relevance and for the EU/Switzerland Agreement)

(2005/376/EG)

THE ADMINISTRATIVE
COMMUNITIES ON SOCIAL SECURITY FOR MIGRANT WORKERS,

COMMISSION OF

THE

EUROPEAN

Having regard to Article 81(a) of Council Regulation (EEC) No
1408/71 of 14 June 1971 on the application of social security
schemes to employed persons, to self-employed persons and to
their family moving within the Community (1),
members of
under which it is the duty of the Administrative Commission to
deal with all administrative matters arising from Regulation
(EEC) No 1408/71 and subsequent regulations,

Having regard to Article 2(1) of Council Regulation (EEC)
No 574/72 of 21 March 1972 fixing the procedure for
implementing Regulation (EEC) No 1408/71 on the application
of social security schemes to employed persons and their
families moving within the Community (2), under which it is the
duty of the Administrative Commission to draw up models of
documents necessary for the application of Regulations (EEC)
No 1408/71 and (EEC) No 574/72,

Having regard to Decision No 146 of 10 October 1990
concerning the interpretation of Article 94(9) of Regulation
(EEC) No 1408/71 (3),

(1) OJ L 149, 5.7.1971, p. 2.
(2) OJ L 74, 27.3.1972, p. 1. Regulation as

last amended by
Commission Regulation (EC) No 77/2005 (OJ L 16, 20.1.2005,
p. 3).

(3) OJ L 235, 23.8.1991, p. 9. Decision as last amended by Decision

Having regard to Decision No 155 of 6 July 1994 on the model
forms necessary for the application of Council Regulations (EEC)
No 1408/71 and (EEC) No 574/72 (E 401 to 411) (4),

Having regard to Decision No 157 of 1 July 1995 on the model
forms necessary for the application of Council Regulations (EEC)
No 1408/71 and (EEC) No 574/72(E 401 to 411) (5),

Whereas:

(1)

(2)

(3)

The enlargement of the European Union on 1 May 2004
requires the forms in the E 400 series to be adapted.

The Agreement on the European Economic Area (EEA
Agreement) of 2 May 1992,
supplemented by the
implements
Protocol of 17 March 1993, Annex VI,
Regulations (EEC) No 1408/71 and (EEC) No 574/72
within the European Economic Area.

The European Community and its Member States, and
the Swiss Confederation have concluded an Agreement
on the free movement of persons (Swiss Agreement)
which entered into force on 1 June 2002. Annex II to
the Agreement refers to Regulations (EEC) No 1408/71
and (EEC) No 574/72.

(4) OJ L 209, 5.9.1995, p. 1.
(5) Not published Decision extending Decision No 155 to Austria,

No 167 (OJ L 195, 11.7.1998, p. 35).

Finland and Sweden.

L 129/2

EN

Official Journal of the European Union

23.5.2005

(4)

For practical reasons, the forms used in the European
Union and under the EEA and Swiss Agreements shall be
identical,

HAS DECIDED AS FOLLOWS:

1. Decision No 155 is deleted and the model forms E 401,
E 402, E 403, E 404, E 405, E 406, E 407 and E 411
reproduced in that Decision are replaced by the model
forms appended hereto.

2. The model form E 413F reproduced in Decision No 146 is

deleted.

3. Decision No 157 is deleted.

4. The competent authorities of the Member States shall make
available to the parties concerned the forms according to
the models appended hereto. These forms shall be available
in the official languages of the Community and laid out in
such manner
the different versions are perfectly
superposable, thereby making it possible for all addressees
to receive the form printed in their own language.

that

5. The present decision shall apply from the first day of the
month following its publication in the Official Journal of the
European Union.

The Chairman
of the Administrative Commission

C. J. VAN DEN BERG

THE ADMINISTRATIVE COMMISSION
ON SOCIAL SECURITY
FOR MIGRANT WORKERS

See ‘instructions’ on page 4

E 401

(1)

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

Reg. 1408/71: Art. 73; Art. 74; Art. 77; Art. 78
Reg. 574/72: Art. 86.2; Art. 88; Art. 90; Art. 91; Art. 92

A. Request for certificate

1.

n Employed person
n Self-employed person

n Person supporting the orphan
n Orphan

n Pensioner (scheme for employed persons) (4)
n Pensioner (scheme for self-employed persons) (4)

1.1. Surname (1a)

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

1.2. Forenames

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

Previous names (1b)
............................................................................

Place of birth (2)
...................................................................

1.3. Date of birth

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

Sex
............................................................................

Nationality
...................................................................

1.4.

Identification/insurance number (3) ....................................................................................................................................................................

1.5. Civil status

n single
n divorced

n married
n separated (5)

n widow/widower
n cohabiting (6) (7)

1.6. Address in the country of residence of the members of the family:

Street ...................................................................................................................................... No ........................................................................

Post code .................................. Town .............................................................................. Country ..............................................................

2.

n Spouse
n Surviving parent (8)

n Spouse divorced or separated from the worker or pensioner
n Cohabiting partner (6) (7)

2.1. Surname (1a)

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

2.2. Forenames

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

Previous names (1b)
............................................................................

Place of birth (2)
...................................................................

2.3. Date of birth

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

Sex
.....................................

Nationality
........................................................

Identification/insurance number (3)
.................................................................................

2.4. Address:

Street ...................................................................................................................................... No ........................................................................

Post code .................................. Town .............................................................................. Country ..............................................................

2.5. Pursuit of gainful employment: n Yes n No

3. n Person or persons, other than the spouse, in whose household the members of the family are living

3.1. Surname (1a)

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

3.2. Forenames

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

Previous names (1b)
............................................................................

Place of birth (2)
...................................................................

3.3. Date of birth

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

Sex
.....................................

Nationality
........................................................

Identification/insurance number (3)
.................................................................................

3.4. Family relationship with child or children ..........................................................................................................................................................

3.5. Address:

Street ...................................................................................................................................... No ........................................................................

Post code .................................. Town .............................................................................. Country ..............................................................

3.6. Pursuit of gainful employment: n Yes n No

1

E 401

4.

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

Surname

Forenames

Date of birth (9)

Relationship (10)

Place of residence

Insurance (3)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

5.

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

5.1. Name ......................................................................................................................................................................................................................

5.2. Address (11)

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

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

5.3. File reference number

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

2

B. Certificate

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

6.

6.1.

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

Surname (1a)

Forenames

Date of birth (9)

Relationship (10)

E 401

1.

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

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

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

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

2.

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

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

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

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

3.

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

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

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

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

4.

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

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

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

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

5.

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

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

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

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

6.

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

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

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

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

7.

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

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

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

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

8.

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

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

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

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

9.

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

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

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

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

10.

6.2.

Remarks (13)

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

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

7.

Information to be supplied if the form is to be sent to a Danish, Icelandic or Norwegian institution (14)

7.1. Person exercising the parental authority

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

7.2. The maintenance of the children

from public funds

7.3. The mother and/or father of the children

n is

n are/is

n is not paid

n are/is not dead (15)

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

7.4. The mother and/or father of the children

receive an old-age invalidity pension

n do/does

n do/does not (15)

8.

Population registration office or authority or administration competent in matters of civil status (12)
The accuracy of the information given above has been verified from the official documents in our possession by:

8.1. Name and address of the registration office, authority or administration (11) ............................................................................................

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

8.2. Stamp

8.3. Date

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

8.4. Signature

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

3

INSTRUCTIONS

E 401

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. It should be completed in the language of the authority designated in
box 8.

NOTES

(1) Symbol of the country to which the institution completing the form belongs: BE = Belgium; CZ = Czech Republic; DK = Denmark;
DE = Germany; EE = Estonia; GR = Greece; ES = Spain; FR = France; IE = Ireland; IT = Italy; CY = Cyprus; LV = Latvia; LT =
Lithuania; LU = Luxembourg; HU = Hungary; MT = Malta; NL = The Netherlands; AT = Austria; PL = Poland; PT = Portugal; SI =
Slovenia; SK = Slovakia; FI=Finland; SE=Sweden; UK=United Kingdom; IS = Iceland; LI = Liechtenstein; NO = Norway; CH =
Switzerland.

(1a) 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.

(1b) Previous names include surname at birth.

