2006/613/EC: Decision No 204 of 6 October 2005 on model forms necessary for the application of Council Regulations (EEC) No 1408/71 and (EEC) No 574/72 (E 200 series) (Text with EEA relevance and for the EU/Switzerland Agreement)

Decision No 204 of 6 October 2005 on model forms necessary for the application of Council Regulations (EEC) No 1408/71 and (EEC) No 574/72 (E 200 series) (Text with EEA relevance and for the EU/Switzerland Agreement) (2006/613/EC) THE ADMINISTRATIVE COMMISSION ON SOCIAL SECURITY FOR MIGRANT WORKERS, Having regard to Article 81(a) of Council Regulation (EEC) No 1408/71 of 14 June 1971 on the application of social security schemes to employed persons, to self-employed persons and to members of their family moving within the Community, under which it is the duty of the Administrative Commission to deal with all administrative matters arising from Regulation (EEC) No 1408/71 and subsequent regulations, Having regard to Article 2(1) of Regulation (EEC) No 574/72 , laying down the procedure for implementing Regulation (EEC) No 1408/71, under which it is the duty of the Administrative Commission to draw up models of documents necessary for the application of Regulations 1408/71 and 574/72, Having regard to Decision No 184 of 10 December 2001 on the model forms necessary for the application of Council Regulations (EEC) No 1408/71 and (EEC) No 574/72 (E 201 to E 207, E 213 and E 215) Having regard to Decision No 188 of 10 December 2002 on the model forms necessary for the application of Council Regulation (EEC) No 574/72 (E 210 and E 211) Whereas:

(1) The enlargement of the European Union on 1 May 2004 requires the forms in the E 200 series to be amended. (2) The Agreement on the European Economic Area (EEA Agreement) of 2 May 1992 , supplemented by the Protocol of 17 March 1993 , Annex VI, implements Regulations (EEC) No 1408/71 and (EEC) No 574/72 within the European Economic Area. (3) 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) For practical reasons, the forms used in the European Union and under the EEA and Swiss Agreements should be identical, HAS DECIDED AS FOLLOWS: 1. The model documents E 202 with additional pages 1 to 9, E 203 with additional pages 1 to 13, E 204 with additional pages 1 to 9, E 205(BE), (CZ), (DK), (DE), (EE), (GR), (ES), (FR), (IE), (IT), (CY), (LV), (LT), (LU), (HU), (MT), (NL), (AT), (PL), (PT), (SI), (SK), (FI), (SE), (UK), (IS), (LI), (NO), (CH), E 207, E 210, E 211, E 213 with additional pages 1 to 5, and E 215 with an additional page are adopted in accordance with the forms attached to this decision.

2. 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 that the different versions are perfectly superposable, thereby making it possible for all addressees to receive the form printed in their own language. 3. This Decision, which replaces Decisions No 184 and No 188, shall be published in the Official Journal of the European Union . It shall apply from the first day of the month following its publication.

The Chairman of the Administrative Commission Anna Hudzieczeck L 254 2006 EN 1 1 01 20051006 EN 001.001 3 1 273 271 THE ADMINISTRATIVE COMMISSION ON SOCIAL SECURITY FOR MIGRANT WORKERS See ‘ Instructions ’ on pages 8, 9 and 10 E 202 (1) Country: Identification No (2) (16) Institution concerned (where applicable, liaison body) (1) (2) (3) (4) (5) INVESTIGATION OF A CLAIM FOR AN OLD-AGE PENSION Regulation (EEC) No 1408/71: Articles 44 to 51a; Article 77 Regulation (EEC) No 574/72: Articles 36 to 38; Articles 41 to 43; Articles 45 to 47; Article 49; Article 90 (*); Article 111 The investigating institution should complete this form and send one copy to each of the institutions with which the employed or self-employed person has been insured (institutions concerned) or to the liaison body.

1. Institution to which the form is addressed (institution concerned or liaison body, as applicable) 1.1 Name: … … 1.2 Address (3): … … A. Information concerning insured person (4) 2. 2.1 Surname (5): … 2.2 Surname at birth (5): … 2.3 Forenames (6): … 2.4 Previous names (7): … 2.5 Sex (8): … 2.6 Father’s surname and forenames (9): … 2.7 Mother’s surname and forenames at birth (9): … 2.8 Civil status: single divorced (10) separated since: … (11) since: … (11) married remarried (10) widow or widower since: … (11) since: … (11) since: … (11) cohabiting since: … (12) (4) 2.9 Taxpayer’s No (13): … Code of tax district: … 2.10 Insurance No (2) (14): … (*) Article 90 of Regulation (EEC) No 574/72 is not applicable in the Netherlands.

E 202 3. Nationality (15) (16): … 4. Details of birth (17) 4.1 Date of birth (17): … 4.2 Place of birth (18): … 4.3 Province, county (19): … 4.4 Country (20): … 5. Address and bank particulars 5.1 Address (3) (21) (22): … … 5.2 Bank particulars or address for direct payment Name of beneficiary as recognised by the bank: … Name of the bank: … Address of the bank: … Bank identification code (BIC/SWIFT): … International bank account No (IBAN): … 6. 6.1 Insurance No at the registering institution: … 6.2 Reference No of file at the investigating institution: … 7. 7.1 The insured person is still pursuing gainful employment as an employed person as a self-employed person civil servant (22a) entailing compulsory pension insurance cover (23) 7.2 The insured person ceased to pursue gainful employment as an employed person as a self-employed person civil servant (22a) since: … 7.3 The insured person intends to retire from gainful employment as an employed person as a self-employed person civil servant (22a) on: … 7.4 The insured person intends to take up gainful employment (24) as an employed person civil servant (22a) as a self-employed person (state nature of activity): … 7.5 Amount of salary of professional income of other income (25) 7.6 Nature of other income: … 7.7 The claimant states that he/she has no income (26).

E 202 8. 8.1 The insured person has applied for the following benefits: is receiving the following benefits: 8.2 Continued wage or salary payments in case of illness 8.3 Sickness insurance cash benefits for incapacity for work 8.4 Rehabilitation allowances 8.5 Invalidity pension (27) 8.6 Old-age pension (27) 8.7 Survivor’s pension (27) 8.8 Pension for accident at work or occupational disease 8.9 Pension-type benefit payable under compulsory motor insurance (road accident indemnity) (28) 8.10 Unemployment benefits or early retirement benefit 8.11 Family benefit (29) 8.12 Refund of contributions 8.13 Transfer of contributions (30) 8.14 Other benefits (please specify) Yes No 8.15 Institutions responsible for paying the benefits indicated in 8.3. to 8.11 [name, address (3), benefit No]:

8 … 8 … 8 … 8 … 8.16 Additional information on the benefits listed in 8.3 to 8.10. Re benefits in item: File reference No: Period or date on which due Amount daily weekly 8 … monthly annual daily weekly 8 … monthly annual daily 8 … 8 … weekly monthly annual daily weekly monthly annual E 202 8.17 The following are regarded as advances on the pension claimed: sickness insurance benefits for incapacity for work unemployment benefits 8.18 The insured person is entitled to sickness benefits in kind under the legislation administered by the investigating institution? Yes No Not yet determined 8.19 The benefit referred to in point 8.6 or 8.7 is based on (31): the claimant’s own insurance periods: see E 205 insurance periods completed by the (former) spouse: see E 205.

9. Additional information for the application of provisions on overlapping benefits 9.1 When benefits of the same kind are granted by the institution or institutions concerned, the pension calculated by the investigating institution may be reduced? No Yes Not yet determined 9.2 The pension calculated by the investigating institution may be reduced Yes No Not yet determined because one or several of the benefits specified at point 8 are taken into account? 8 … 8 … 8 … 8 … because of income other than the benefits specified at point 8? income from employment/self-employment other (32): … 9.3 The institution concerned is requested to specify the part of the pension accruing from voluntary contribution payments (point 6.7 in form E 210)? Yes No 9.4 The benefit due from the investigating institution is (partly or entirely) based on voluntary contributions? Yes No 10.

Information to be supplied if the form is to be sent to Danish (10.1, 10.2 and 10.3), German, Greek, Spanish, Austrian, Polish (10.1 and 10.2), French (10.1, 10.2 and 10.4), Icelandic, Slovene (10.2 and 10.3), Portuguese, Czech, Finnish and Norwegian (10.2) institutions 10.1 The claimant (33) declares that he/she is unfit for work (see medical report enclosed) declares that he/she is totally incapable of performing duties and current invalidity is related to performed duties (see medical report enclosed) (33a) declares that he/she is not unfit for work. 10.2 The claimant (33) (34) declares that he/she needs someone in constant attendance for the performance of one of the ordinary activities of everyday life (see medical report enclosed) declares that he/she does not need someone in constant attendance for the performance of one of the ordinary activities of everyday life declares that his or her functional capacity has, on account of an illness or injury, diminished with the result that he or she is not capable of performing ordinary activities of everyday life unaided or that the illness or injury imposes an added long-term financial strain (28).

10.3 The claimant (33) declares that he/she does not have sufficient means of subsistence. E 202 10.4 The investigating institution awards an increase in benefits to the extent that the applicant is incapable of carrying out normal day-to-day activities unaided? Yes No Not yet determined In addition to the benefit referred to at point 8 … the applicant receives an additional benefit if he/she is incapable of carrying out normal day-to-day activities? The additional benefit may be reduced if a similar benefit is granted by another institution concerned? Yes No Not yet determined B. Information concerning the members of the insured person’s family (4) 11.

Spouse Cohabiting partner (12) (35) 11.2 Forenames (6): 11.3 Date of birth: … 11.4 Nationality (15) (16): … 11.5 Address (3): … 11.6 Insurance No (2) (14): … 11.7 Date of marriage/cohabiting: … Does the insured person live in the same household as the spouse or partner? Yes, since: … No: … Not anymore, since: … 11.8 The spouse/partner pursues 11.9 If in the affirmative, state amount of weekly earnings (36): … 11.10 The spouse/partner aged between 60 and 65 declares himself/herself fit for work 11.11 The spouse/partner has submitted a claim for a pension under the scheme for receives a pension under the scheme for does not receive a pension 11.12 Type of pension (38): … 11.13 Pension No (16): … 11.14 Institution responsible for payment: … 11.15 Amount monthly quarterly annual weekly 11.1 Surname (5):

Previous names (7): Place of birth (18): … does not pursue gainful employment annual earnings (37): … unfit for work (33) employed persons self-employed persons all residents civil servants (37a) Where appropriate, indicate E 202 11.16 The spouse/partner receives does not receive other benefits (39) unemployment sickness invalidity other 11.17 Date of commencement (40): … 11.18 Amount monthly quarterly annual weekly 11.19 Other known resources: … Type: … Amount (40): … 11.20 The benefit referred to in 11.11 is based on (31): the claimant’s own insurance periods : see E 205. insurance periods completed by the (former) spouse : see E 205.

12. Children (16) 12.1 Surname (5): Forenames: Insurance number: Sex (M/F): Place and date of birth, marriage or death (41): Relationship (i.e. : own child, adopted child, foster child): 1. 2. 3. 4. 12.2 The following institution is competent to grant benefits pursuant to Article 77 of Regulation (EEC) No 1408/71: the investigating institution the institution designated as follows: … 12.3 The investigating institution, for the children referred to in line Nos … of item 12.1, is granting benefits until … inclusive. amount of pension increase and family allowance per child (42): is not granting benefits in respect of the children referred to in line Nos … of item 12.1 (43). has not yet taken a decision regarding entitlement to benefits.

12.4 Address (3) (44): … 12.5 Remarks (45) (46) (49): … E 202 C. Miscellaneous information 13. Date of submission of this claim: … Date chosen by claimant for commencement of pension payments in country [refer to box above section 1] Date from which the pension is payable in the country of the investigating institution: … The claimant has asked for payment (47) directly in the State of residence to a representative in the State of origin. Additional information for the purposes of the Finnish institutions: in Finnish The claimant wishes to have the decision in Swedish 14. The claimant has requested has not requested deferment of the calculation of an old-age pension to which he/she would be entitled.

Where appropriate, indicate the country and the date chosen for pension payments: … … 15. The investigating institution pays does not pay benefits on a provisional basis under Article 45(1) of Regulation (EEC) No 574/72. 15.1 If not, the institutions concerned are requested to investigate the possibility of paying benefits on a provisional basis under Article 45(2) of Regulation (EEC) No 574/72. 16. There are grounds There are no grounds for making deductions to compensate for overpayment in accordance with Article 111 of Regulation (EEC) No 574/72. 16.1 Any pension arrears can cannot be paid direct to the beneficiary.