(2)

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

(personnummer);

to an Icelandic institution,

(3) Where the form is being sent to a Czech institution, state the birth number; to a Cypriot institution, if a Cypriot national state the
Cypriot identification number, if not a Cypriot national state the Alien Registration Certificate (ARC) number; to a Danish institution,
indicate the CPR number; to a Finnish institution, indicate the population register number; to a Swedish institution, indicate the
personal number
to a
Liechtenstein institution, indicate the AHV insurance number; to a Lithuanian institution state the personal identification number; to a
Latvian institution state the identity number state; to a Hungarian institution, state the TAJ (social insurance identification) number;
to a Maltese institution, in the case of Maltese nationals, state the identity card number, or, if not a Maltese national, state the
Maltese social security number; to a Norwegian institution, indicate the personal
to a
Belgian institution, indicate the national social security number (NISS); to a German institution of the general pension insurance
scheme, indicate the insurance number (VSNR); to a Spanish institution, state the number appearing on the national identity card
(DNI) or N.I.E. in the case of foreign people, even if the card is out of date; to a Polish institution, state the PESEL and NIP
numbers;
the person
concerned has been insured under the social security scheme for civil servants in Portugal; to a Slovak institution, state the birth
number; to a Slovene institution, state the personal identification number (EMŠO) and tax number; to a Swiss institution, state the
AVS/AI (AHV/IV) insurance number.

indicate also the registration number with the general pensions scheme,

identification number (fødselsnummer);

to a Portuguese institution,

indicate the personal

identification number

(kennitala);

if

(4) Denmark, Poland, Slovakia, Liechtenstein, Norway and Switzerland do not differentiate between Pensioner (scheme for employed

persons) and Pensioners (scheme for self-employed persons).

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

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

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

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

(8) Except if already mentioned in box 1.

(9) For the purpose of Danish and Norwegian institutions indicate only children under the age of 18. For the purpose of Latvian
institutions indicate only children under the age of 15, and, if they are attending general or vocational educational establishments
and not receiving scholarships and are not married, children under the age of 20.

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

A = legitimate child. In Spain and Poland child born in wedlock (matrimonial) and child born out of wedlock (non-matrimonial).
B = legitimised child.
C = adopted child.
D = natural child (if the form is completed for a male worker, the natural children must be mentioned only if the paternity or the

worker’s obligation to maintain them has been officially recognised).

E = child of a spouse belonging to the worker’s household.
F = grandchildren, brothers and sisters whom the person concerned has taken into his household. Also nephews and nieces to the
third degree where the competent institution is a Greek institution. Where the competent institution is a Polish institution, only
grandchildren and siblings, whose legal guardian is an entitled person or his/her spouse.
G = other children belonging permanently to the household on the same footing as the worker’s children (foster children). Where the
competent institution is a Polish institution, only other children, whose legal guardian is an entitled person or his/her spouse.
H = for the purposes of the Czech institutions describe further forms of custody (custody awarded following the court decision to
other persons than parents, guardian, curator, etc.).
Other relationships (e.g. grandfather) must be written in full. If a child is married, divorced, a widow or a widower, mention this in
item 4 and 6.1. Also, if a child has no father or no mother, for the purposes of Greek institutions.

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

4

E 401

(12) In Spain, the ‛Dirección Provincial del Instituto Nacional de Seguridad Social’ (Provincial Directorate of the National Social Security
In case of seamen

the place of residence, or the ‛Autoridad Municipal’ (Municipal Authority) where appropriate.

Institute) of
‛Direccion Provincial del Instituto Social de la Marina’ (Provincial Directorate of the Marine’s Social Institute);
in France, the ‛mairie’ (registrar’s office) or the ‛caisse d’allocations familiales’ (fund for family allowances);
in Ireland, Child Benefit Section, Department of Social and Family Affairs, St. Oliver Plunkett Road, Letterkenny, County Donegal;
in Cyprus the Ministry of Finance, Grants and Benefits Service, 1489 Nicosia;
in Latvia, the ‛Valsts sociālās apdrošināšanas aģentūra’ (State Social Insurance Agency), Riga;
in Poland, commune or district;
in Portugal, the ‛Junta de Freguesia’ (Parish Council) of the place of residence of the members of the family;
in Slovakia, the ‛úrad práce, sociálnych vecí a rodiny’ (Office of Labour, Social Affairs and Family) in the place of residence of
claimant;
in Finland, the Social Insurance Institution, Helsinki;
in Sweden, the ‛forsäkringskassan’ (social insurance office) at the place of residence;
in the United Kingdom, Inland Revenue, Child Benefit Office (GB), PO Box 1, Newcastle-upon-Tyne NE 88 IAA or for Northern
Ireland, Child Benefit Office (NI), Windsor House, 9-15 Bedford Street Belfast BT2 7UW, and Inland Revenue, Tax Credits Office
(Northern Ireland), 52-58 Great Victoria Street, Belfast BT2 7WF, as appropriate;
in Switzerland, the local administration (registry office) of the place of residence.

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

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

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

5

THE ADMINISTRATIVE COMMISSION
ON SOCIAL SECURITY
FOR MIGRANT WORKERS

E 401 Annex PL

CERTIFICATE CONCERNING THE AMOUNT OF A FAMILY’S INCOME FOR THE PURPOSE OF GRANTING FAMILY BENEFITS
ACCORDING TO POLISH LAW

Reg. 1408/71: Art. 73; Art. 74; Art. 77; Art. 78
Reg. 574/72: Art. 86; Art. 88; Art. 90

To be used for the purpose of the granting of family benefits according to Polish legislation.
This form is to be completed by the institution of a Member State other than the competent Member State (1).

1.

Gross income received by persons listed in points 1, 2 and 4 of the E 401 form in the period from .....................................................

until ...............................................................

in a Member State other than the competent one (2)

Person listed
in point 1
of the E 401 form

Person listed
in point 2
of the E 401 form)

Child/children
(persons listed in point 4
of the E 401 form

1.1.

Salary from gainful employment

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

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

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

1.2. Other incomes from professional activities

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

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

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

(self-employment incomes)

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

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

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

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

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

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

1.3.

Social security benefits:

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

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

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

— family benefits

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

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

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

1.4.

Alimony received (3)

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

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

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

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

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

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

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

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

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

1.5.

Incomes in total

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

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

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

1.6.

Alimony paid in favour of other persons (4)

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

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

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

1.7.

Social insurance contributions

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

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

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

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

1.8.

Personal Income Tax (PIT)

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

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

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

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

2.

Institution of a Member State other than the competent Member State (1)

2.1. Name .........................................................................................................................................................................................................................

2.2.

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

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

2.3.

File reference number ............................................................................................................................................................................................

2.4.

Stamp

2.5. Date

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

2.6. Signature

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

1

E 401 Annex PL

NOTES

(1) To be completed by the institution mentioned in the Annex to Decision No 151 or new Decision No 201 (approving that form). If
either all or part of the information requested cannot be confirmed by the institution, this form should be returned even though it has
been left blank or only partially completed; where possible, it should be sent together with a certified statement containing the
necessary information from the person or persons concerned.

If they were not included in incomes listed in point 1.3.

(2) Period the form refers to is to be completed by the institution listed in point 5 of the E 401 form.
(3)
(4) Persons other than listed in points 1, 2 and 4 of the E 401 form.
(5) Street, number, post code, town, country.

2

THE ADMINISTRATIVE COMMISSION
ON SOCIAL SECURITY
FOR MIGRANT WORKERS

See ‘instructions’ on page 3

E 402

(1)

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

Reg. 1408/71: Art. 73; Art. 74; Art. 77; Art. 78
Reg. 574/72: Art. 86; Art. 88; Art. 90; Art. 91; Art. 92

A. Request for certificate

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

1.

Applicant for family benefits
n Employed person
n Self-employed person
n Persons other than the aforementioned

1.1. Surname (1a)

n Pensioner (scheme for employed persons)
n Pensioner (scheme for self-employed persons)
n Orphan

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

1.2. Forenames

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

Previous names (1a)
............................................................................

Place of birth (2)
..................................................................

1.3. Date of birth

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

Sex
....................................

Nationality
.......................................................

Identification/insurance number (3)
................................................................................

1.4. Address (5) .............................................................................................................................................................................................................

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

2.

Pupil or student

2.1. Surname (1a)

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

2.2. Forenames

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

Previous names (1a)
.................................................................................................................................................

2.3. Place of birth (2) (4)

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

Date of birth
...................................................................

Identification/insurance number (3)
..........................................................................

2.4. Address (5)

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

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

2.5. n has completed higher education

n has not completed higher education (11)

3.

Institution competent as regards granting family benefits

3.1. Name ......................................................................................................................................................................................................................

3.2. Address (5) .............................................................................................................................................................................................................

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

3.3. File reference number .........................................................................................................................................................................................