17. 17.1 Attached forms E 205 E 207 (48) E 213 or all available medical evidence 17.2 Please send us your E 205 E 210 Decision Arrears E 213 Remarks: … 18. Investigating institution 18.1 Name: … 18.2 Address (3): … 18.3 Stamp 18.4 Date: … 18.5 Signature: E 202 INSTRUCTIONS Please complete this form in block letters or typewriting, writing on the dotted lines only. It consists of ten 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. (2) 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 Liechtenstein institution, indicate the AHV insurance number; to a Lithuanian institution state the personal identification number; to a Latvian institution, state the identity 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 identification number (fødselsnummer); 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) and to an institution of the social security scheme for civil servants, indicate the personal identification number (PRS-Kenn-Nr); to an Austrian institution, state the Austrian insurance number(VSNR); to a Polish institution, state the reference number of the pension file for the person who applied for or had established the right to a pension from the Polish social security system; for person applying for Polish pension for the first time, state PESEL and NIP or NKP number (NKP number — if the person concerned is subject to social insurance for farmers), if there is no such number state the series and number of identity card or passport; to a Portuguese institution, indicate the registration number with the general insurance scheme, and if it is the case, 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, reference number of the file if known, if this number is known, the number under note 16 is omitted; to a Swiss institution, state the AVS/AI (AHV/IV) insurance number.

(3) Street, number, post code, town, country, telephone number. (4) For the purpose of Norwegian institutions, complete also form E 202/additional page 3. For the purpose of Swiss institutions, complete also form E 202/additional page 4. For the purpose of Polish Institutions, complete also form E 202 additional page 5, in the case of Poland, the term ‘ insured person ’ also refers to persons that are subject to special schemes. For the purpose of Czech Institutions also complete E 202 Additional page 6. For the purpose of Lithuanian institutions, don’t complete part B of the form but complete E 202 Additional page 7.

For the purpose of Latvian institutions, do not complete part B of the form E 202, but complete form E 202/additional page 9. (5) For surname please state usual surname or surname acquired by marriage. The ‘ surname at birth ’ must always be given; if same as current surname, put ‘ IDEM ’ . Expressions such as ‘ called … ’ or ‘ alias … ’ and prefixes to surnames must be written in full in the order in which they appear on the birth certificate. If the form is being completed by a Netherlands institution, in cases where the insured person or the rightful claimant is a married woman or a woman who was married before, put the present or last husband’s surname for current surname and the maiden name for surname at birth.

In the case of Spanish nationals state both names at birth. In the case of Portuguese nationals state all names (forenames, surname, maiden name) in the order of civil status in which they appear on the identity card or passport. (6) Give all forenames in the order in which they appear on the birth certificate. (7) To be stated particularly in the case of adoption or in the case of other names in current use; expressions such as ‘ called … ’ or ‘ alias … ’ and prefixes to surnames must be written in full in the order in which they appear on the birth certificate. (8) Put M for male and F for female.

(9) This information is required when the worker is a Spanish national, or when the form is to be sent to a French, Hungarian, Greek or a Polish institution, regardless of the worker’s nationality. (10) Complete where possible if the form is being sent to a German, Belgian, French, Hungarian, Italian, Luxembourgish, Netherlands, Polish, Austrian, Liechtenstein, Finnish or Norwegian institution. If the sending institution does not have this information available, the competent institution should contact the person concerned directly. (11) For the purposes of Belgian, Hungarian, Polish, United Kingdom, Liechtenstein and Finnish institutions, specify also the date beside the corresponding box.

(12) For the purposes of Netherlands, Finnish, Hungarian, Icelandic and Norwegian institutions, this information is based on a statement from the person concerned. Under the Netherlands General Law on Old-Age Insurance the following persons are also regarded as ‘ married ’ or ‘ spouse ’ : unmarried persons of the same or different sexes who are living in a joint household on a permanent basis. A joint household means that two unmarried persons are jointly providing for their housing with each contributing to the costs of the household or providing for each other’s upkeep in another way.

Under the Finnish legislation parties to a registered partnership of the same sex are treated as ‘ married ’ . (13) To be completed only if the form is to be forwarded to a Portuguese or Slovene institution. (14) For the purposes of Netherlands institutions complete Sofi number, if known. For the purpose of Belgian institutions complete national social security number (NISS). E 202 (15) Where appropriate, indicate the date of naturalisation. (16) For the purposes of Spanish institutions in the case of Spanish nationals state the number appearing on the national identity card DNI (Documento Nacional de Identidad) or the NIE (Número de Identificación de Extranjeros) in the case of foreign people, for both cases if it exists, even if the identity card is out of date.

Failing this, state ‘ None ’ . For the purposes of Maltese Institutions, in the case of Maltese nationals, state the identity card number, if not a Maltese national, state Maltese social security number. In the case of Slovene nationals, state the personal identification number EMŠO. (17) The day and the month should be shown by two digits each and the year by four digits (example: 1 August 1921 = 01.08.1921). (18) For French towns comprising several arrondissements, please give the number of the arrondissement (example: Paris 14). In the case of Portuguese districts state also the parish and the local authority.

In the case of Netherlands towns state also the name of the municipality. (19) This information is obligatory for insured persons of Spanish, French or Italian nationality. Here, the territorial area or district in which the place of birth is located should be stated (example: in the case of France if the place (commune) of birth is Lille, the department of birth should be shown as ‘ Nord ’ followed by the area code if known to the insured person; in this case: 59. The complete entry should therefore read: ‘ Nord 59 ’ ). In the case of persons born in Spain, state only the province. (20) The symbol of the insured person’s country of birth in accordance with ISO code 3166-1.

(21) If the form is being sent to a German, Polish, Austrian, Liechtenstein, Finnish or Swiss institution, state, if applicable, the address of the legal representative (legal counsellor, guardian, curator …) in the box below. Address (3): … … (22) If the form is being sent to a Danish, Finnish, Icelandic, Latvian, Polish or Norwegian institution, give the claimant’s last address in the corresponding country in the box below. Address (3): … … (22a) In the case of Poland, the term ‘ civil servant ’ refers to persons who are subject to special schemes. (23) For the purposes of Spanish and Slovene institutions.

(24) Complete if the form is being sent to a Belgian, German, Hungarian, Spanish, Irish, Luxembourgish, Polish, Portuguese, Slovak, Austrian or Norwegian institution. (25) Complete if the form is being sent to a Belgian, Czech, Danish, French, Italian, Luxembourgish, Austrian, Icelandic or Norwegian institution (annual amount) or to a Greek, Polish or Portuguese institution (monthly amount). If the form is being sent to an Italian institution, indicate all income except for the following: the claimant’s home, family benefits, cash benefits for accident at work or occupational disease, purely assistance benefits.

(26) Complete if the form is being sent to an Italian or Greek institution. In Italy the following sources are not considered as income: the claimant’s home, family benefits, cash benefits for accident at work or occupational diseases or purely assistance benefits. (27) For the purposes of Liechtenstein institutions indicate also if the insured person applied for or received the pension of the occupational scheme as cash compensation. For the purpose of Maltese institutions indicate if the insured person has applied for, or is receiving an occupational pension from a former employer. Rate of pension should be that as on original award.

Provide the details in point 8.16. (28) For the purposes of Finnish institutions. (29) Complete if the form is being sent to an Italian institution. (30) For the purposes of Liechtenstein institutions. (31) To be completed for Latvian and Netherlands institutions. (32) State the type of income taken into account by the investigating institution in applying its overlapping rules. (33) The Greek, Spanish, French, Austrian and Polish institutions may subsequently request an E 213 form. (33a) For the purposes of Polish institutions in the case of an old-age pension claimed under a special scheme. (34) For the purposes of Portuguese institutions, complete also form E 202/additional page 2.

(35) For the Netherlands institutions a form E 205 for the (former) spouse/partner should be submitted at the same time. (36) Complete also if the form is being sent to an Irish, Austrian or United Kingdom institution. (37) Complete if the form is being sent to a Belgian, Danish, Spanish, French, Italian, Luxembourgish, Netherlands, Austrian, Icelandic or Norwegian institution. For the purposes of Netherlands institutions also add proof. (37a) In the case of Poland, the term ‘ pension under the scheme for civil servants ’ refers to benefits under special schemes. (38) For Spanish, French, Austrian or Liechtenstein institutions, indicate the nature of the risk (invalidity, old age) and the type of entitlement (direct or indirect).

(39) Complete if the form is being sent to a Belgian, Danish, Spanish, French, Irish, Italian, Netherlands, Austrian, United Kingdom, Icelandic or Norwegian institution. E 202 (40) Complete if the form is being sent to a Danish, Spanish, Netherlands, Austrian, Icelandic or Norwegian institution (annual amount), to a French institution (quarterly amount) or to an Italian institution (monthly amount). (41) Indicate with the following symbols which date you are referring to: * birth, °° marriage, † death. (42) Provide details of rates from date of pension award with any subsequent change of rate.

(43) Complete form E 202/additional page No 1 if the form is being sent to an Italian or Norwegian institution. Additional information is also given on additional page No 1 if the institution concerned specially asked for it. (44) Indicate the common address. If any of the children live at a different address, indicate in the box below. Surname and forenames: … Address (3): … … (45) For the purposes of Spanish institutions, state whether the children are economically dependent on the insured person and whether any of the children have a disability. In the latter case, state whether the child receives an invalidity pension in his or her own right.

(46) Indicate whether the child is married, an invalid, deceased (date of death), an apprentice or a student. For the purposes of a Liechtenstein or a Swiss institution, a copy of the indentures of apprenticeship or a certificate of the training centre should be attached for each child being a student or apprentice between the age of 18 and 25. For the purpose of Cypriot institutions a copy of a certificate of full time education should be attached for each child being a student between the ages of 16 and 23 in the case of a female and the ages 16 and 25 in the case of a male. (47) Complete if the form is being sent to an Italian or Greek institution.

(48) If form E 202 is to be sent to a Liechtenstein institution, add form(s) E 207 for the insured person and, if applicable, for the (actual and former) spouse(s) of the insured person. (49) For the purposes of Hungarian institutions, verify whether the claimant, younger than 62, brought up children named in the item 12.1 at least 10 years in own household. E 202 additional page 1 ITEM 12 ‘ CHILDREN ’ ADDITIONAL INFORMATION (complete a separate page for each child) 1. The child named in line No … of item 12.1 pursues gainful employment does not pursue gainful employment Amount of income (1) per:

1.1 If the answer is in the affirmative, please state: Type of occupation (employed or self-employed): … week month year 2. The child named in line No … of item 12.1 has other sources of income does not have any other sources of income 2.1 If the answer is in the affirmative, please specify: nature of income: social security benefits: amount per: week month year other income (2): amount per: week month year 3. In respect of the child named in line No … of item 12.1 the following person (name, forename): … (address): … … is entitled to family benefits or allowances by virtue of his/her pursuit of a professional activity or trade (Article 79(3) of Regulation (EEC) No 1408/71) amount: … commencing on: … 3.1 The following institutions are responsible for paying these family benefits or allowances:

(name): … (address): … … (name): … (address): … … 4. The child named in line No … of item 12.1 is unfit for work. Form E 404 is enclosed. (1) All income should be declared with the exception of severance payments, family benefits, wage arrears, life annuities for accidents at workor occupational disease, war pensions, pensions for disablement sustained during military service, attendance allowance, travel allowance. (2) ‘ Other income ’ means income from real estate or capital (bank or postal deposits or current accounts, government stock, investment funds, shares, bonds, etc.).

E 202 additional page 2 PT ITEM 10.2 ADDITIONAL INFORMATION FOR THE PURPOSES OF PORTUGUESE INSTITUTIONS To be completed where the claimant has declared that he/she needs the assistance of another person to perform the ordinary activities ofeveryday life. 1. Identification of the person providing assistance 1.1 Name: … Forenames: … 1.2 Address (street, number, post code, district county): … … 2. Information provided by investigating institution 2.1 We have ascertained that the person referred to above is the other person who actually assists the claimant in performing the ordinary activities of everyday life (personal hygiene, feeding, movement, etc.).

2.2 Assistance provided by the other person referred to above has not been ascertained. 3. Has the need for assistance been caused by a third party? Yes No 4. Is the person concerned in receipt of an allowance for assistance by a third party or a similar benefit? Yes No 4.1 Name and address of paying institution: … 4.2 Monthly amount: … E 202 additional page 3 NO ADDITIONAL INFORMATION FOR THE PURPOSES OF NORWEGIAN INSTITUTIONS 1. The claimant Has applied for Is receiving Basic benefit covering extra expenses due to permanent illness Assistance benefit 2. The spouse has applied for a pension as a non-working person is receiving a pension as a non-working person is not receiving a pension as a non-working person 3.

Children Are all of the children supported by the claimant? Yes No If ‘ No ’ , state the name of the child (children) and the amount of the child’s income per year … … If the parents are married: do all the children live with both parents? Yes No If ‘ No ’ state which child (children): If the parents are not married: do all the children live with both parents? Yes No If ‘ Yes ’ , give information about the other parent: name: … date of birth: … income per year (all kinds. Specify): … name of the child (children) if not all children are concerned: … … 4. Cohabiting partner Has the claimant previously been married to the cohabiting partner? Yes No Does the claimant have or has he/she had children by the cohabiting partner? Yes No E 202 additional page 4 CH ADDITIONAL INFORMATION FOR THE PURPOSES OF SWISS INSTITUTIONS 1.