3.4. Stamp

3.5. Date

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

3.6. Signature

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

1

E 402

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

4.

4.1. The person named in box 2 has been attending the establishment shown in box 7

since .........................................................................................................................................................................................................................

4.2. The school year started .................................................................. (date) and finished .................................................................. (date)

4.3. Type of school (6) .................................................................................................................................................................................................

The form of study (6a) ..........................................................................................................................................................................................

4.4. His/her education in this establishment will probably last until

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

4.5. The number of hours of the course is ........................................................................................................................................ a week (7).

These hours are spread over ................................................................................................................................................... half days (8).

4.6. Estimate number of hours required to do homework .............................................................................................................. a week (9).

5.

Information to be provided only for the institutions in the Czech Republic, France, Latvia, Luxembourg and the Netherlands

5.1. The person named in box 2 has been attending the establishment shown in box 7 where s/he has been following education

of the following nature:
n general education n higher or university education

n technical or vocational training n other (please specify)

5.2. Special cases (please specify):
n Correspondence course
n Courses involving less than 20 hours a week
n Education of less than one school year, from .................................................................
to .................................................................
n Other .................................................................................................................................................................................................................

n evening courses

5.3. Amount of college fee (9) ....................................................................................................................................................................................

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

n Yes

n No

5.4.1. Amount of the study grant ..................................................................................................................................................................................

5.5. Form of remuneration or allowance (10) ...........................................................................................................................................................

5.6. Marital status ........................................................................................................................................................................................................

6.

Information to be provided only for the institutions in Germany, if the course involves less than 10 hours a week

6.1. The course is prescribed or recommended by a State approved curriculum.

If no,

6.2. The course ends with a prescribed or generally recognised exam.

If no,

6.3. There are regular proficiency tests during the course.

If no,

6.4. The lessons in the course require extensive preparation or follow-up.

If no,

n Yes

n No

n Yes

n No

n Yes

n No

n Yes

n No

6.5. Additional knowledge or skills are acquired which are necessary or useful for the course.

n Yes

n No

7.

School, university or establishment of higher education

7.1. Name ......................................................................................................................................................................................................................

7.2. Address (5)

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

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

7.3. Stamp

2

7.4. Date

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

7.5. Signature

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

Please complete this form in block letters, writing on the dotted lines only. It should be completed in the language of the
establishment named in box 7.

INSTRUCTIONS

(1) Symbol of the country to which the institution completing the form belongs: BE = Belgium; CZ = Czech Republic; DK = Denmark;
DE = Germany; EE = Estonia; GR = Greece; ES = Spain; FR = France; IE = Ireland; IT = Italy; CY = Cyprus, LV = Latvia;
LT = Lithuania; LU = Luxembourg; HU = Hungary; MT = Malta; NL = The Netherlands; AT = Austria; PL = Poland; PT = Portugal;
SI = Slovenia; SK = Slovakia; FI = Finland; SE = Sweden; UK = United Kingdom; IS = Iceland; LI = Liechtenstein; NO = Norway;
CH = Switzerland.

NOTES

E 402

(1a) 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 the Czech republic,
when family benefits are claimed by a student, persons specified under points 1 and 2 are identical.
In the case of Portuguese districts, state also the parish and the local authority.

(2)
(3) Where the form is being sent to a Czech institution, state the birth number; to a Cypriot institution, if a Cypriot national state the
Cypriot identification number, if not a Cypriot national state the Alien Registration Certificate (ARC) number; to a Danish institution,
indicate the CPR number; to a Finnish institution, indicate the population register number; to a Swedish institution, indicate the
personal number (personnummer); to an Icelandic institution, indicate the personal identification number (kennitala); to a Latvian
institution, state the identity number; to a Liechtenstein institution, indicate the AHV insurance number; to a Lithuanian institution,
state the personal
insurance identification) number; to a
Maltese institution, in the case of Maltese nationals, state the identity card number, or, if not a Maltese national, state the Maltese
to a Belgian
indicate the personal
social security number;
institution, indicate the national social security number (NISS); to a German institution of the general pension insurance scheme,
indicate the insurance number (VSNR); to a Spanish institution, state the number appearing on the national identity card (DNI), or
N.I.E in the case of foreign people, even if the card is out of date; to a Polish institution, state the PESEL and NIP numbers; 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; to a Slovak institution, state the birth number; to a Slovene
institution, state the personal identification number (EMŠO); to a Swiss institution, state the AVS/AI (AHV/IV) insurance number.
In the case of Swedish nationals information cannot be provided unless stated necessary.

(4)
(5) Street, number, post code, town, country.
(6) Please indicate whether it is a publicly maintained school, ‘public school’, or State-controlled school. To be completed only if the

identification number; to a Hungarian institution, state the TAJ (social

identification number (fødselsnummer);

to a Norwegian institution,

institution shown in box 3 is an institution in the United Kingdom.

(6a) For the purposes of Slovak institutions, please indicate if the study is full-time or part-time.
(7) For the purposes of German institutions, please fill in point 6 if the course involves less than 10 hours a week.
(8) To be completed if the form is to be sent to a Belgian or Finnish institution; the number of half-days is to be indicated in the case of

primary and secondary schools.

(9) For the purposes of Netherlands institutions.
(10) For the purposes of Maltese institutions, state whether the child receives some form of remuneration for his or her studies, and state

weekly amount.

(11) For the purpose of Slovak institutions please state if the education of second grade has been completed.

3

THE ADMINISTRATIVE COMMISSION
ON SOCIAL SECURITY
FOR MIGRANT WORKERS

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

E 402 Annex

(1)

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

1.

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

half-days ..............................................................................................

hours ....................................................................................................

1.2. The lessons

1.3. The pupil

n are

n does

n are not given before 7 p.m.

n does not attend lessons regularly.

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

1.4. The lessons mentioned in 1.1 above

(a) n include

n do not include

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

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

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

for the period: from................................................................
n do not include

(b) n include

to ...........................................................................................................

hours of practical lessons which take place in the establishment.

If they do, show the number of hours a week

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

(c) n include

n do not include

hours devoted to study in the establishment.

If they do, show the number of hours a week

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

1.5. Type of education provided
n general education
n higher non-university education

n technical or vocational training
n university education

n art education

1.6. The student

a thesis.

n has been preparing

n has not been preparing

If he/she has, indicate
— since when?
— when must he/she submit the thesis?

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

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

1.7. The study programme

n is
n corresponds to

1.8. Show the periods of holidays
— Christmas holidays:
— Easter holidays:
— Summer holidays:

n is not recognized by the State
n does not correspond to a study programme recognized by the State

from ........................................................................

to ................................................................................

from ........................................................................

to ................................................................................

from ........................................................................

to ................................................................................

2.

School, university or establishment of higher education

2.1. Name .......................................................................................................................................................................................................................

2.2. Address (5) ..............................................................................................................................................................................................................

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

2.3. Stamp

2.4. Date

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

2.5. Signature

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

1

THE ADMINISTRATIVE COMMISSION
ON SOCIAL SECURITY
FOR MIGRANT WORKERS

See ‘instructions’ on page 3

E 403

(1)

CERTIFICATE OF APPRENTICESHIP AND/OR VOCATIONAL TRAINING FOR THE PURPOSE OF THE GRANTING OF FAMILY
BENEFITS

Reg. 1408/71: Art. 73; Art. 74; Art. 77; Art. 78
Reg. 574/72: Art. 86; Art. 88; Art. 90; Art. 91; Art. 92

A. Request for certificate

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

1.

Applicant for family benefits
n Employed person
n Self-employed person
n Persons other than the aforementioned

1.1. Surname (1a)

n Pensioner (scheme for employed persons)
n Pensioner (scheme for self-employed persons)
n Orphan

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

1.2. Forenames

Previous names (1a)

Place of birth (2)

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

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

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

1.3. Date of birth

Sex

Nationality

Identification/insurance number (3)

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

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

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

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

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

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

2. n Apprentice

2.1. Surname (1a)

n Vocational trainee (5)

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

2.2. Forenames

Previous names (1a)

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

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

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

2.3. Place of birth (2)

Date of birth

Sex

Identification/insurance number (3)

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

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

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

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

2.4. Address (4)

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

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

3.

Institution competent as regards the granting of family benefits

3.1. Name .......................................................................................................................................................................................................................

3.2. Address (4) ..............................................................................................................................................................................................................

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

3.3. File reference number ..........................................................................................................................................................................................

3.4. Stamp

3.5. Date

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

3.6. Signature

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

1

E 403

B. Certificate

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

4.

Information concerning the apprenticeship

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

to receive training in the following trade: ..........................................................................................................................................................

4.2. The apprenticeship is provided

n ......................... days per week

n ........................... hours per week

and will last until

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

4.3. The apprentice
n is receiving

n an apprenticeship allowance or wage

n net (6)

n gross amounting to

n weekly

n monthly

n other benefits (7) namely

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

n accommodation

n full board

n part board

n tips

n ............................ meals a day

n other (8)

from .............................................................. to ..............................................................amounting to ..............................................................
n is not receiving

n an apprenticeship allowance or wage

n other benefits

4.4. Place of work ..........................................................................................................................................................................................................

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

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

4.6. Address (4) ..............................................................................................................................................................................................................

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

4.7. Stamp

4.8. Date

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

4.9. Signature

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

5.

Endorsement of the body responsible for supervision of the apprenticeship (9)

5.1. Name .......................................................................................................................................................................................................................

5.2. Address (4) ..............................................................................................................................................................................................................

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

5.4. Date

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

5.5. Signature

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

5.3. Stamp

2

E 403

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

INSTRUCTIONS

NOTES
(1) Symbol of the country to which the institution completing the form belongs: BE = Belgium; CZ = Czech Republic; DK = Denmark;
DE = Germany; EE = Estonia; GR = Greece; ES = Spain; FR = France; IE = Ireland; IT = Italy; CY = Cyprus; LV = Latvia;
LT = Lithuania; LU = Luxembourg; HU = Hungary; MT = Malta; NL = The Netherlands; AT = Austria; PL = Poland; PT = Portugal;
SI = Slovenia; SK = Slovakia; FI = Finland; SE = Sweden; UK = United Kingdom; IS = Iceland; LI = Liechtenstein; NO = Norway;
CH = Switzerland.

(1a) 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 the Czech republic,
when family benefits are claimed by a student, persons specified under points 1 and 2 are identical.
In the case of Portuguese districts, state also the parish and the local authority.

(2)
(3) Where the form is being sent to a Czech institution, state the birth number; to a Cypriot institution, if a Cypriot national state the
Cypriot identification number, if not a Cypriot national state the Alien Registration Certificate (ARC) number; to a Danish institution,
indicate the CPR number; to a Finnish institution, indicate the population register number; to a Swedish institution, indicate the
personal number (personnummer); to an Icelandic institution, indicate the personal identification number (kennitala); to a Latvian
institution, state the identity number; to a Liechtenstein institution, indicate the AHV insurance number; to a Lithuanian institution,
state the personal
insurance identification) number; to a
Maltese institution, in the case of Maltese nationals, state the identity card number, or, if not a Maltese national, state the Maltese
social security number;
to a Belgian
indicate the personal
institution, indicate the national social security number (NISS); to a German institution of the general pension insurance scheme,
indicate the insurance number (VSNR); to a Spanish institution, state the number appearing on the national identity card (DNI), or
N.I.E in the case of foreign people, even if the card is out of date; to a Polish institution, state the PESEL and NIP numbers; 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; to a Slovak institution, state the birth number; to a Slovene
institution, state the personal identification number (EMŠO); to a Swiss institution, state the AVS/AI (AHV/IV) insurance number.

identification number; to a Hungarian institution, state the TAJ (social

identification number (fødselsnummer);

to a Norwegian institution,

(4) Street, number, post code, town, country.
(5) For the French institutions form ‘E 403 Annex’ should be completed if the person concerned follows practical vocational training.
(6) For German institutions only indicate the gross amount of the education allowance.
(7)

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

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

(8) This box should be completed by the following institutions: in Ireland: Child Benefit Section, Department of Social and Family
Affairs, St. Oliver Plunkett Road, Letterkenny, County Donegal, in the case of apprenticeships that are not supervised by the
industrial training authority (FAS); in Italy: by the ‘Ufficio provinciale del lavoro e della massima occupazione’ (Provincial Office of
Labour and Employment); in Slovenia, the Chamber of Crafts of Slovenia.

(9)

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

(10) Indicate the amount received in the currency of the State in the territory in which the professional training is followed.
(11) Complete if such an organisation exists in the territory in which the professional training is followed.

3

THE ADMINISTRATIVE COMMISSION
ON SOCIAL SECURITY
FOR MIGRANT WORKERS

For instructions and notes see page 3 of an E 403 form

E 403 Annex

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

1.

Information concerning the vocational training (9)

1.1. The person named in box 2 of form E 403

n has been attending vocational training since .............................................................................................................................................
n attended vocational training from .............................................................................. to .............................................................................

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

n yes

n no

1.3. Nature of the training provided ...........................................................................................................................................................................

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

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

1.5. Number of hours of training:

— theoretical part

— practical training

n ............................................ per week
n ............................................ per week

n .......................................... per month
n .......................................... per month

1.6. Does the person concerned receive pay during training?

n yes

n no

If yes, please specify nature

Net amount per month (10)

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

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

1.7. Place of training

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

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

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

1.9. Address (4) ..............................................................................................................................................................................................................

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

1.10. Stamp

1.11. Date

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

1.12. Signature

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

2.

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

2.1. Name .......................................................................................................................................................................................................................

2.2. Address (4) ..............................................................................................................................................................................................................

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

2.3. Stamp

2.4. Date

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

2.5. Signature

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

1

THE ADMINISTRATIVE COMMISSION
ON SOCIAL SECURITY
FOR MIGRANT WORKERS

See ‘instructions’ on page 3

E 404

(1)

MEDICAL CERTIFICATE FOR THE PURPOSE OF THE GRANTING OF FAMILY BENEFITS

Reg. 1408/71: Art. 73; Art. 74; Art. 77; Art. 78
Reg. 574/72: Art. 86; Art. 88; Art. 90; Art. 91; Art. 92

A. Request for certificate

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

1.

Applicant for family benefits
n Employed person
n Self-employed person
n Persons other than the aforementioned

1.1. Surname (1a)

n Pensioner (scheme for employed persons)
n Pensioner (scheme for self-employed persons)
n Orphan

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

1.2. Forenames

Previous names (1a)

Place of birth (2)

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

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

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

1.3. Date of birth

Sex

Nationality

Identification/insurance number (3)

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

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

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

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

1.4. Address (4) ..............................................................................................................................................................................................................

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

2.

Person to whom the medical certificate relates

2.1. Surname (1a)

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

2.2. Forenames

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

Previous names (1a)
.....................................................................................................................................................

2.3. Place of birth (2)

Date of birth

Sex

Identification/insurance number (3)

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

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

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

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

2.4. Address (4)

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

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

3.

Institution competent as regards the granting of family benefits

3.1. Name .......................................................................................................................................................................................................................

3.2. Address (4) ..............................................................................................................................................................................................................

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

3.3. File reference number ..........................................................................................................................................................................................

3.4. Stamp

3.5. Date

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

3.6. Signature

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

1

B. Certificate

To be completed by the doctor designated by the liaison body (5) (6) in the country of residence of the person examined and to be sent
to the institution mentioned in box 3.

E 404

4.

4.1.

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

n have diminished

n have not diminished

If they have, indicate percentage of diminution ....................... %

(b) The person examined

n is capable of earning his/her living
n is incapable or earning his/her living and continue in the occupational training by studying

owing to physical or mental deficiency

(c) The person examined

n is

If she is, indicate whether n she is

(d) Observations

n is not a housewife
n she is not in a fit condition to look after her home

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

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

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

(e) Description of the condition of the person examined

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

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

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

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

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

4.3. Probable duration ..................................................................................................................................................................................................

4.4.

(a) A further examination

n is necessary

n is not necessary

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

5.

5.1. Surname and forenames of the doctor .............................................................................................................................................................

5.2. Address (4) ..............................................................................................................................................................................................................

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

5.3. Date

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

5.4. Signature

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

2

E 404

INSTRUCTIONS

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

NOTES
(1) Symbol of the country to which the institution completing the form belongs: BE = Belgium; CZ = Czech Republic; DK = Denmark;
DE = Germany; EE = Estonia; GR = Greece; ES = Spain; FR = France; IE = Ireland; IT = Italy; CY = Cyprus; LV = Latvia; LT =
Lithuania; LU = Luxembourg; HU = Hungary; MT = Malta; NL = The Netherlands; AT = Austria; PL = Poland; PT = Portugal; SL =
Slovenia; SK = Slovakia; FI = Finland; SE = Sweden; UK = United Kingdom; IS = Iceland; LI = Liechtenstein; NO = Norway; CH =
Switzerland.