Information concerning the insured person Surname (point 2.1): … Forenames (point 2.3): … Date of birth (point 4.1): … 2. If the insured person is a Swiss national, please indicate the place of origin: … and the date of acquisition of the Swiss nationality: … 3. Information concerning residence in Switzerland of the insured person Place: from (month/year): to (month/year): Type of residence permit: Please attach copies of certificates of residence or residence permits. 4. To be completed if the insured person is or has been married 1st marriage: 2nd marriage: 3rd marriage: 4.1 Marriage celebrated on:

4.2 Dissolved by divorce on: 4.3 Information concerning the spouse, ex-spouse or deceased spouse Surname and forenames: Surname at birth: Date of birth: Date of death: 5. Information concerning residence in Switzerland of the spouse, any ex-spouses or deceased spouses during marriage Surname and forenames: Place of residence: from (month/year): to (month/year): Type of residence permit: Please attach copies of certificates of residence or residence permits. E 202 additional page 4 CH (continued) 6. To be completed for children of separated or divorced parents Surname: Forenames: Date of birth: Custody to: the father the mother joint other person the father the mother joint other person the father the mother joint other person the father the mother joint other person the father the mother joint other person 7.

Does the insured person wish to bring forward entitlement to the pension? yes no If yes, by how much? 1 year 2 years 8. Does the insured person wish to delay the payment of the pension? yes no E 202 additional page 5 PL ADDITIONAL INFORMATION FOR THE PURPOSES OF POLISH INSTITUTIONS To be completed by the claimant and added to the E 202 form 1. Personal details of the claimant 1.1 Surname: … 1.2 Surname at birth: … 1.3 Forename(s): … 1.4 Date of birth: … 1.5 NIP No: … 2. In order to establish the amount of old-age pension under national social insurance scheme, the claimant applies for the following to be accepted as benefit assessment basis:

Average basis of contribution assessment for social insurance or old-age and disability insurance according to Polish regulations, in the period of 10 subsequent calendar years, selected from the past 20 calendar years, immediately preceding the year in which the claim was submitted, i.e. from … until … (*). Average basis of contribution assessment for social insurance or old-age and disability insurance according to Polish regulations, in the period of 20 calendar years prior to the year of claim submission, selected from the whole period of insurance (*). Average basis of contribution assessment for social insurance or old-age and disability insurance according to Polish regulations, in the period of 10 subsequent calendar years immediately preceding the year in which the insurance started abroad for the first time, if there had not been an insurance in Poland during 20 calendar years, immediately preceding the year in which the claim was submitted.

Assessment basis of old-age pension or pension due to incapacity for work being received earlier. Assessment basis of old-age pension accepted for the establishing pre-pension benefit. 3. Was the claimant receiving sickness benefit or rehabilitation benefit or payment for the period of incapacity for work from social insurance when the claim was submitted? Yes No if ‘ Yes ’ , please indicate the expiry date of benefits received: … 4. Is the claimant still working? Yes No if ‘ Yes ’ , please indicate the date when he/she will stop working: … 5. In order to establish the amount of old-age pension from social insurance for farmers, indicate whether the claimant (his/her spouse) is an owner (co-owner) or a holder of a farm.

Yes No if ‘ Yes ’ , please indicate the area of the farm (in hectares): … 6. In order to investigate the claim for policemen’s pension, the claimant should indicate the name of the unit where he/ she was on duty before exemption, type of duty and the date of exemption: 7. In order to re-assess the amount of policemen’s pension due to the fact that the claimant started to work again for the Police, Internal Security Agency, Intelligence Agency, Border Guard, Government Security Bureau, National Fire Brigades or Prison Guard and worked there permanently for the period of at least 12 months, the claimant applies for: leaving the current assessment basis of old-age pension accepting the remuneration of the last position held (from the month of duty’s exemption) as the assessment basis of old-age pension.

E 202 additional page 5 PL (continued) 8. In order to investigate the claim for policemen’s pension, the claimant declares that he/she: receives, for period … does not receive remuneration or similar benefit in cash after duty’s exemption. receives does not receive Polish pension, pension for retired judge or prosecutor, survivor’s pension from retired judge or prosecutor, pre-retirement benefit, cash benefit financed by Unemployment Fund. If he/she ‘ receives ’ , please indicate the benefit number, date since this benefit has been paying and the name of paying institution: … is is not a member of an open pension fund.

9. In order to receive the military pension, the claimant should indicate the name of the unit where the former professional soldier was on the Army supply until the day of exemption from the professional military service and to indicate the date of exemption: The claimant declares that he/she will receive similar remuneration or similar benefit in cash after exemption from duty: Yes No If ‘ Yes ’ — please indicate for what period: … (from — until/day, month, year) Date Signature of the claimant (*) In the case of persons employed, the certificate with the data about the assessment basis for social insurance contribution or for the old-age and disability insurance or the certificate of salary issued by employer or successor to the rights, and insurance card with the amount of the salary received should be enclosed.

Originals of the abovementioned documents or copies certified by foreign insurance institution, notary public or RP consul, are to be shown. In the case of self-employed persons, bank account number of the contribution payer is required or if the business activity was performed before social insurance was obligatory, a certificate of professional and social organisation (e.g. Guild of Crafts) is required. E 202 Additional page 6 CZ ADDITIONAL INFORMATION FOR THE PURPOSES OF CZECH INSTITUTIONS For the purposes of Czech institutions, complete the following table for children named in the item 12.1:

Forename and surname of the child Day, month and year of birth of the child Father’s forename and surname Mother’s forename and surname Period of personal care of the child, from to If the child is/was in custody of a different person or institution (indicate where and from to) E 202 additional page 7 LT ADDITIONAL INFORMATION FOR THE PURPOSES OF LITHUANIAN INSTITUTIONS 1. Lithuanian state social insurance certificate serial number and number 2. The claimant was on military service in Lithuania or former USSR: Yes No If ‘ Yes ’ , indicate if he served as a conscript or as a reenlistee 3.

The time of nursing/caring at home in Lithuania (filled in, if engaged in nursing before 1 January 1995): 3.1 for mothers — the time of caring for and nursing a disabled child under the age of 16 Yes No 3.2 for family members — the time of nursing the disabled of Group 1 Yes No 4. The claimant was: 4.1 political prisoner Yes No 4.2 deportee Yes No 4.3 resistant Yes No 4.4 deported for forced works beyond former USSR border Yes No 4.5 in ghettos, concentration camps and other types of places of forced confinement during the World War II Yes No E 202 additional page 8 BE ADDITIONAL INFORMATION FOR THE PURPOSES OF BELGIAN INSTITUTIONS 1.

Did the applicant study in Belgium in or after the year of his/her 20th birthday? Yes No If ‘ YES ’ , study period: from … … 2. To be completed by persons who have been married more than once: 1st marriage : celebrated: … date of separation (*): … dissolved: date of divorce: … date of spouse’s death: … spouse: Surname, forename: … date of birth: … nationality: … 2nd marriage : celebrated: … date of separation (*): … dissolved: date of divorce: … date of spouse’s death: … spouse: Surname, forename: … date of birth: … nationality: … 3nd marriage : celebrated: … date of separation (*): … dissolved: date of divorce: … date of spouse’s death: … spouse:

Surname, forename: … date of birth: … nationality: … 3. To be completed by persons who are currently widowed or divorced: 1st marriage: was the former spouse or deceased spouse gainfully employed in Belgium? Yes No If ‘ Yes ’ , under which scheme? self-employed employed public authorities 2nd marriage: was the former spouse or deceased spouse gainfully employed in Belgium? Yes No If ‘ Yes ’ , under which scheme? self-employed employed public authorities 3rd marriage: was the former spouse or deceased spouse gainfully employed in Belgium? Yes No If ‘ Yes ’ , under which scheme? self-employed employed public authorities (*) The date of separation is the date from which the spouses are no longer officially resident at the same address.

E 202 additional page 9 LV ADDITIONAL INFORMATION FOR THE PURPOSES OF LATVIAN INSTITUTIONS 1. The insured person belongs to one of the following categories: Permanently disabled (indicate length of period of disability …) Person of restricted growth Person who has been employed under working conditions recognised as dangerous and of arduous nature Person who participated in the rectification of the consequences of the accident at the Chernobyl Atomic Power Plant or who has been evacuated from respective territories affected by radiation Politically prosecuted Student before 1991 Person has taken care of a group I invalid or a child who has been recognised as invalid from childhood — up to age of 16, or a person aged over 80 before 1991 2.

In case the insured person was in military service in Latvia or the former USSR before 1996, indicate 2.1 the period: … 2.2 if he served as a conscript or as a reenlistee 3. Information concerning the insured person`s children in case the person has brought up five or more children or a child who has been recognised as invalid from childhood — up to age of eight years Children: Surname Forenames Date of birth Period of care Remarks (*) 1. 2. 3. 4. 5. (*) Indicate whether the child is an invalid or deceased (date of death) or if the child was in custody of another person or in institutional care.

THE ADMINISTRATIVE COMMISSION ON SOCIAL SECURITY FOR MIGRANT WORKERS See ‘ Instructions ’ on pages 8, 9, 10 and 11 E 203 (1) Country: Identification No (2) (13) Institution concerned (where applicable, liaison body) (1) (2) (3) (4) (5) INVESTIGATION OF A CLAIM FOR A SURVIVOR’S PENSION Regulation (EEC) No 1408/71: Articles 44 to 51a; Articles 78, 78a, 79 and 79a Regulation (EEC) No 574/72: Articles 36 to 38; Articles 41 to 43; Articles 45 to 47; Article 49; Article 90 (*); Article 111 The investigating institution should complete the form and send one copy to each of the institutions with which the worker has been insured (institutions concerned) or to the liaison body.

1. Institution to which the form is addressed (institution concerned or liaison body, as applicable) 1.1 Name: … … 1.2 Address (3): … … A. Information concerning the deceased insured person (3a) 2. 2.1 Surname (4): … 2.2 Surname at birth (4): … 2.3 Forenames (5): … 2.4 Previous names (6): … 2.5 Sex (7): … 2.6 Father’s surname and forenames (8): … 2.7 Mother’s surname and forenames at birth (8): … 2.8 Civil status: single divorced (9) separated since: … (10) since: … (10) married remarried (9) widow or widower since: … (10) since: … (10) since: … (10) cohabiting since: … (11) Did the cohabitors live together at the time of death? (60) 3.

Nationality (12) (13): … (*) Article 90 of Regulation (EEC) No 574/72 is not applicable in the Netherlands. E 203 4. Details of birth: 4.1 Date of birth (14): … 4.2 Place of birth (15): … 4.3 Province, department county (16): … 4.4 Country (17): … 5. Last address of the deceased insured person (3) (18) … … 6. 6.1 Insurance No at the registering institution: … 6.2 Reference No of the file at the investigating institution: … 7. On the date of death, the insured person was still pursuing gainful employment (18a). no longer pursued gainful employment (18a). 8. 8.1 Date and place of death: … 8.2 Death (19) is assumed is not assumed to have been the result of an accident at work (20) or of an occupational disease.

8.3 Death (21) is assumed is not assumed to have been caused by a third party. to have been caused by the claimant (60). 8.4 Death (22) is assumed is not assumed to have been the result of a road accident (compulsory motor liability insurance) (22). 8.5 In the case of a missing person: date last heard of (22a): … date of death officially presumed (23) (24): … 9. 9.1 At the date of his/her marriage, the insured person (25) was was not receiving a pension under the scheme for employed persons self-employed persons civil servant (25a) 9.2 At the time of his/her death, the insured person was was not receiving a pension under the scheme for employed persons self-employed persons civil servant (25a) all residents 9.3 At the time of death, the deceased (employed person) was was not insured under legislation for survivor’s insurance (26).

Where appropriate, indicate 9.4 Type of pension: … E 203 9.6 Institution responsible for paying the pension: … 9.8 Date when pension ceased, where applicable: … 9.9 The benefit referred to in 9.4 is based on (26): 9.5 Pension No: … 9.7 Date from which the pension was due: … the claimant’s own insurance periods, see E 205. insurance periods completed by the (former) spouse, see E 205. 10. The deceased insured person : had requested had not requested deferment of the calculation of an old-age pension to which he/she would have been entitled. (Where appropriate, indicate the country: … ) 10.1 The deceased insured person The spouse had requested had obtained refund of contributions. transfer of contributions. lump-sum payment of the deceased person’s insurance.