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

surname, maiden name) in the order of civil status in which they appear on the identity card or passport.
In the case of Portuguese districts, state also the parish and the local authority.

(2)
(3) Where the form is being sent to a Czech institution, state the birth number; to a Cypriot institution, if a Cypriot national state the
Cypriot identification number, if not a Cypriot national state the Alien Registration Certificate (ARC) number; to a Danish institution,
indicate the CPR number; to a Finnish institution, indicate the population register number; to a Swedish institution, indicate the
personal number (personnummer); to an Icelandic institution, indicate the personal identification number (kennitala); to a Latvian
institution, state the identity number; to a Liechtenstein institution, indicate the AHV insurance number; to a Lithuanian institution,
state the personal
insurance identification) number; to a
Maltese institution, in the case of Maltese nationals, state the identity card number, or, if not a Maltese national, state the Maltese
to a Belgian
indicate the personal
social security number;
institution, indicate the national social security number (NISS); to a German institution of the general pension insurance scheme,
indicate the insurance number (VSNR); to a Spanish institution, state the number appearing on the national identity card (DNI), or
N.I.E in the case of foreign people, even if the card is out of date; to a Polish institution, state the PESEL and NIP numbers; 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; to a Slovak institution, state the birth number; to a Slovene
institution, state the personal identification number (EMŠO); to a Swiss institution, state the AVS/AI (AHV/IV) insurance number.

identification number; to a Hungarian institution, state the TAJ (social

identification number (fødselsnummer);

to a Norwegian institution,

(4) Street, number, post code, town, country.
(5) Or the doctor of the fund designated by the liaison body.
(6)

In Slovenia, this is the chosen physician.

3

THE ADMINISTRATIVE COMMISSION
ON SOCIAL SECURITY
FOR MIGRANT WORKERS

See ‘instructions’ on page 3

E 404 Annex PL

MEDICAL CERTIFICATE FOR THE PURPOSE OF THE GRANTING OF FAMILY BENEFITS ACCORDING TO POLISH
LEGISLATION

Reg. 1408/71: Art. 73; Art. 74; Art. 77; Art. 78
Reg. 574/72: Art. 86; Art. 88; Art. 90; Art. 91; Art. 92

To be used for the purpose of granting family benefits depending on the health of family members, according to Polish legislation.

A. Application for certificate

To be completed by the Polish institution competent to grant family benefits.

1.

Person applying for family benefits
n Employed person
n Self-employed person
n Other than the above mentioned

1.1. Surname (1)

n Pensioner (Employed person scheme)
n Pensioner (Self-employed person scheme)
n Orphan

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

1.2. Forenames

Previous names (1)

Place of birth (2)

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

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

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

1.3. Date of birth

Sex

Nationality

PESEL and NIP numbers

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

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

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

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

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

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

2.

Person to whom the medical certificate applies

2.1. Surname (1)

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

2.2. Forenames

Previous names and surnames (1)

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

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

2.3. Place of birth (2)

Date of birth

Sex

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

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

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

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

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

3.

Institution competent to grant family benefits

3.1. Name .......................................................................................................................................................................................................................

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

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

3.3. Reference number of files ...................................................................................................................................................................................

3.4. Stamp

3.5. Date

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

3.6. Signature

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

1

B. Certificate

To be completed by a doctor appointed by liaison institution (4) in the country of residence of examined person and to be sent to the
institution stated in box 3. Depending on the age of the person to whom the certificate applies, part I or part II is to be completed.
Depending of the state of health of persons aged over 16, part IIa or part IIb is to be completed.

E 404 Annex PL

I. It applies to persons under 16

4.

Disability

4.1. Age of child on the day of examination:................................................................. years ................................................................ months

Weight of child............................................................................................ Height

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

4.2. Expected period of physical or mental

impairment due to congenital malformation, long-term illness or body injury is over

12 months
n Yes n No

4.3. Requires permanent care of assistance to fulfil basic living needs in a manner that is appropriate for a person of this age

n Yes n No

II. It applies to persons over 16

a. Advanced level of disability (due to physical impairment)

4.4. Limited employment:

(a) incapable of work

(b) capable of working under condition of protected labour only

4.5. He/she requires one of the following in order to fulfil social roles:

(a) permanent care and assistance of others

(b) long-term care and assistance of others

4.6. He/She is incapable of living independently

b. Intermediate level of disability (due to physical impairment)

4.7. Limited employment:

(a) incapable of work

(b) capable of working under condition of protected labour only

4.8. He/she requires one of the following in order to fulfil social roles:

(a) temporary care and assistance of others

(b) partial care and assistance of others

4.9. Period when disability occurred: before the ages of 16

5.

n Yes n No
n Yes n No

n Yes n No
n Yes n No

n Yes n No

n Yes n No
n Yes n No

n Yes n No
n Yes n No

n Yes n No

5.1. Surname and forenames of the doctor .............................................................................................................................................................

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

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

5.3. Stamp

2

5.4. Date

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

5.5. Signature

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

Please complete the form in block capitals and write text over dotted lines only. In other places please mark the answer YES
or NO. To be completed in the language of the doctor issuing the certificate.

INSTRUCTIONS

E 404 Annex PL

NOTES

(1)

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.

(2)
(3) Street, number, post code, town, country.
(4) Or the doctor of the fund designated by the liaison body.

INFORMATION

impairment during an
According to Polish law, persons who are under 16 are treated as disabled if they have physical or mental
expected period exceeding 12 months, due to congenital malformation, long-term illness or bodily injury and they require permanent
care or support to fulfil basic living needs, in a manner that is appropriate for a person of their age.

A marked ‘YES’ in points 4.2 and 4.3 means that a person is disabled according to Polish law.

According to Polish law, persons may belong to one of three groups of disability due to physical or mental
intermediate and light.

impairment: advanced,

— A person with advanced disability is a person who has physical impairment, who is incapable of work or capable of work under the
conditions of protected labour, who is not able to live independently and requires permanent or long-term care and support from
others in order to fulfil their social roles.

— A person with intermediate disability is a person who has physical impairment, who is incapable of work or capable of work under
the conditions of protected labour, or who requires temporary or partial care and assistance from others in order to fulfil their social
roles.

A marked ‘YES’ in points 4.4a, 4.5a, 4.6 or 4.4a, 4.5b, 4.6 or 4.4b, 4.5a, 4.6 or 4.4b, 4.5b, 4.6 means that a person is disabled at the
advanced level; 4.7a or 4.7b or 4.8a or 4.8b means that a person is disabled at the intermediate level.

3

THE ADMINISTRATIVE COMMISSION
ON SOCIAL SECURITY
FOR MIGRANT WORKERS

See ‘instructions’ on page 3

E 405

(1)

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

Reg. 1408/71: Art. 12; Art. 72
Reg. 574/72: Art. 10a; Art. 85.2 and 3

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

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

registered.

1.

1.1.

1.2.

n Employed person

n Self-employed person n Unemployed person

Surname (1a)
..................................................................................................................................................................................................................................

Forenames
..........................................................................

Previous names (1a)
..........................................................................

Place of birth (2)
......................................................................

1.3. Date of birth

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

Sex
............................................

Nationality
.............................................

Identification/insurance number (3)
...................................................................................

1.4. Civil status

n single
n divorced

n married
n separated

n widow/widower
n cohabiting (4) (5)

1.5.

Address (6) .............................................................................................................................................................................................................
..................................................................................................................................................................................................................................

2.

2.1.

2.2.

Person who should receive the family benefits

Surname (1a)
..................................................................................................................................................................................................................................

Forenames
..........................................................................

Previous names (1a)
..........................................................................

Place of birth (2)
......................................................................

2.3. Date of birth

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

Sex
............................................

Nationality
............................................

Identification/insurance number (3)
................................................................................

2.4.

Address (6) .............................................................................................................................................................................................................
..................................................................................................................................................................................................................................
..................................................................................................................................................................................................................................

3.

Period for which the information is requested

3.1.

From ..................................................................................................

to ........................................................................................................

3.2. Name and address of employer (7) ..................................................................................................................................................................

3.3. Nature of self-employment (7) ...........................................................................................................................................................................

4.

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

4.1. Name .....................................................................................................................................................................................................................

4.2.

Address (6) ............................................................................................................................................................................................................

5.

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

5.1. Name .....................................................................................................................................................................................................................

5.2.

Address (6) ............................................................................................................................................................................................................

1

6.

Institution with which the insured person is currently registered

6.1. Name .......................................................................................................................................................................................................................

6.2. Address (6) ..............................................................................................................................................................................................................
....................................................................................................................................................................................................................................

6.3. File reference number ..........................................................................................................................................................................................
....................................................................................................................................................................................................................................

6.4. Stamp

E 405

6.5. Date

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

6.6. Signature

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

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

previously registered

7.

7.1. We certify that the insured person named in box 1

was insured from ............................................................ to ............................................................ (8) ...........................................................

7.2.

In (9) ........................................................................................................................................................................................................................

7.3. n He/she is entitled

n He/she is not entitled to family benefits

7.4.

Family benefits were paid to him/her from ...................................................................................

to ........................................................

7.5.

Family members for whom the family benefits were paid:

7.5.1. Surname

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

Forenames
...................................................
...................................................
...................................................
...................................................

Date of birth
..................................................
..................................................
..................................................
..................................................

Monthly amount
..............................................................
..............................................................
..............................................................
..............................................................

7.5.2. Are the amounts adjusted? ...............................................................................................................................................................................
..................................................................................................................................................................................................................................

8.

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

8.1. Name .......................................................................................................................................................................................................................

8.2. Address (6) ..............................................................................................................................................................................................................
....................................................................................................................................................................................................................................

8.3. Stamp

8.4. Date

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

8.5. Signature

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

9.

Remarks ...................................................................................................................................................................................................................

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

2

E 405

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

(1) Symbol of the country to which the institution completing the form belongs: BE=Belgium; CZ=Czech Republic; DK=Denmark;
DE=Germany; EE=Estonia; GR=Greece; ES=Spain; FR=France;
IT=Italy; CY=Cyprus; LV=Latvia; LT=Lithuania;
LU=Luxembourg; HU=Hungary; MT=Malta; NL=The Netherlands; AT=Austria; PL=Poland; PT=Portugal; SI=Slovenia; SK=Slovakia;
FI=Finland; SE=Sweden; UK=United Kingdom; IS=Iceland; LI=Liechtenstein; NO=Norway; CH=Switzerland.

IE=Ireland;

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

NOTES

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.

(2)
(3) Where the form is being sent to a Czech institution, state the birth number; to a Cypriot institution, if a Cypriot national state the
Cypriot identification number, if not a Cypriot national state the Alien Registration Certificate (ARC) number; to a Danish institution,
indicate the CPR number; to a Finnish institution, indicate the population register number; to a Swedish institution, indicate the
personal number (personnummer); to an Icelandic institution, indicate the personal identification number (kennitala); to a Latvian
institution, state the identity number; to a Liechtenstein institution, indicate the AHV insurance number; to a Lithuanian institution,
state the personal
insurance identification) number; to a
Maltese institution, in the case of Maltese nationals, state the identity card number, or, if not a Maltese national, state the Maltese
to a Belgian
indicate the personal
social security number;
institution, indicate the national social security number (NISS); to a German institution of the general pension insurance scheme,
indicate the insurance number (VSNR); to a Spanish institution, state the number appearing on the national identity card (DNI) or
N.I.E, in the case of foreign people, even if the card is out of date; to a Polish institution, state the PESEL and NIP numbers; 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; to a Slovak institution, state the birth number; to a Slovene
institution, state the personal identification number (EMŠO); to a Swiss institution, state the AVS/AI (AHV/IV) insurance number.

identification number; to a Hungarian institution, state the TAJ (social

identification number (fødselsnummer);

to a Norwegian institution,

(4) For the purpose of Czech, Danish, Icelandic and Norwegian institutions.
(5) This information is based on a statement from the person concerned.
(6) Street, number, post code, town, country.
(7) For the period preceding the worker’s transfer to the Member State to whose legislation he/she is currently subject.
(8)

(a)

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

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

number of days as an employed person ............................................................................................................................................................
number of days as a self-employed person .......................................................................................................................................................

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

Number of days in employment

Number of hours in employment

Gross wage/salary received

During the last month

During the last three months

During the last six months

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

3

THE ADMINISTRATIVE COMMISSION
ON SOCIAL SECURITY
FOR MIGRANT WORKERS

See ‘instructions’ on page 2

E 405 Annex PL

CERTIFICATE CONCERNING THE PERSON ON PARENTAL LEAVE FOR THE PURPOSE OF THE GRANTING OF FAMILY
BENEFITS

Reg. 1408/71: Art. 12; Art. 72; Art. 73
Reg. 574/72: Art. 10a; Art. 85; Art. 86

To be used for the purpose of the granting of family benefits according to Polish legislation.

A. Application for certificate

1.

Person applying for family benefits
n Employed person

1.1. Surname (1)

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

1.2. Forenames

Previous names and surnames (1)

Place of birth (2)

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

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

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

1.3. Date of birth

Sex

Nationality

PESEL and NIP number

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

1.4. Civil status

.....................................
n unmarried
n divorced

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

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

n married
n in separation

n widow/widower
n common-law husband/wife (3) (4)

1.5. Address (5) ..............................................................................................................................................................................................................
....................................................................................................................................................................................................................................

2.

Person concerned by the certificate

2.1. Surname (1)

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

2.2. Forenames

Previous names and surnames (1)

Place of birth (2)

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

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

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

2.3. Date of birth

Sex

Nationality

PESEL and NIP number

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

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

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

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

2.4. Address (5)

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

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

2.5. Period to which application applies

from ........................................................

until

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

3.

Institution competent for granting family benefits

3.1. Name .......................................................................................................................................................................................................................

3.2. Address (5) ..............................................................................................................................................................................................................
....................................................................................................................................................................................................................................

3.3. File reference number ..........................................................................................................................................................................................

3.4. Stamp

3.5. Date

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

3.6. Signature

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

1

B. Certificate

To be completed by the competent institution for granting family benefits where the person was previously registered.

4.

This is to certify that the person named in box 2

4.1. was a wage worker in the period from ....................................................................... until ....................................................................... (6)
in .......................................................................................................................................................................................................................... (7)

E 405 Annex PL

5.

The person named in box 2

5.1.

is currently employed or works in another paid work

5.2.

is currently on parental leave (8)

n Yes
n Yes

n No
n No

6.

The name of the institution where the person named in box 2 was recently registered as an employed person

6.1. Name .......................................................................................................................................................................................................................

6.2. Address (5) ..............................................................................................................................................................................................................
....................................................................................................................................................................................................................................

6.3. Stamp

6.4. Date

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

6.5. Signature

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

Please complete the form in block capitals and write the text over dotted lines only. The form consists of two pages of which
none should be omitted, even if they do not contain relevant information.

INSTRUCTIONS

NOTES

(1)

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.

Information is based on the declaration of the interested person.

(2)
(3) For the purposes of Dutch, Icelandic, Norwegian and Polish institutions.
(4)
(5) Street, number, post code, town, country.
(6) Please, indicate the exact dates (day/month/year).
(7) Country where the given work is being performed.
(8)

It refers to benefits granted for a child when one of parents is on parental leave.

2

THE ADMINISTRATIVE COMMISSION
ON SOCIAL SECURITY
FOR MIGRANT WORKERS

See ‘instructions’ page 2

E 406

(1)

CERTIFICATE OF POST-NATAL MEDICAL EXAMINATIONS

Reg. 1408/71: Art. 73; Art. 74
Reg. 574/72: Art. 86; Art. 88

Information for the insured person

In order to qualify for French family benefits in accordance with Article 73 or 74,
the child must undergo post-natal medical
examinations, one examination during the 9th or 10th month from birth and the other during the 24th or 25th month. Failure to comply
with this obligation and these deadlines will lead to loss of part of the entitlement. In order to qualify for Slovak parental allowance in line
with the Slovak legislation, the child has to be officially registered as the patient of a practitioner and has to regularly undergo preventive
medical examinations including inoculation as per the obligatory vaccination regime.

A. Request for certificate

1. n Employed person

n Self-employed person

1.1. Name (1a)

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

1.2. Forenames

Previous name (1a)

Place of birth (1b)

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

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

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

1.3. Date of birth

Sex

Nationality

Identification/insurance number (1c)

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

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

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

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

1.4. Address (2) ...............................................................................................................................................................................................................

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

2.

Child for whom the certificate is requested

2.1. Surname (1a)

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

2.2. Forenames

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

2.3. Place of birth (1b)

Date of birth

Sex

Identification/insurance number (1c)

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

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

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

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

2.4. Address (2) ...............................................................................................................................................................................................................

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

3.

Institution responsible for the granting of family benefits

3.1. Name .......................................................................................................................................................................................................................