B. Information concerning the claimants (29) 11. Widow Widower Other claimants, excluding children (27) (28) 11.1 Surname (4) (61): … 11.2 Forenames: : Previous names: … Place of birth (15): … 11.3 Date of birth: … Nationality (2) (12) (13): … 11.4 Address (3) (30): … … 11.5 Bank particulars or address for direct payment: … Name of the beneficiary as recognised by the bank: … Name of the bank: … Address of the bank: … Bank identification code (BIC/SWIFT): … International bank account (IBAN): … 11.6 Taxpayer’s number (31): Code of tax district: Insurance No (2) (32): … E 203 11.7 Date of marriage with the deceased insured person: … 11.8 Did the claimant live in the same household as the spouse or partner? Yes, No, since: … since: … 11.9 Do the spouses have, or have they had, a child in common (either natural or adopted children) (33)? Yes No 11.10 Where applicable, date of separation from bed and board (34): … Divorce: … 11.11 Where applicable, date of remarriage: … 11.12 Surnames and forenames of other spouse(s) (35): … 11.13 Is the widow/widower living together with another person as husband and wife (11)? Yes No not known 11.14 Relationship and civil status (for claimants other than the widow or widower):

12. The person named in box 11 12.1a is engaged in is not engaged in gainful employment. 12.1b is engaged in is not engaged in an activity covered under a special scheme for civil servants (35a). 12.2 is self-employed is not self-employed. 12.3 states that he/she has no income (36). 12.4 Where appropriate, state amount of annual income (37) … in … 12.5 The person named in box 11 12.6 was was not a dependent of the deceased insured person (38). 12.7 is is not permanently unfit for work. temporarily unfit for work, namely for more than three months (39). 12.8 needs (40) does not need someone in constant attendance (41).

12.9 The person named in box 11 has applied for Basic benefit covering extra expenses due to permanent illness Assistance benefit Educational training benefit for widows/widowers Benefit covering expenses for care of children due to the widow’s/widower’s work or education E 203 receives a pension from … to … does not receive a pension. may qualify for a (survivor’s) pension. 12.11 Type of pension (42): … 12.12 Pension No: … 12.13 Amount on date of claim: … 12.14 Institution responsible for payment of pension: … 12.16 The widow/widower (44) is raising a child is not raising a child Yes No 12.17 Institution responsible for payment thereof: … 12.18 If the person named in box 11 is pregnant, give the expected date of confinement: … 12.19 The person named in box 11 is entitled to sickness benefits in kind under the legislation administered by the investigating institution Yes No Not yet determined 12.15 The person named in box 11 (43) 12.10 The person named in box 11 is entitled to a survivor’s pension under accident at work or occupational disease insurance from the following institution:

Name of i nstitution: … Pension No: … for whom he/she receives a family allowance or an orphan’s pension: 13. 13.1 Other resources of the widow/widower (45) none 13.2 Other Nature :… Amount: (46): … in … Nature:… Amount (46): … in … E 203 14. Additional information permitting the implementation of provisions concerning overlapping 14.1 When benefits of the same kind are granted by the institution or institutions concerned, the pension calculated by the investigating institution may be reduced Yes No Not yet determined 14.2 The pension calculated by the investigating institution may be reduced Yes No Not yet determined because one or several of the benefits specified at point 12 are taken into account 12 … 12 … 12 … 12 … because of income other than the benefits specified at point 12 income from employment/self-employment other … (47) 14.3 The institution concerned is requested to specify the part of the pension accruing from voluntary contribution payments (point 6.7 in form E 210) Yes No 14.4 The benefit due from the investigating institution is (partly or entirely) based on voluntary contributions Yes No 15.

Children (13) (48) (49) 15.1 Surname (4): Forenames: Nationality: Place and date of birth, marriage or death (50): Relationship (i.e.: own child, adopted child, foster child) (51): 1. 2. 3. 4. 5. 15.2 The following institution is competent to grant benefits pursuant to Article 78 of Regulation (EEC) No 1408/71: the investigating institution the institution designated as follows: … 15.3 The investigating institution in respect of the children referred to in lines No … of item 15.1, is granting benefits until … inclusive Amount of orphan’s pension and family allowances per child … (52) is not granting benefits in respect of the children referred to in lines No ……of item 15.1 (53) has not yet taken a decision concerning entitlement to benefits 15.4 Address (3) (54): … … 15.5 Remarks (55) (56) (57) (57a): … … E 203 C.

Miscellaneous information 16. Date of submission of this claim: … Date from which the pension is payable in the country of the investigating institution: … The claimant has asked for payment (58) directly in the State of residence to a representative in the State of origin. Additional information for the purposes of Finnish institutions: the claimant wishes to have the decision in Finnish Swedish 17. The investigating institution pays does not pay benefits on a provisional basis under Article 45(1) of Regulation (EEC) No 574/72. 17.1 If not, the institutions concerned are requested to investigate the possibility of paying benefits on a provisional basis under Article 45(2) of Regulation (EEC) No 574/72.

18. There are grounds There are no grounds for making deductions to compensate for overpayment in accordance with Article 111 of Regulation (EEC) No 574/72. 18.1 Any pension arrears may may not be paid direct to the beneficiary. 19. 19.1 Attached forms: E 205 E 207 (59) E 213 19.2 Please send us your: E 205 E 210 Decision Arrears E 213 Remarks: … … 20. Investigating institution 20.1 Name: … … 20.2 Address (3): … … 20.3 Stamp 20.4 Date: … 20.5 Signature: E 203 INSTRUCTIONS Please complete this form in block letters or typewriting, writing on the dotted lines only It consists of 11 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. (2) 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 Liechtenstein institution, indicate the AHV insurance number; to a Lithuanian institution, state the personal identification number; to a Latvian institution state the identity 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 identification number (fødselsnummer); 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) and to an institution of the social security scheme for civil servants, indicate the personal identification number (PRS-Kenn-Nr); to an Austrian institution, state the Austrian insurance number (VSNR); to a Polish institution, state the reference number of the pension file for the person who applied for or had established the right to a pension from the Polish social security system, for a person applying for Polish pension for the first time, state PESEL and NIP or NKP number (NKP number — if the person concerned is subject to social insurance for farmers), if there is no such number state the series and number of identity card or passport; to a Portuguese institution, indicate the registration number with the general insurance scheme, and if it is the case, 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, reference number of the file if known, if this number is known, the number under Note 13 is omitted: to a Swiss institution, state the AVS/AI (AHV/IV) insurance number.

(3) Street, number, post code, town, country, telephone number. (3a) For Germany and Austria the term ‘ insured persons ’ encompasses individuals insured under the general social security scheme as well as civil servants and individuals treated as such who are insured under a special scheme. The term ‘ pension ’ is considered to encompass pensions for civil servants. In the case of Poland, the term ‘ persons insured ’ also refers to the persons who are subject to special schemes. (4) For surname please state usual surname or surname acquired by marriage. The ‘ surname at birth ’ must always be given; if same as current surname, put ‘ IDEM ’ .

Expressions such as ‘ called … ’ or ‘ alias … ’ and prefixes to surnames must be written in full in the order in which they appear on the birth certificate. If the form is being completed by a Netherlands institution, in cases where the insured person or the rightful claimant is a married woman or a woman who was married before, put the present or last husband’s surname for current surname and the maiden name for surname at birth. In the case of Spanish nationals state both names at birth. In the case of Portuguese nationals state all names (forenames, surname, maiden name) in the order of civil status in which they appear on the identity card or passport.

(5) Give all forenames in the order in which they appear on the birth certificate. (6) To be stated particularly in the case of adoption or in the case of other names in current use; expressions such as ‘ called ’ and ‘ alias ’ and prefixes to surnames must be written in full in the order in which they appear on the birth certificate. (7) Put M for male and F for female. (8) This information is required where the worker is a Spanish national, or when the form is to be sent to a French, Greek or Hungarian institution, regardless of the worker’s nationality. For the purpose of Polish institutions in the case of investigation of a claim for survivor’s pension under a special scheme.

(9) Complete where possible if the form is being sent to a German, Belgian, French, Hungarian, Italian, Lithuanian, Luxembourgish, Netherlands, Polish, Slovak, Austrian, Portuguese, Swedish, Liechtenstein, Finnish or Norwegian institution. (10) For the purposes of Belgian, Hungarian, Lithuanian, Polish, Slovak, the Netherlands, Swedish, United Kingdom, Finnish and Liechtenstein institutions, specify also the date beside the corresponding box. (11) This information is based on a statement from the person concerned. For the purposes of Norwegian institutions, complete also additional page No 5. For the Netherlands, it should be noted that under the General Surviving Dependents’ Insurance Act (Algemene Nabestaandenwet), the following persons are also regarded as married or spouses: single persons of the same or different sex permanently sharing a household, unless they are blood relations of first degree.

A shared household means that two persons together provide for their home, and that each contributes towards the household costs or makes other provision for their subsistence costs. For Lithuania tick if the claimant is de jure spouse. Under the Finnish legislation parties to a registered partnership of the same sex are treated as ‘ married ’ .This information should also be provided to Hungarian institutions. (12) Where appropriate, indicate the date of naturalisation. (13) For the purposes of Spanish institutions in the case of Spanish nationals state the number appearing on the national identity card DNI (Documento Nacional de Identidad) or the NIE (Número de Identificación de Extranjeros) in the case of foreign people, for both cases if it exists, even if the identity card is out of date.

Failing this, state ‘ None ’ For the purposes of Maltese Institutions, in the case of Maltese nationals, state the identity card number, if not a Maltese national, state Maltese social security number. In the case of Slovene nationals, state the personal identification number EMŠO. If the form is sent to a Norwegian institution indicate in point 11.3 the population register number. (14) The day and the month should be shown by two digits each and the year by four digits (example: 1 August 1921 = 01.08.1921). (15) For French towns comprising several arrondissements, please give the number of the arrondissement (example:

Paris 14). In the case of Portuguese districts, state also the parish and the local authority. In the case of Netherlands towns, state also the name of the municipality. E 203 (16) Must be stated for insured persons of Spanish, French or Italian nationality. Here, the territorial area or district in which the place of birth is located should be stated (example: in the case of France if the place (commune) of birth is Lille, the department of birth should be shown as ‘ Nord ’ followed by the area code, if known to the insured person; in this case: ‘ 59 ’ . The complete entry should therefore read: ‘ Nord 59 ’ ).

In the case of persons born in Spain, state only the province. (17) Symbol of the insured person’s country of birth in accordance with the ISO code 3166-1. (18) If the form is being sent to a Danish, Finnish, Icelandic, Latvian, Polish or Norwegian institution, give the deceased person’s last address in the corresponding country in the box below. Address (3): … … (18a) In the case of Poland, the term ‘ gainful employment ’ also refers to service of persons who are subject to special schemes. (19) Complete if the form is being sent to a Belgian, Cypriot, German, Greek, Polish, Slovak, Spanish, Irish, Italian, Luxembourgish, Austrian, Portuguese, United Kingdom, Finnish, Icelandic or Norwegian institution.

(20) For the purposes of Belgian, Cypriot, Luxembourgish and Swiss institutions, mark the first box for any accident, irrespective of its nature. (21) Complete if the form is being sent to a Czech, Slovak, Swiss, German, Greek, Spanish, Luxembourgish, Austrian, Portuguese or Liechtenstein institution. (22) Complete if the form is being sent to a Finnish institution. (22a) For the purposes of Polish institutions, in the case of investigation of a claim for survivor’s pension payable to the survivor of a missing police officer or soldier. Please enclose a document confirming the disappearance. (23) If the form is being sent to a Greek, French, Finnish or Swedish institution, complete indicating the declared date of the disappearance to the police.

If the form is sent to a Latvian, or Lithuanian institution, indicate the date of the Court’s decision on recognition of a person being a missing person. (24) For the purposes of Spanish, Finnish, Swedish or Liechtenstein institutions, state also the circumstances of the disappearance. (25) Complete if the form is being sent to a Greek, French, Hungarian, Luxembourg or Austrian institution. (25a) In the case of Poland, the term ‘ pension under the scheme for civil servants ’ refers to benefits under special schemes. (26) This information is required by Hungarian and Dutch institutions. (27) If there are several persons to be entered in box 11, please insert on one or more additional copies of page 3, as boxes 11 and 12 must be completed for each person separately.

Please note that in the Netherlands, widows, divorced or separated women may be entitled to a widow’s pension if they are younger than 65 years of age. Widows, divorced or separated women who are older than 65 years of age are entitled to an old-age pension. In these cases, an E 202 form must be drawn up in the name of the woman concerned. In Portugal, the survivor’s pension is payable to relatives of the deceased in the ascending order if they were dependants of the deceased and where there are no other members of the family (spouse, ex-spouse and relatives in the descending order) who are entitled to receive the benefits.

In Liechtenstein, the widow and the divorced or separated wife may be entitled to a widow’s pension, if they are less than 62 years of age. This entitlement is terminated by remarriage. The widow, the divorced or separated wives beyond the age of 62 may have a claim to an old-age pension. In this case, a form E 202 has to be completed on behalf of the woman. In Norway, both separated and divorced spouses may be entitled to a survivor’s pension. In Slovenia, claimants to a survivor’s/widow’s pension are parents and adoptive parents of the insured person (if they were dependants of the deceased), brothers and sisters (if dependant on the deceased person until his/her death and do not have their own means of subsistence) and a divorced spouse (if he/she enjoyed the maintenance until the death of the insured person);

In Estonia, the range of entitled persons for survivors’ pension is wider: parent, brother, sister, divorced spouse, a parent or guardian of a provider’s child, step-children or foster-children, step-parent or foster-parent. In Latvia the range of entitled persons includes children, dependant stepchildren, brothers, sisters or grandchildren. In Poland the right to a survivor’s pension have also both separated and divorced spouses, if they had the right to receive alimony by Court order or agreement in Court, also parents (including stepfather, stepmother). (28) For the purposes of Italian institutions, complete also additional page 1.