3.2. Address (2) ..............................................................................................................................................................................................................

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

3.3. File reference number ..........................................................................................................................................................................................

3.4. Stamp

3.5. Date

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

3.6. Signature

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

1

B. Certificate

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

4.

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

4.2. n a medical examination during the 9th or 10th month from birth

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

E 406

5.

5.1. Doctor’s surname and forename .......................................................................................................................................................................

5.2. Address (2) ..............................................................................................................................................................................................................

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

5.3. Date

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

5.4. Signature

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

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

INSTRUCTIONS

(1) Symbol of the country to whose legislation the worker is subject: FR = France; SK = Slovakia.
(1a) In the case of Spanish nationals, state both names at birth.

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

NOTES

(1b) In the case of Portuguese districts, state also the parish and the local authority.
(1c) Where the form is being sent to a Czech institution, state the birth number; to a Cypriot institution, if a Cypriot national state the
Cypriot identification number, if not a Cypriot national state the Alien Registration Certificate (ARC) number; to a Danish institution,
indicate the CPR number; to a Finnish institution, indicate the population register number; to a Swedish institution, indicate the
personal number (personnummer); to an Icelandic institution, indicate the personal identification number (kennitala); to a Latvian
institution, state the identity number; to a Liechtenstein institution, indicate the AHV insurance number; to a Lithuanian institution,
state the personal
insurance identification) number; to a
Maltese institution, in the case of Maltese nationals, state the identity card number, or, if not a Maltese national, state the Maltese
social security number;
to a Belgian
indicate the personal
institution, indicate the national social security number (NISS); to a German institution of the general pension insurance scheme,
indicate the insurance number (VSNR); to a Spanish institution, state the number appearing on the national identity card (DNI) or
N.I.E, in the case of foreign people, even if the card is out of date; to a Polish institution, state the PESEL and NIP numbers; 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; to a Slovak institution, state the birth number; to a Slovene
institution, state the personal identification number (EMŠO); to a Swiss institution, state the AVS/AI (AHV/IV) insurance number.

identification number; to a Hungarian institution, state the TAJ (social

identification number (fødselsnummer);

to a Norwegian institution,

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

2

THE ADMINISTRATIVE COMMISSION
ON SOCIAL SECURITY
FOR MIGRANT WORKERS

See ‘instructions’ on page 4

E 407

(1)

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

Reg. 1408/71: Art. 73; Art. 74
Reg. 574/72: Art. 86; Art. 88

A. Request for certificate

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

1. n Employed person

n Self-employed person

1.1. Surname (1a)

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

1.2. Forenames

Previous names (1a)

Place of birth (1b)

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

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

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

1.3. Date of birth

Sex

Nationality

Identification/insurance number (1c)

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

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

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

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

1.4. Address (2)

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

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

2.

Child for whom the certificate is requested

2.1. Surname (1a)

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

2.2. Forenames

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

2.3. Place of birth (1b)

Date of birth

Sex

Identification/insurance number (1c)

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

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

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

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

2.4. Address (2)

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

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

3.

Institution responsible for the granting of family benefits

3.1. Name .......................................................................................................................................................................................................................

3.2. Address (2)

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

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

3.3. File reference number ..........................................................................................................................................................................................

3.4. Stamp

3.5. Date

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

3.6. Signature

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

1

E 407

B. Certificate

The doctor designated by the institution of the place of residence of the examined child should complete this page and the next page
and send it to the institution mentioned in box 3, enclosing all recent supporting medical documents (photographs, X-rays, results of
medical examinations, etc.) (4).

4.

4.1. Child’s age on date of examination ................................................................... years .................................................................. months

Child’s weight

................................ kilograms ................................. grams

height:

.................................................. centimetres

4.2. Psychomotor retardation

Retardation taking account of normal level for the child’s age

n Yes n No

If yes, please specifiy ..........................................................................................................................................................................................

4.3.

Independence
Can the child sit up unaided?
Can he/she talk?

Can he/she eat unaided?

n Yes n No
n Yes n No

n Yes n No

4.4. Assistance

Can he/she walk?
Can he/she dress
unaided?
Does he/she write?
Is he/she incontinent?

n Yes n No

n Yes n No
n Yes n No (3)
n Yes n No (3)

Does the child’s condition necessitate attendance by another person?
Constant attendance? n Yes
Or other measures (please specify) ..................................................................................................................................................................

Daily attendance though not continuous?

n Yes n No
n Yes n No

n No

4.5. Nature of the principal disability

Is the child’s disability
sensory?

visual? ...................................................................................................................................................................................

motor

mental

auditory? ...............................................................................................................................................................................

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

mental level

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

behaviour

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

other

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

4.6. Origin of disability (3)

— congenital anomaly ..........................................................................................................

— disease ...............................................................................................................................

n Yes n No
n Yes n No

date of onset of disability ...............................................................................................................................................................................

date of diagnosis

month ..........................................

year .......................................................................................

beginning of treatment

month ..........................................

year .......................................................................................

— accident

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

n Yes n No

date of accident

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

4.7. Associated disabilities

Which ones? ..........................................................................................................................................................................................................

Other deficiencies .................................................................................................................................................................................................

4.8. Additional observations

Disabilities in the family .......................................................................................................................................................................................

Supplementary examinations already carried out
(Copies of reports of examinations should be enclosed, where appropriate)

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

2

E 407

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

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

Since when? ..........................................................................................................................................................................................................

What forms of treatment are recommended? .................................................................................................................................................

— Surgery ..............................................................................................................................................................................................................

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

— Hospitalisations (the last three years) .........................................................................................................................................................

— Treatment at home (medicaments) ........................................................................................................... Since when ……/……/……

........................................................................................................................................................................... Since when ……/……/……

........................................................................................................................................................................... Since when ……/……/……

— Rehabilitation

Beginning

Frequency

Where?

Logopedy

Physiotherapy

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

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

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

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

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

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

Occupational therapy

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

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

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

(Psycho)therapy

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

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

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

Earliest help at home

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

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

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

4.10. Educational and training measures

What forms of education and training are being provided? .........................................................................................................................

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

Since when? ..........................................................................................................................................................................................................

What education and training is recommended? .............................................................................................................................................

4.11. Prognosis

Please specify:

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

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

4.12. ICD (International Classification of Diseases — WHO) code of illness

4.13. Beginning of illness

4.14. Date of next control

5.

5.1. Doctor’s surname and forename .......................................................................................................................................................................

5.2. Address (2)

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

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

5.3. Date

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

5.4. Signature

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

3

INSTRUCTIONS

E 407

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

NOTES

(1) Symbol of

the country to whose legislation the worker is subject: BE = Belgium; CZ = Czech Republic; DK = Denmark;
DE = Germany; EE = Estonia; GR = Greece; ES = Spain; FR = France; IE = Ireland; IT = Italy; CY = Cyprus; LV = Latvia;
LT = Lithuania; LU = Luxembourg; HU = Hungary; MT = Malta; NL = The Netherlands; AT = Austria; PL = Poland, PT = Portugal;
SI = Slovenia, SK = Slovakia, FI = Finland, SE = Sweden, UK = United Kingdom; IS = Iceland; LI = Liechtenstein; NO = Norway;
CH = Switzerland.

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

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

(1b) In the case of Portuguese districts, state also the parish and the local authority.
(1c) Where the form is being sent to a Czech institution, state the birth number; to a Cypriot institution, if a Cypriot national state the
Cypriot identification number, if not a Cypriot national state the Alien Registration Certificate (ARC) number; to a Danish institution,
indicate the CPR number; to a Finnish institution, indicate the population register number; to a Swedish institution, indicate the
personal number (personnummer); to an Icelandic institution, indicate the personal identification number (kennitala); to a Latvian
institution, state the identity number; to a Liechtenstein institution, indicate the AHV insurance number; to a Lithuanian institution,
insurance identification) number; to a
state the personal
Maltese institution, in the case of Maltese nationals, state the identity card number, or, if not a Maltese national, state the Maltese
social security number;
to a Belgian
indicate the personal
institution, indicate the national social security number (NISS); to a German institution of the general pension insurance scheme,
indicate the insurance number (VSNR); to a Spanish institution, state the number appearing on the national identity card (DNI), or
N.I.E in the case of foreign people, even if the card is out of date; to a Polish institution, state the PESEL and NIP numbers; 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; to a Slovak institution, state the birth number; to a Slovene
institution, state the personal identification number (EMŠO); to a Swiss institution, state the AVS/AI (AHV/IV) insurance number.
Failing this, indicate ‘None’.

identification number; to a Hungarian institution, state the TAJ (social

identification number (fødselsnummer);

to a Norwegian institution,

(2) Street, number, post code, town, country.
(3) Need only to be filled in if a Belgian or Slovak institution is responsible for granting family benefits.
(4)

In Slovenia it is completed by a medical commission appointed by the Minister of Labour, Family and Social Affairs.