For the purposes of Swedish institutions, complete also additional page 6. For the purposes of Lithuanian institutions complete also E 203/additional page 7. For the purposes of Swiss institutions also fill in form E 203/additional page 10; For the purposes of Polish institutions, complete also additional page 11. For the purposes of Finnish institutions, complete also additional page 13. (29) If the form is being sent to a German, Austrian, Polish, Latvian, Liechtenstein, Finnish or Swiss institution, state — if applicable — the address of the legal representative (legal counsellor, guardian, curator, …) in the box below.

Address (3): … … (30) If the form is being sent to a Czech, Danish, Finnish, Icelandic, Latvian or Norwegian institution, give the claimant’s last address in the corresponding country in the box below. Address (3): … … (31) To be completed only if the form is to be forwarded to a Portuguese or Slovene institution. (32) For the purposes of Netherlands institutions complete Sofi number, if known. For the purposes of Belgian institutions complete national social security number (NISS). (33) Complete if the form is being sent to Finnish or Swedish institutions. (34) For the purposes of Spanish or Swedish institutions, state whether the separation is a de facto or de jure.

(35) For the purposes of a Liechtenstein or Swiss institution, state also the date of birth of the spouse. (35a) In the case of Poland, the term ‘ activity under a special scheme for civil servants ’ refers to the service of persons who are subject to special schemes. (36) Complete if the form is being sent to an Italian, Polish, Netherlands or Greek institution. In Italy the following sources are not considered as income: the claimant’s home, family benefits, cash benefits for accident at work or occupational diseases or purely assistance benefits. E 203 (37) Complete if the form is being sent to a Belgian, Danish, Portuguese, Spanish, French, Italian, Luxembourgish, Netherlands, Finnish, Swedish, Icelandic or Norwegian institution.

If the form is being sent to an Italian institution, indicate all income except for the following: the claimant’s home, family benefits, cash benefits for accident at work or occupational disease or purely assistance benefits. (38) Complete if the form is being sent to a German, Greek, French, Italian, Latvian, Luxembourg, Netherlands, Austrian, Portuguese, Slovene, Finnish, Swedish, Icelandic institution. (39) Complete if the form is being sent to a Belgian, Hungarian, Polish, Netherlands or Swedish institution (add form E 213). (40) For the purposes of Portuguese institutions, complete also additional page 3.

For the purposes of Slovene institutions complete also form E 213. (41) Complete if the form is being sent to a Greek, French, Irish, Netherlands, Austrian or United Kingdom institution. (42) If the form is being sent to a Belgian, Hungarian, Polish, German, Spanish, French, Italian, Netherlands, Austrian, Portuguese or Finnish institution, please specify whether this is a personal or a survivor’s pension. For Maltese institutions provide details of all occupational pensions paid/expected to be paid. Rate of pension should be that as on original award of pension/s. (43) Complete if the form is being sent to a Belgian, German, Luxembourgish, Austrian, Portuguese or Finnish institution.

(44) Complete if the form is being sent to a Belgian, Czech, Hungarian, Polish, Slovak, German, French, Italian, Luxembourgish, Netherlands, Austrian, Finnish, Swedish, Icelandic or Norwegian institution. (45) For the purposes of Finnish institutions, please state income from interest, rent and dividend. (46) Complete if the form is being sent to a Danish, Spanish, Luxembourgish, Netherlands, Austrian, Icelandic or Norwegian institution (annual amount) to a French institution (quarterly amount) or to an Italian institution (monthly amount). (47) State the type of income taken into account by the investigating institution in applying its overlapping rules.

(48) Complete if the form is being sent to a Danish, German, Greek, Hungarian, Spanish, French, Irish, Italian, Luxembourgish, Netherlands, Austrian, Portuguese, Finnish, Swedish, United Kingdom, Icelandic, Liechtenstein, Polish, Slovak, Slovene or Swiss institution. If the form is being sent to a Portuguese institution, please indicate the names of any stepchildren for whom the deceased was required to provide food, and the names of any grandchildren. If the form is being sent to a Latvian or Slovene institution, indicate the names of any stepchildren, grandchildren and other parentless children dependant on the deceased insured person.

For an Italian institution, if the entitled person is an only child, E 203/additional page 2 should also be completed. If the form is being sent to a Spanish institution, E 203/additional page 2 should also be completed. If the form is being sent to a Lithuanian institution complete also E 203/additional page 7. If the form is being sent to a Czech institution, complete also Additional page 8; For the purposes of Swiss Institutions also fill in form E 203/additional page 10. For the purposes of Polish institutions, complete also additional page 11. (49) For Norwegian institutions, state only the children of the deceased.

For Maltese institutions, only provide details of children under 18 years whose parents are both the deceased and the widow/er. (50) Indicate with the following symbols which date you are referring to: * birth, °° marriage, † death. If the form is being sent to a Finnish, Hungarian or Slovak institution, indicate the population register number. (51) If the form is being sent to a Finnish institution, please state whether the child in question is common to the widow/widower and the deceased or whether the child is of either the deceased or of the widow/widower alone. Please state also if the widow/widower is raising the child.

State also nationality in case of adoption. (52) This information should be provided from the date of the parent’s death, showing any subsequent change in rate. (53) Please complete also additional page 2 if the form is being sent to a German, Italian or Polish institution. Please complete additional page 4 if the form is being sent to a Portuguese or Slovak institution. (54) Indicate the common address. If any of the children live at a different address, indicate in the box below. Address (3): … (55) Indicate whether the child is married, an invalid, deceased (date of death), an apprentice or a student. for the purposes of Portuguese institutions, in the case of an invalid child requiring the assistance of another person, complete additional page 3.

For the purposes of a Liechtenstein or Swiss institution, a copy of the indentures of apprenticeship or a certificate of the training centre should be attached for each child being a student or apprentice between the age of 18 and 25; for the purposes of Czech institutions, a copy of a certificate of continuation of studies, apprenticeship and/or vocational training should be attached for each child being a student or apprentice between the ages of 15 and 26; for the purpose of a Slovene institution, a certificate of the training centre or a copy of the indentures of apprenticeship should be attached for each child being a regular student or apprentice between the ages of 15 and 26; for the purpose of a Slovak institution, a certificate of the training centre or school should be attached for each child between the ages of 16 and 26; for the purposes of Polish institution, enclose school certificate referring to each child aged between 16 and 25 who is a pupil or a student, for the purposes of Hungarian institutions, a copy of a certificate of continuation of studies, apprenticeship and/or vocational training should be attached for each child being a student or apprentice between the ages of 16 and 25.

Indicate whether the child is married, an invalid, deceased (date of death), or a student. A copy of a certificate of full time education should be attached for each child being a student between the ages of 16 and 23 in the case of a female and the ages of 16 and 25 in the case of a male for the purposes of Cypriot institutions. (56) For the purposes of Hungarian, Slovak, Spanish and Norwegian institutions, state whether the children are economically dependent on the insured person and whether any of the children have a disability. In the latter case, state whether the child receives any invalidity pension in his or her own right.

For the purposes of Finnish institutions, state whether the child/children lived in the same household as the insured person. If not, state the date since not anymore. (57) For the purposes of Hungarian, Portuguese or Norwegian institutions, if one of the children has a legal representative other than the person representing the other children, indicate this in the box below: For the purposes of Finnish institutions, indicate in the box below the name, date of birth and address of the legal representative of the child/children. Child: Surname: … Forename: … Legal representative: Surname: … Forenames: … Address (3): … … E 203 (57a) For the purposes of Latvian institutions indicate if the other parent of the child is also deceased:

Yes No If the answer is ‘ yes ’ , please indicate following information: Surname: … Forenames: … Previous surnames: … Sex: … Identity No: … Nationality: … Date of birth: … Date of death: … (58) To be completed for Italian and Greek institutions. (59) If the form is to be sent to a Liechtenstein institution, add form E 207 concerning the insured deceased person and concerning the (last and any former) spouse(s) of the insured person. (60) The information is required when the form is being sent to Cypriot, Hungarian and Finnish institutions. (61) For the purposes of Hungarian institutions also state the surname and forenames at birth of the claimant’s mother:

Mother of claimant: Surname: … Forename: … E 203 additional page 1 IT IITEM 11 ‘ RIGHTFUL CLAIMANTS OTHER THAN CHILDREN ’ ADDITIONAL INFORMATION FOR ITALIAN INSTITUTIONS To be completed if the pension is claimed abroad by the sole surviving parent, an unmarried brother or an unmarried sister of the deceased worker. 1. If the claimant is the sole surviving parent, please state whether the deceased worker is survived by spouse: Yes No children: Yes No 2. If the claimant is a brother or sister of the deceased worker, please state whether the latter is survived by spouse: No children: Yes Yes No parents Yes No E 203 additional page 2 ITEM 15 ‘ CHILDREN ’ ADDITIONAL INFORMATION (Complete a separate page for each child) 1.

The child named in line No … of item 15.1 pursues gainful employment. does not pursue gainful employment. 1.1 If the answer is in the affirmative, please state: Type of occupation (employed or self-employed): Amount of income (1) per week month year 2. The child named in line No … of item 15.1 has other sources of income does not have any other sources of income 2.1 If the answer is in the affirmative, please specify: Nature of income: Social security benefits: Amount per week month year Other income (2): Amount per week month year 3. In respect of the child named in line No … of item 15.1, the following person:

(surname, forenames): … (address): … is entitled to family benefits or allowances by virtue of his/her pursuit of a professional activity or trade (Article 79(3) of Regulation (EEC) No 1408/71) Amount: … Commencing on: … 3.1 The following institutions are responsible for paying these family benefits or allowances: (Name): … (Address): … … (Name): … (Address): … … 4. The child named in line No … of item 15.1 is unfit for work. Form E 404 is attached. (1) All income should be declared with the exception of severance payments, family benefits, wage arrears, life annuities for accidents at work or occupational disease, war pensions, pensions for disablement sustained during military service, attendance allowance, travel allowance.

(2) ‘ Other income ’ means income from real estate or capital (bank or postal deposits or current accounts, government stock, investment funds, shares, bonds, etc.). E 203 additional page 3 PT ITEM 12 (12.8) ADDITIONAL INFORMATION FOR THE PURPOSES OF THE PORTUGUESE INSTITUTIONS To be completed where the claimant has declared that he/she needs the assistance of another person to perform the ordinary activities of everyday life. 1. Identity of the other person 1.1 Surname: … Forenames: … 1.2 Address (street, number, post code, district, country): … … 2. Information provided by the investigating institution 2.1 We have ascertained that the person referred to above is the other person who actually assists the claimant in performing the ordinary activities of everyday life (personal hygiene, feeding, movement, etc.).

2.2 Assistance provided by the other person referred to above has not been ascertained. 3. Has the need for assistance been caused by a third party? Yes No 4. Is the person concerned in receipt of an allowance for assistance by a third party or a similar benefit? Yes No 4.1 Name and address of the paying institution: … 4.2 Monthly amount: … E 203 additional page 4 PT-SK ITEM 15 ‘ CHILDREN ’ ADDITIONAL INFORMATION FOR THE PURPOSES OF PORTUGUESE AND SLOVAK INSTITUTIONS The descendants shown in box 15.1 are in one of the following situations: 1. Attending school: indicate for each child whether the educational institution in question is at secondary, intermediate or higher education level or whether the course being attended is a first degree course or a postgraduate course:

2. Undergoing vocational training: indicate for each child the level of school education (secondary, intermediate or higher) required to enrol for the course in question and the monthly income received, if any: 3. Actively employed: indicate for each child the monthly income received: 4. Unable to work: indicate for each child if social security benefits are received because the child is unable to work, the nature of the disability and the monthly amount: E 203 additional page 5 NO ADDITIONAL INFORMATION FOR THE PURPOSES OF NORWEGIAN INSTITUTIONS 1. To be completed if the claimant was not married to the deceased at the time of death:

1.1 Was the claimant previously married to the deceased? Yes No 1.2 Does the claimant have or has he/she had children by the deceased? Yes No 2. To be completed if the widow/widower is living with another person as husband and wife: 2.1 Has the claimant been previously married to the cohabiting partner? Yes No 2.2 Does the claimant have or has he/she had children by the cohabiting partner? Yes No E 203 additional page 6 SE ITEM 11 ADDITIONAL INFORMATION FOR THE PURPOSES OF SWEDISH INSTITUTIONS 1. Is the claimant living with a child under 21 years of age for whom a child’s pension/annuity is being requested or received? No Yes 2.

Does the claimant have a child by the deceased? No Yes To be completed if the claimant was married to the deceased at the time of death 3.1 Was the claimant living with the deceased at the time of death? No Yes 3.2 If the answer to 3.1 is ‘ No ’ , was the survivor economically dependent on the deceased? No Yes 4. At the time of death, was the claimant living with a child under 18 years of age of whom the claimant and/or the deceased had custody? No Yes Name of the child: … Swedish personal number/date of birth: … To be completed if the claimant was married to but not living with the deceased 5.

Did the claimant, after having ceased living with the spouse but before his/her death, live with a man/woman to whom the claimant was previously married or by whom the claimant has or has had a child? No Yes To be completed if the claimant was not married to the deceased at the time of death 6. Was the claimant previously married to the deceased? No Yes 7. Does the claimant have, or has he/she had, children by the deceased? No Yes 8. Was the claimant expecting a child by the deceased at the time of death? No Yes Anticipated confinement date (year, month, day): … 9. Please answer question number 4.

E 203 additional page 6 SE (continued) To be completed by women born in 1944 or earlier for assessment of entitlement to a widow’s pension/widow’s annuity in accordance with previous legislation. 10. Was the claimant married to the deceased at any time before 31 December 1989? No Yes 11. Did the claimant have a child by the deceased on or before 31 December 1989? No Yes 12. Was the claimant living with the deceased on 31 December 1989? No Yes 13. What was the marital status of the claimant on 31 December 1989? unmarried married widowed divorced 14. What was the marital status of the deceased on 31 December 1989? unmarried married widowed divorced To be completed if, at the time of death, the claimant was under 50 years of age and/or at the time of death the claimant had not been married to or living with the deceased for at least five years.

15. Is the claimant living with a child under 16 years of age of whom she has custody? No Yes Name of the child: … Swedish personal No/date of birth: … 16. At the time of death, was this child permanently living with the claimant or in the common home of the claimant and the deceased? No Yes 17. If the child is not a child of the claimant, a copy of the court judgment or other document showing who has custody of the child should be enclosed. To be completed by women born in 1945 or subsequently for assessment to widow’s pension/widow’s annuity in accordance with previous legislation. 18.

Please answer questions 11-15. 19. On 31 December 1989 was the claimant living with a child under 16 years of age of whom she had custody? No Yes Name of the child: … Swedish personal No/date of birth: … 20. Was this child permanently living with the claimant or in the common home of the claimant and the deceased on 31 December 1989? No Yes E 203 additional page 6 SE (continued) To be completed if the claimant was married to the deceased on 31 December 1989. 21. Was the claimant living apart from her husband on 31 December 1989? No Yes 22. After ceasing to live with her husband, but before his death, did the claimant live with a man to whom she has been married or by whom she has or has had a child? No Yes 23.

Was the claimant living with a child under 16 years of age of whom she had custody on 31 December 1989? No Yes Name of the child: … Swedish personal No/date of birth: … 24. On 31 December1989 was this child permanently living with the claimant or in the common home of the claimant and the deceased? No Yes To be completed if, at the time of death, the claimant was under 50 years of age and/or at the time of death the claimant had not been married to or living with the deceased for at least five years. Please answer questions number 16 to 18. E 203 additional page 7 LT ADDITIONAL INFORMATION FOR LITHUANIAN INSTITUTIONS Data of the deceased person 1.

Lithuanian personal identification number … 2. Lithuanian State social insurance certificate serial number and number … 3. The deceased person was on military service in Lithuania or former USSR: Yes No If ‘ Yes ’ , indicate if he served as a conscript or as a reenlisted 4. The time of nursing/caring at home in Lithuania (complete, if engaged in nursing before 1 January 1995): 4.1 for mothers — the time of caring for and nursing a disabled child under the age of 16? Yes No 4.2 for family members — the time of nursing the disabled of Group Yes No 5. The deceased person was: 5.1 political prisoner? Yes No 5.2 deportee? Yes No 5.3 resistant? Yes No 5.4 deported for forced work beyond former USSR border? Yes No 5.5 in ghettos, concentration camps and other types of places of forced confinement during the World War II? Yes No 6.

To be completed if there are survivors of the deceased who are (were) granted widow(er)’s/orphans’s pensions: Name: Surname: Lithuanian personal identification number, or failing this, date of birth: Institution responsible for payment of pension: E 203 additional page 7 LT (continued) Data of the claimant 7. Lithuanian personal identification number: … 8. Lithuanian State social insurance certificate serial No and No: … 9. Claimant’s pensions: … 9.1 Social insurance pensions: Pension type: Date of application: Date of granting: Date of suspension: 9.1.1 old age 9.1.2 disability 9.1.3 widow’s (widower’s) 9.1.4 orphan’s 9.1.5. survivor’s (of those deceased prior to 31 December 1994) Institution responsible for payment of pension:

In case of 9.1.4 and 9.1.5 should be noted: for deceased father (mother) for other deceased person date of his/her death: … date of his/her death: … 9.2 The claimant’s state pensions Pension type: Date of application: Date of granting: Date of suspension: Institution responsible for payment of pension: 9.2.1 old age 9.2.2 widow’s (widower’s) 9.2.3 orphans 10. Was the claimant recognised as disabled (don’t complete for guardians)? Yes No If ‘ Yes ’ , indicate: the date of the commencement of disability: … disability was determined till: … termless: E 203 additional page 7 LT (continued) Points 11 and 12 to be completed only by claimants for widow (widower)’s pensions 11.

Is the claimant raising the deceased person’s children (adopted children) under the age of 18 (or if they are full time students under the age of 19) and/or nursing the deceased person’s children (adopted children) - the disabled of Group 1, who became disabled under the age of 18? Yes No If ‘ Yes ’ , indicate these children (adopted children): Name: Surname: Group of disability: Lithuanian personal identification number, or failing this, date of birth: A copy of certificate of educational institution should be enclosed for abovementioned children (adopted children) full time students under the age of 19.

12. The claimant is mother/father guardian stepmother/stepfather to the children he/she is raising. 13. Are you a full time student (to be completed only by the claimant if aged between 18-24)? Yes No If ‘ Yes ’ , a copy of certificate of educational institution should be enclosed. ADDITIONAL INFORMATION FOR CZECH INSTITUTIONS E 203 additional page 8 CZ For the purposes of Czech institutions, complete the following table for children named in the item 15.1 Forename and surname of the child Day, month and year of birth of the child Father’s forename and surname Mother’s forename and surname Period of personal care of the child, from—to If the child is/was in custody of a different person or institution (indicate where and from—to) Birth number of the child (1) (1) Indicate only if you apply for orphan’s pension.

E 203 additional page 9 SK ITEM 8 ADDITIONAL INFORMATION FOR THE NEEDS OF THE SLOVAK INSTITUTIONS If the death is assumed to be the result of an occupational accident, the following information must also be given: registration of the occupational accident, investigation by the labour inspectorate or the police and any court judgement. Was the occupational accident the only cause of death? Yes No Activity during which the occupational accident occurred: During performance of the worker’s duties During activities with a direct link to the worker’s duties On the journey to or from work On the way to or from a cafeteria, canteen or similar Place where the occupational accident occurred:

At the work place On the employer’s premises Outside the employer’s premises If the death is assumed to be the result of an occupational disease, the following information must also be given: confirmation from an occupational medicine department or other institution, with the date of diagnosis and/or the date of origin of the occupational disease, confirmation of a link between the death and the occupational disease, i.e. if the disease was the only cause of death. E 203 additional page 10 CH ADDITIONAL INFORMATION FOR THE PURPOSE OF SWISS INSTITUTIONS 1. Information concerning the deceased insured person Surname (point 2.1): … Forenames (point 2.3): … Date of birth (point 4.1): … 2.

If the deceased insured person was a Swiss national, please indicate the place of origin: … and the date of acquisition of the Swiss nationality: … 3. Information concerning residence in Switzerland of the deceased insured person Place: from (month/year): to (month/year): Type of residence permit: Please attach copies of certificates of residence or residence permits. 4. To be completed if the deceased insured person has been married 1st marriage: 2nd marriage: 4.1 Marriage celebrated on: 4.2 Dissolved by divorce on: Surname and forenames: Surname at birth: Date of birth: Date of death: 3rd marriage:

4.3 Information concerning the spouse, ex-spouse or deceased spouse 5. Information concerning residence in Switzerland of the spouse, any ex-spouses or deceased spouses during marriage Surname and forenames: Place of residence: from (month/year): to (month/year): Type of residence permit: Please attach copies of certificates of residence or residence permits. E 203 additional page 10 CH (continued) Yes No If yes, please indicate the duration of the marriage(s): 6. Was the claimant (widow/widower) married more than once? 1st marriage: 2nd marriage: 3rd marriage: 6.1 Celebrated on: 6.2 Dissolved by divorce on:

6.3 Date of death of the spouse: … 7. To be completed for children of separated or divorced parents Surname: Forenames: Date of birth: Custody to: the father the mother joint other person the father the mother joint other person the father the mother joint other person the father the mother joint other person the father the mother joint other person 8. To be completed for claimants (widows/widowers) who, at the time of death of their spouse, did not have any children, including adopted children. Did you live together in the same household with one or more of the spouse’s children at the time of his/her death? Yes No If yes :

Surname: Forenames: Date of birth: E 203 additional page 11 PL ADDITIONAL INFORMATION FOR THE PURPOSES OF THE POLISH INSTITUTIONS To be completed by the claimant and added to the E 203 form 1. Personal details of the claimant 1.1 Surname: … 1.2 Surname at birth: … 1.3 Forename(s): … 1.4 Date of birth: … 1.5 NIP No: … 2. Information concerning a widow /widower applying for Polish survivor’s pension 2.1 Was there a conjugal community until the day of spouse’s death? Yes No If there was no conjugal community or the spouses were divorced or separated please indicate: 2.2 Was the right to receive alimony established? Yes No If yes, please enclose a court order or agreement in court or any other official document, which is the ground for awarded alimony.

2.3 Please indicate PESEL or NKP No: … 3. Information concerning parents applying for Polish survivor’s pension 3.1 Was the insured deceased contributing to maintaining the claimant directly before death? Yes No 3.2 If yes, please give details: … 3.3 Is the claimant bringing up a child (aged up to 16) of the insured deceased or, if the child has been attending a school, aged up to 18? Yes No 3.4 Is the claimant taking care of a child which is totally incapable of working and living independently or is totally incapable of working and which has the right to receive survivor’s pension? Yes No If yes, please indicate the surname and the name of the child: … Please, indicate PESEL or NKP No: … E 203 additional page 11 PL (continued) 4.

Information concerning children applying for Polish survivor’s pension: 4.1 Surname and name: Date of birth: PESEL No: Family relations (1): Name of school: Is a child totally incapable of working and to living independently or is totally incapable of working? 4.2 In the case of children accepted to be brought up and maintained before they reach 18, grandchildren, brother(s) or sister(s) or other children, including children from foster family, please indicate the following: the exact date of accepting them to be brought up and maintained: … Are the child’s parents alive? Yes No If yes, please answer the following questions:

Are they able to maintain the child? Yes No Was deceased or his/her spouse a guardian of the child ordered by court? Yes No Does the child have the right to receive a pension due to the death of his/her parents? Yes No 5. In order to establish the amount of pension in the general social insurance scheme, the claimant applies for the following to be accepted as benefit assessment basis that would be vested in the deceased: Average basis of contribution assessment for social insurance or old age and disability insurance according to Polish regulations, in the period of 10 subsequent calendar years, selected from the past 20 calendar years, immediately preceding the year in which the claim was submitted, i.e. from … until … (2).

Average basis of contribution assessment for social insurance or old age and disability insurance according to Polish regulations, in the period of 20 calendar years prior to the year of claim submission, selected from the whole period of insurance (2). Average basis of contribution assessment for social insurance or old age and disability insurance according to Polish regulations, in the period of 10 subsequent calendar years immediately preceding the year in which the deceased started to be insured abroad for the first time, if the deceased had not been insured in Poland during 20 calendar years, immediately preceding the year in which the claim was submitted.

Assessment basis of contributions according to Polish regulations from the period of being actually subject to insurance. Assessment basis of old-age or disability pension of the deceased. 6. In order to establish the amount of survivor’s pension under social insurance scheme for farmers please answer the following questions: 6.1 Is the adult claimant (or his/her spouse) an owner (co-owner) or a holder of a farm? Yes No 6.2 If ‘ Yes ’ , please indicate the area of the farm (in hectares): … E 203 additional page 11 PL (continued) 7. In order to investigate the application for a Police survivor’s pension please fill in the points 2 to 4 and indicate:

7.1 Name of the unit where the deceased/missing officer was on duty or from where he was exempted, type of duty and date of exemption: Concerning the death of the officer, has/was an application made for granting and paying compensation due in the case of accidents or diseases in connection with his/ her duty? Yes No Concerning the death of the officer, have/were criminal proceedings made in connection with his/her duty? Yes No Has the death or disappearance of the officer occurred while on duty outside Polish territory? Yes No 7.2 In order to investigate the claim for policemen’s pension, the claimant declares that he/she: receives does not receive a Polish pension, pension for retired judge or prosecutor, survivor’s pension from retired judge or prosecutor, pre-retirement benefit or cash benefit financed by Unemployment Fund.