4

THE ADMINISTRATIVE COMMISSION
ON SOCIAL SECURITY
FOR MIGRANT WORKERS

See ‘instructions’ on page 4

E 411

(1)

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

Reg. 1408/71: Art. 76
Reg. 574/72: Art. 10

A. Request for certificate

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

1. n Employed person

n Self-employed person

1.1. Surname (1a)

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

1.2. Forenames

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

Previous names (1a)
.......................................................................

Place of birth (2)
...........................................................................

1.3. Date of birth

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

Sex
.....................................

Nationality
........................................................

Identification/insurance number (3)
.................................................................................

1.4. Address (4) ..............................................................................................................................................................................................................

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

2.

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

2.1. Surname (1a)

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

2.2. Forenames

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

Previous names (1a)
.....................................

Date of birth
........................................................

Identification/insurance number (3)
.................................................................................

2.3. Address (4) ..............................................................................................................................................................................................................

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

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

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

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

2.5. Period for which the information is requested .................................................................................................................................................

3.

Members of the family (6)

3.1.

3.2.

3.3.

Surname (1a)

Forenames

Date of birth

Relationship (5)

Actual place
of residence (7)

Identification/
insurance No (3)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

1

E 411

4.

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

4.1. Employer .................................................................................................................................................................................................................

4.2. Address (4) ..............................................................................................................................................................................................................

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

4.3. Self-employment ....................................................................................................................................................................................................

4.4. Activity treated as an occupation as defined by Decision No 119 (15)

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

5.

Competent institution

5.1. Name .......................................................................................................................................................................................................................

5.2. Address (4) ..............................................................................................................................................................................................................

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

5.3. File reference number (8) .....................................................................................................................................................................................

5.4. Stamp

B. Certificate

5.5. Date

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

5.6. Signature

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

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

6.

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

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

n pursued an occupation (or an activity treated as such as defined in Decision No 119) (15)

from ............................................................ to ............................................................

n did not pursue an occupation (or an activity treated as such as defined in Decision No 119) (15)

from ............................................................ to ............................................................

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

n is entitled to family benefits for the members of the family
n total amount of family benefits .......................................................................................................................................................................
n is not entitled to family benefits for the following reasons
....................................................................................................................................................................................................................................
n has not submitted a claim (10)
....................................................................................................................................................................................................................................

6.3.

Income of the persons named in box 2 and 3 (4a)

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

2

E 411

7.

1.
2.
3.
4.
5.
6.

1.
2.
3.
4.
5.
6.

8.

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

Surname

Forenames

Date of birth

Relationship

Place of residence

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

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

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

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

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

Additional information per family member:

Family member

Kind of benefit (14)

Amount (12)

Periodicity (week/month)

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

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

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

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

Employer of the person named in box 2 (9)

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

8.2. Address (4) ..............................................................................................................................................................................................................

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

8.3. Stamp

8.4. Date

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

8.5. Signature

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

9.

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

9.1. Name .......................................................................................................................................................................................................................

9.2. Addres (4) ................................................................................................................................................................................................................

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

9.3. File reference number ..........................................................................................................................................................................................

9.4. Stamp

9.5. Date

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

9.6. Signature

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

3

INSTRUCTIONS

E 411

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.

NOTES

(1) Symbol of the country to which the institution completing the form belongs: BE = Belgium; CZ = Czech Republic; DK = Denmark;
DE = Germany; EE = Estonia; GR = Greece; ES = Spain; FR = France; IE = Ireland; IT = Italy; CY = Cyprus; LV = Latvia;
LT = Lithuania; LU = Luxembourg; HU = Hungary; MT = Malta; NL = The Netherlands; AT = Austria; PL = Poland; PT = Portugal;
SI = Slovenia; SK = Slovakia; FI = Finland; SE = Sweden; UK = United Kingdom; IS = Iceland; LI = Liechtenstein; NO = Norway;
CH = Switzerland.

(1a) 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.

(2)
(3) Where the form is being sent to a Czech institution, state the birth number; to a Cypriot institution, if a Cypriot national state the
Cypriot identification number, if not a Cypriot national state the Alien Registration Certificate (ARC) number; to a Danish institution,
indicate the CPR number; to a Finnish institution, indicate the population register number; to a Swedish institution, indicate the
personal number (personnummer); to an Icelandic institution, indicate the personal identification number (kennitala); to a Latvian
institution, state the identity number; to a Liechtenstein institution, indicate the AHV insurance number; to a Lithuanian institution,
state the personal
insurance identification) number; to a
Maltese institution, in the case of Maltese nationals, state the identity card number, or, if not a Maltese national, state the Maltese
to a Belgian
indicate the personal
social security number;
institution, indicate the national social security number (NISS); to a German institution of the general pension insurance scheme,
indicate the insurance number (VSNR); to a Spanish institution, state the number appearing on the national identity card (DNI) or
N.I.E,in the case of foreign people, even if the card is out of date; to a Polish institution, state the PESEL and NIP numbers; 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; to a Slovak institution, state the birth number; to a Slovene
identification number (EMŠO) and tax number; to a Swiss institution, state the AVS/AI (AHV/IV)
institution, state the personal
insurance number.

identification number; to a Hungarian institution, state the TAJ (social

identification number (fødselsnummer);

to a Norwegian institution,

(4) Street, number, post code, town, country. If the form is being sent to a Hungarian institution, indicate the last Hungarian address as

well.

(4a) For the purposes of the Czech institutions, submit the income documentation of persons specified in items 2 and 3. When the
benefit is claimed up to 30 September of the current year, the income documentation concerns the calendar year preceding the
previous year; when the benefit is claimed after 1 October of the current year, the income documentation concerns the previous
calendar year. Please state all kinds of
rents, stipends,
maintenance payments, etc.) including benefits (unemployment benefits, pensions, sickness benefits, family benefits, etc.).

income according to their source (employment, self-employment,

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

A = legitimate child. In Spain and Poland child born in wedlock (matrimonial) and child born out of wedlock (non-matrimonial).
B = legitimised child.
C = adopted child.
D = natural child (if the form is completed for a male worker, the natural children must be mentioned only if the paternity or the
worker’s obligation to maintain them has been officially recognised).
E = child of a spouse belonging to the worker’s household.
F = grandchildren, brothers and sisters whom the person concerned has taken into his household. Also, nephews and nieces to the
third degree where the competent institution is a Greek institution. Where the competent institution is a Polish institution, only
grandchildren and siblings whose legal guardian is an entitled person or his/her spouse.
G = other children belonging permanently to the household on the same footing as the worker’s children (foster children).
Where the competent institution is a Polish institution, only other children whose legal guardian is an entitled person or his/her
spouse.
H = for the purposes of Czech institutions, describe further forms of custody (custody awarded following a court decision to other
persons than parents, guardian, curator, etc.). Other relationships (e.g. grandfather) must be written in full.
According to Czech legislation, legitimised and adopted children under B and C have equal status.

(6) For the purposes of Norwegian institutions, state only children under the age of 16. For the purpose of Latvian institutions indicate
only children under the age of 15, and, if they are attending general or vocational educational establishments and not receiving
scholarship and are not married, children under the age of 20.

(7)

If the member of the family resides at an address other than that indicated at 2.3, please indicate here. For the purposes of Latvian
and Norwegian institutions, please state if the child resides in an orphanage, a special school or another residential institution.

Surname and forenames

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

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

Address (4)

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

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

4

(8) For use by the sending institution.
(9) The certificate should be completed by the employer only if he/she has to pay the family benefits of the country of residence.
(10) In this case the institution of the place of residence should indicate the amount of family benefits that would have been granted if a
claim had been submitted. If it does not have sufficient information to do so it should indicate in box 7 the tariffs provided for by its
legislation for each member of the family.

(11) For Norwegian family benefits only the total amount will be given.
(12) Where appropriate, indicate the tariffs referred to in footnote 10.
(13) To be completed by the institution of the place of residence of the members of the family or, failing this, by the liaison body.
(14) For Slovak and Czech institutions state the kind of family benefit.
(15) OJ C 295, 2.11.1983, p. 3.

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