If he/she ‘ receives ’ , please indicate the benefit number, date since this benefit has been paying and the name of paying institution: … 8. In order to investigate a claim for military survivor’s pension, the claimant should indicate the following: Military unit where the deceased/missing professional soldier was on duty or in which he was exempted from duty and the date of exemption: … Whether the death of the soldier after exemption from duty occurred: (a) as a result of an accident while in active military service or an disease connected with particular qualities or conditions of military service:

Yes No (b) as a result of injuries received while on duty or diseases occurred at the time of duty: Yes No Has the death or disappearance of the officer occurred at the time of duty outside Polish territory? No Yes In the case of applying for military survivor’s pension payable to the survivor of a missing professional soldier, please enclose a document confirming the fact of his/ her being missing. … Date Signature of the claimant (1) While completing the form, please indicate the family relations by writing an appropriate letter: (a) children: your own, your husband’s and adopted; (b) accepted to be brought up and maintained before they reach 18, grandchildren, brother(s) or sister(s) and other children, including children within a foster family.

(2) In the case of persons employed, the certificate with the data about the assessment basis for social insurance contribution or for the old age and disability insurance or the certificate of remuneration issued by employer or successor to the rights, insurance card with the amount of the remuneration received should be enclosed. Originals of the abovementioned documents or copies certified by foreign insurance institution, notary or RP consul, are to be shown. In the case of self-employed persons, bank account number of the contribution payer is required or if the business activity was performed before social insurance was obligatory, certificate of professional and social organisation (e.g.

Guild of Crafts) is required. E 203 additional page 12 BE ADDITIONAL INFORMATION FOR THE PURPOSES OF BELGIAN INSTITUTIONS 1. Did the deceased spouse study in Belgium in or after the year of his/her 20th birthday? Yes No If ‘ Yes ’ , study period: from … to … 2. To be completed by persons who have been married more than once: 1st marriage: celebrated: … date of separation (*): … dissolved: date of divorce: … date of spouse’s death: … spouse: Surname, forename: … date of birth: … nationality: … 2nd marriage: celebrated: … date of separation (*): … dissolved: date of divorce: … date of spouse’s death: … spouse:

Surname, forename: … date of birth: … nationality: … 3rd marriage: celebrated: … date of separation (*): … dissolved: date of divorce: … date of spouse’s death: … spouse: Surname, forename: … date of birth: … nationality: … 3. To be completed by persons who are currently widowed or divorced: 1st marriage: was the former spouse or deceased spouse gainfully employed in Belgium? Yes No If ‘ Yes ’ , under which scheme? self-employed employed public authorities 2nd marriage: was the former spouse or deceased spouse gainfully employed in Belgium? Yes No If ‘ Yes ’ , under which scheme? self-employed employed public authorities 3rd marriage: was the former spouse or deceased spouse gainfully employed in Belgium? Yes No If ‘ Yes ’ , under which scheme? self-employed employed public authorities (*) The date of separation is the date from which the spouses are no longer officially resident at the same address.

E 203 additional page 13 FI ADDITIONAL INFORMATION FOR THE PURPOSE OF FINNISH INSTITUTIONS Item 11 Surviving spouse 1. Surname (item 11.1): … 2. Forenames (item 11.2): … 3. Finnish identity No (if known): … 4. Insurance No at the investigating institution: … 5. Employment of the surviving spouse: … 5.1. If the surviving spouse has worked in the country of the investigating institution, please submit his/her E 205 form. 5.2. Please indicate the countries where the surviving spouse has worked: … 6. If the claimant is the former spouse, please submit the copy of the maintenance agreement.

7. Type of the surviving spouse’s own employment-based pension: … 8. Amount of the surviving spouse’s own employment-based pension at the date of death of the deceased: … or 9. Estimate of the amount of the surviving spouse’s own employment-based pension at the date of death of the deceased, if he/she was not retired: … 10. Type of the surviving spouse’s own residence-based pension: … 11. Amount of the surviving spouse’s own residence-based pension at the date of death of the deceased: … 12. Type of the deceased person’s employment-based pension: … 13. Amount of the deceased person’s employment-based pension at the date of death: … or 14.

Estimate of the amount of the deceased person’s employment-based pension at the date of death, if he/she was not retired: … THE ADMINISTRATIVE COMMISSION ON SOCIAL SECURITY FOR MIGRANT WORKERS See ‘ instructions ’ on pages 9 to 11 E 204 (1) Country: Identification No (2) (17) Institution concerned (where applicable, liaison body) (1) (2) (3) (4) (5) INVESTIGATION OF A CLAIM FOR AN INVALIDITY PENSION Regulation (EEC) No 1408/71: Article 44 to 51a; Article 77 Regulation (EEC) No 574/72: Article 36 to 38; Article 41 to 43; Article 45 to 47; Article 49; Article 90 (*); Article 111 The investigating institution should complete this form and send one copy to each of the institutions with which the employed or self-employed person has been insured (institutions concerned) or to the liaison body.

1. Institution to which the form is addressed (institution concerned or liaison body, as applicable) 1.1 Name: … … 1.2 Address (3): … … A. Information concerning insured person (3a) 2. 2.1 Surname (4): … 2.2 Surname at birth (4): … 2.3 Forenames (5): … 2.4 Previous names (6): … 2.5 Sex (7): … 2.6 Father’s surname and forenames (8): … 2.7 Mother’s surname and forenames at birth (8): … 2.8 Civil status: single divorced (9) separated since: … (10) since: … (10) married remarried (9) widow or widower since: … (10) since: … (10) since: … (10) cohabiting since: … (11) (12) (13) 2.9 Taxpayer’s No (14): … and code of tax district: … 2.10 Insurance No (2) (15): … (*) Article 90 of Regulation (EEC) No 574/72 is not applicable in the Netherlands.

E 204 3. Nationality (16) (17): … 4. Details of birth (18) 4.1 Date of birth (18): … 4.2 Place of birth (19): … 4.3 Province, department, county (20): … 4.4 Country (21): … 5. Address and bank particulars 5.1 Address (3) (22) (23): … … 5.2 Bank particulars or address for direct payment: … Name of the beneficiary as recognised by the bank: … Name of the bank: … Address of the bank: … Bank identification code (BIC/SWIFTT): … International bank account number (IBAN): … 6. 6.1 Insurance No at the registering institution: … 6.2 Reference No of file at the investigating institution: … 7.

7.1 Date which has been determined as the commencement of invalidity: … 7.2 Date of commencement of incapacity for work followed by invalidity: … 7.3 The person concerned is still engaged in is no longer engaged in gainful employment activity as a civil servant (23a) self employment 7.4 If he/she is engaged in gainful employment or in an activity as a civil servant indicate (23a) (24) Amount of wage/salary: … Number of hours worked: … 7.5 Date of cessation of gainful employment as an employed person: … as a self employed person: … as a civil servant (23a): … 7.6 Type of activity (24a):

If he/she is carrying out an activity as a self employed person indicate the amount of professional income (25): … 7.7 Nature of activity: … 7.8 Other known resources (amount and nature) (26): … 7.9 The claimant states that he/she has no income (27). E 204 7.10 The invalidity is assumed is not assumed to have been caused by a liable third party. is the result of is not the result of an accident at work or an occupational disease (28). is the result of is not the result of an accident other than an accident at work or an occupational disease (29). is the result of is not the result of injuries received on duty or diseases occurring at the time of duty (28a). is the result of is not the result of an accident in connection with duty or a disease occurring in connection with particular qualities or conditions of duty (28a). is assumed is not assumed to have been caused by the claimant on purpose (50).

7.11 At the moment of commencement of incapacity for work, the claimant was insured as a worker against invalidity. insured other than as a worker against invalidity. not insured against invalidity. 8. 8.1 Since the commencement of incapacity for work, the person concerned has followed rehabilitation courses. has not followed rehabilitation courses. has followed occupational courses. has not followed occupational courses. 8.2 Where appropriate, indicate for what kind of occupation: … 8.3 The employer for whom he/she works in this new occupation: Name of employer or firm: … Address (3): … 8.4 Date of commencement and termination of this employment: … 9.

9.1 The insured person has applied for the following benefits: is receiving the following benefits: 9.2 Continued wage or salary payments in case of illness 9.3 Sickness insurance cash benefits for incapacity for work 9.4 Rehabilitation allowances Occupational allowances 9.5 Invalidity pension (30) 9.6 Old-age pension (30) 9.7 Survivor’s pension (30) 9.8 Pension for accident at work or occupational disease 9.9 Unemployment benefits or early retirement benefit 9.10 Benefits in respect of assistance by another person (31) 9.11 Family benefit (32) 9.12 Refund of contribution 9.13 Transfer of contributions (33) 9.14 Other benefits (please specify) Yes No E 204 Re benefits in item:

File reference No: Period or date on which due 9.15 Institutions responsible for paying the benefits indicated in 9.2 to 9.11 (name, address (3), benefit number): 9. … 9. … 9. … 9. … 9.16 Additional information on the benefits listed in 9.2 to 9.11 Amount daily weekly 9. … monthly annual daily weekly 9. … monthly annual daily weekly 9. … monthly annual 9.17 The following are regarded as advances on the pension claimed: sickness insurance benefits for incapacity for work. unemployment benefits. 9.18 The insured person is entitled to sickness benefits in kind under the legislation administered by the investigating institution Yes No Not yet determined 9.19 The investigating institution, or other institution, awards an increase in benefit to the extent that the applicant is incapable of carrying out normal day to day activities unaided Yes No Not yet determined In addition to the benefits referred to at point 9…, the applicant receives an additional benefit if he/she is incapable of carrying out normal day to day activities The additional benefit may be reduced if a similar benefit is granted by another institution concerned Yes No Not yet determined E 204 10.

Additional information for the application of provisions on overlapping benefits 10.1 When benefits of the same kind are granted by the institution or institutions concerned, the pension calculated by the investigating institution may be reduced Yes No Not yet determined 10.2 The pension calculated by the investigating institution may be reduced Yes No Not yet determined because one or several of the benefits specified at point 9 are taken into account 9. … 9. … 9. … 9. … because of income other than the benefits specified at point 9 Income from employment/self-employment other (34): … 10.3 The institution concerned is requested to specify the part of the pension accruing from voluntary contribution payments (point 6.7 in form E 210) Yes No 10.4 The benefit due from the investigating institution is (partly or entirely) based on voluntary contributions Yes No B.

Information concerning the members of the insured person’s family 11. Spouse (13) (17) (35) Cohabiting partner (11) 11.1 Surname (4): … Identification/insurance No (2) (15) (17): … 11.2 Forenames: … Previous names: … 11.3 Date of birth: … Place of birth (19): … 11.4 Address (3): … 11.5 Date of marriage/cohabiting: … Does the insured person live in the same household as the spouse or partner? Yes, since … No Not anymore, since … 11.6 The spouse/partner pursues does have does not pursue gainful employment does not have other income 11.7 Where appropriate, state amount of weekly earnings (36): … monthly earnings (37): … annual earnings (38): … 11.8 The spouse/partner has submitted a claim for a pension under the scheme for employed persons civil servants (38a) self-employed persons receives a pension does not receive a pension In the affirmative, indicate:

11.9 Type of pension: … 11.10 Pension No (17): … E 204 11.11 Institution responsible for payment: … 11.12 Amount monthly quarterly annual 11.13 The spouse/partner receives does not receive other benefits (39) unemployment sickness invalidity other 11.14 Date of commencement: … 11.15 Amount monthly quarterly annual 11.16 Other known resources: Type: … Amount (40): … 12. Children (13) (17) 12.1 Surname (4) (17): Forenames: Place and date of birth, marriage or death (41): Relationship (i.e. own child, adopted child, foster child): 1. 2. 3. 4. 12.2 The following institution is competent to grant benefits pursuant to Article 77 of Regulation (EEC) No 1408/71: the investigating institution the institution designated as follows: … 12.3 The investigating institution for the children referred to in line Nos … of item 12.1 is granting benefits until … inclusive.

Amount of family allowance and/or orphan’s pension per child (42): is not granting benefits in respect of the children referred to in line Nos … of item 12.1 (43). has not yet taken a decision regarding entitlement to benefits. 12.4 Address (3) (44): … 12.5 Remarks (45) (46): … E 204 13. Ascendants and other members of the household (47) 13.1 Surname (4): Forenames: Date of Birth: Relationship: 1. 2. 3. 4. 13.2 Address (3) (44): … 13.3 Remarks: … C. Miscellaneous information 14. Date of submission of this claim: … Date from which the pension is payable in the country of the investigating institution: … 14.1 The claimant has asked for payment (48) directly in the State of residence. to a representative in the State of origin.

15. The investigating institution pays does not pay benefits on a provisional basis under Article 45(1) of Regulation (EEC) No 574/72. 15.1 If not, the institutions concerned are requested to investigate the possibility of paying benefits on a provisional basis under Article 45(2) of Regulation (EEC) No 574/72 16. There are grounds There are no grounds for making deductions to compensate for overpayment in accordance with Article 111 of Regulation (EEC) No 574/72. can cannot be paid direct to the beneficiary. 16.1 Any pension arrears E 204 17.1 Attached forms E 205 E 207 (49) E 213 17.2 Please send us your E 205 E 210 Decision Remarks: … Arrears 18.

Investigating institution 18.1 Name: … 18.2 Address (3): … 18.3 Stamp 18.4 Date: … 18.5 Signature: E 204 INSTRUCTIONS Please complete this form in block letters or typewriting, writing on the dotted lines only. It consists of 11 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. (2) 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 Liechtenstein institution, indicate the AHV insurance number; to a Lithuanian institution state the personal identification number; to a Latvian institution, state the identity 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 identification number (fødselsnummer); 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) and to an institution of the social security scheme for civil servants, indicate the personal identification number (PRS-Kenn-Nr); to an Austrian institution, state the Austrian insurance number (VSNR); to a Polish institution, state the reference number of the pension file for the person who applied for or had established the right to a pension from the Polish social security system, for person applying for Polish pension for the first time, state PESEL and NIP or NKP number (NKP number — if the person concerned is subject to social insurance for farmers), if there is no such number state the series and number of identity card or passport; to a Portuguese institution, indicate the registration number with the general pensions scheme, and, if it is the case, 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 reference number of the file if known, if this number is known, the number under note 17 is omitted; to a Swiss institution, state the AVS/AI (AHV/IV) insurance number.

(3) Street, number, post code, town, country, telephone number. (3a) For Germany and Austria, the term ‘ insured persons ’ encompasses individuals insured under the general social security scheme as well as civil servants and individuals treated as such who are insured under a special scheme. The term ‘ pension ’ is considered to encompass pensions for civil servants. In the case of Poland the term ‘ insured person ’ also refers to persons who are subject to special schemes. (4) For surname please state usual surname or surname acquired by marriage. The ‘ surname at birth ’ must always be given; if same as current surname, put ‘ IDEM ’ .

Expressions such as ‘ called … ’ or ‘ alias … ’ and prefixes to surnames must be written in full in the order in which they appear on the birth certificate. If the form is being completed by a Netherlands institution, in cases where the insured person or the rightful claimant is a married woman or a woman who was married before, put the present or last husband’s surname for current surname and the maiden name for surname at birth. In the case of Spanish nationals state both names at birth. In the case of Portuguese nationals state all names (forenames, surname, maiden name) in the order of civil status in which they appear on the identity card or passport.

(5) Give all forenames in the order in which they appear on the birth certificate. (6) To be stated particularly in the case of adoption or in the case of other names in current use; expressions such as ‘ called … ’ or ‘ alias … ’ and prefixes to surnames must be written in full in the order in which they appear on the birth certificate. (7) Put M for male and F for female. (8) This information is required when the worker is a Spanish national, or when the form is to be sent to a French, Greek, Hungarian or Polish institution, regardless of the worker’s nationality. (9) Complete where possible if the form is being sent to a German, Belgian, French, Italian, Luxembourg, Netherlands, Austrian, Portuguese, Swedish, Finnish, Liechtenstein or Norwegian institution.

(10) For the purposes of Belgian, Netherlands, Polish, Swedish, United Kingdom, Finnish and Liechtenstein institutions, specify also the date beside the corresponding box. (11) For the purposes of Belgian, Netherlands, Finnish, Icelandic and Norwegian institutions. (12) This information is based on a statement from the person concerned. Under the Netherlands General Law on Old-Age Insurance the following persons are also regarded as ‘ married ’ or ‘ spouse ’ : unmarried persons of the same or different sexes who are living in a joint household on a permanent basis, unless they are persons who are blood relations of first or second degree.

A joint household means that two unmarried persons are jointly providing for their housing with each contributing to the costs of the household or providing for each other’s upkeep in another way. Under the Finnish legislation parties to a registered partnership of the same sex are treated as ‘ married ’ . (13) For the purposes of Norwegian institutions, please complete form E 204/additional page 4. For the purposes of the Swiss institutions, also fill in form E 204/additional page 5. If the form is sent to a Lithuanian institution don’t complete part B but complete additional page 6. (14) To be completed only if the form is to be forwarded to a Portuguese or Slovene institution.

(15) For the purposes of Netherlands institutions complete Sofi number, if known. For the purposes of Belgian institutions complete national social security number (NISS). (16) Where appropriate, indicate the date of naturalisation. E 204 (17) For the purpose of Spanish institutions in the case of Spanish nationals state the number appearing on the national identity card DNI (Documento Nacional de IdentidadI) or the NIE (Número de Identificación de Extranjeros) in the case of foreign people, for both cases if it exists, even if the identity card is out of date. Failing this, state ‘ None ’ In the case of Slovene nationals , state the personal identification number — EMŠO.

In the case of Maltese nationals state the identity card number, if not a Maltese national, state the Maltese social security number. (18) The day and the month should be shown by two digits each and the year by four digits (example: 1 August 1921 = 01.08.1921). (19) For French towns comprising several arrondissements, please give the number of the arrondissement (example: Paris 14). In the case of Portuguese districts state also the parish and the local authority. (20) Must be stated for insured persons of Spanish, French or Italian nationality. Here, the territorial area or district in which the place of birth is located should be stated (example: in the case of France if the place (commune) of birth is Lille, the department of birth should be shown as ‘ Nord ’ followed by the area code if known to the insured person; in this case:

59. The complete entry should therefore read: ‘ Nord 59 ’ ). In the case of persons born in Spain, state only the province. In the case of Netherlands towns state also the name of the municipality. (21) The symbol of the insured person’s country of birth in accordance with ISO code 3166-1. (22) If the form is being sent to a German, Polish, Austrian, Latvian, Finnish, Liechtenstein, or Swiss institution, state, if applicable, the address of the legal representative (legal counsellor, guardian, curator…) in the box below. Address (3): … … (23) If the form is being sent to a Danish, French, Finnish, Latvian, Polish, Icelandic or Norwegian institution, give the claimant’s last address in the corresponding country in the box below.

Address (3): … … (23a) In the case of Poland, the term ‘ civil servant ’ refers to the persons who are subject to special schemes. (24) Complete if the form is being sent to a Belgian, Czech, Danish, German, Greek, French, Italian, Luxembourg, Netherlands, Polish, Austrian, Slovak, Swedish, United Kingdom, Icelandic or Norwegian institution. (24a) For the purposes of Portuguese institutions indicate the type of activity in which the person concerned was engaged during his/her last three years of activity. (25) Complete if the form is being sent to a Belgian, Czech, Danish, German, Greek, Spanish, French, Italian, Luxembourg, Netherlands, Polish , Austrian, Portuguese, Icelandic or Norwegian institution.

(26) Complete if the form is being sent to a Danish, Spanish, Italian, Austrian, Portuguese, Icelandic or Norwegian institution. If the form is being sent to an Italian institution all income should be indicated with the exception of the following: the claimant’s home, family benefits, cash benefits for accident at work or occupational disease, purely assistance benefits. (27) Complete if the form is being sent to an Italian or Greek institution. In Italy the following sources are not considered as income: the claimant’s home, family benefits, cash benefits for accident at work or occupational disease, purely assistance benefits.

(28) Complete if the form is being sent to a Belgian, Cypriot, German, Greek, Hungarian, Spanish, French, Italian, Luxembourg, Austrian, Latvian, Polish, Portuguese, Slovak, Finnish or Norwegian institution. (28a) For the purposes of Polish institution, in the case of an invalidity pension claimed under a special scheme. The information is required when the form is being sent to Hungarian institutions. (29) Complete only if the form is being sent to a Cypriot, Greek, Hungarian, Slovak, Spanish or Luxembourg institution. (30) For the purposes of Liechtenstein institutions indicate also if the insured person applied for or received the pension of the occupational scheme as cash compensation.

For the purpose of Slovak institutions survivor’s pensions includes survivors’ accident pension. For the purpose of Maltese institutions indicate if the insured person has applied for or is receiving an occupational pension from a former employer. Rate of pension should be that as on original award. Provide the details of this in point 9.16. For the purposes of Polish institutions also complete form E 204 additional page 7. (31) For the purposes of Portuguese institutions, where the insured person needs the assistance of another person, also complete additional page 2. (32) To be completed for Italian institutions.

(33) For the purposes of Liechtenstein institutions. (34) State the type of income taken into account by the investigating institution in applying its overlapping rules. (35) For the purposes of a Liechtenstein institution, box 11 on page 5 is to be completed for each divorced or separated wife. (36) Complete if the form is being sent to an Irish, Austrian or United Kingdom institution. (37) Complete if the form is being sent to a Belgian institution. (38) Complete if the form is being sent to a Danish, French, Italian, Luxembourg, Netherlands, Austrian, Icelandic or Norwegian institution. (38a) In the case of Poland the term ‘ pension under a scheme for civil servants ’ refers to benefits from special schemes.

E 204 (39) Complete if the form is being sent to a Belgian, Danish, German, French, Irish, Italian, Netherlands, Austrian, United Kingdom, Icelandic or Norwegian institution. (40) Complete if the form is being sent to a Danish, Italian, Spanish, Netherlands, Icelandic or Norwegian institution (annual amount); to a French institution (quarterly amount) or to a Belgian, German, Greek or Austrian institution (monthly amount). (41) Indicate with the following symbols which date you are referring to: * birth, °° marriage, † death. (42) Provide details of rates from date of pension award with any subsequent change of rate.

(43) Please complete additional page 1 enclosed if the form is being sent to a German, Italian or Norwegian institution. (44) Indicate the common address. If one of the children or ascendants lives at a different address, state this address in the box below. Surname and forenames: … Address (3): … … (45) Indicate whether the child is married, an invalid, deceased (date of death), an apprentice or a student, or if he/she receives a benefit or has his/her own source of income. For the purposes of a Liechtenstein or Swiss institution, a copy of the indentures of apprenticeship or a certificate of the training centre should be attached for each child being a student or apprentice between the ages of 18 and 25.

For the purpose of Cypriot institutions a copy of a certificate of full time education should be attached for each child being a student between the ages of 16 and 23 in the case of a female, and the ages of 16 and 25 in the case of a male. (46) For the purposes of Spanish and Norwegian institutions, please state whether the children are economically dependent on the insured person and whether any of the children have a disability. In the latter case, state whether the child receives an invalidity pension in his or her own right. (47) Complete if the form is being sent to a Belgian or United Kingdom institution.

(48) To be completed for Italian and Greek institutions. (49) If form E 204 is to be sent to a Liechtenstein or Latvian institution, add form(s) E 207 for the insured person and — if applicable — for the (actual and former) spouse(s) of the insured person. (50) The information is required when the form is being sent to a Hungarian institution. E 204 additional page 1 ITEM 12 ‘ CHILDREN ’ ADDITIONAL INFORMATION (complete a separate page for each child) 1. The child named in line No … of item 12.1 pursues gainful employment. does not pursue gainful employment. 1.1 If the answer is in the affirmative, please state:

Type of occupation (employed or self-employed): … Amount of income (1) week month year 2. The child named in line No … of item 12.1 has other sources of income. does not have any other sources of income. 2.1 If the answer is in the affirmative, please specify: nature of income: social security benefits: amount week month year other income (2): amount week month year 3. In respect of the children named in line No … of item 12.1 the following person (surname, forename): … (address): … … is entitled to family benefits or allowances by virtue of his/her pursuit of a professional activity or trade (Article 79(3) of Regulation (EEC) No 1408/71) Amount: … Commencing on: … 3.1 The following institutions are responsible for paying these family benefits or allowances:

(name): … (address): … … (name): … (address): … … 4. The child named in line No … of item 12.1 is unfit for work. Form E 404 is enclosed. (1) All income should be declared with the exception of severance payments, family benefits, wage arrears, life annuities for accidents at work or occupational disease, war pensions, pensions for disablement sustained during military service, attendance allowance, travel allowance. (2) ‘ Other income ’ means income from real estate or capital (bank or postal deposits or current accounts, government stock, investment funds, shares,bonds, etc.).

E 204 additional page 2 PT ITEM 9 (9.10) ADDITIONAL INFORMATION FOR THE PURPOSES OF PORTUGUESE INSTITUTIONS To be completed where the claimant has declared that he/she needs the assistance of another person to perform the ordinary activities of everyday life. 1. Identity of the other person 1.1 Surname: … Forenames: … 1.2 Address (street, number, post code, district, country): … … 2. Information provided by the investigating institution 2.1 We have ascertained that the person referred to above is the other person who actually assists the claimant in performing the ordinary activities of everyday life (personal hygiene, feeding, movement, etc.).

2.2 Assistance provided by the other person referred to above has not been ascertained. 3. Has the need for assistance been caused by a third party? Yes No Yes No 4.1 Name and address of paying institution: 4.2 Monthly amount: 4. Is the person concerned in receipt of an allowance for assistance by a third party or a similar benefit? … … E 204 additional page 3 FI ADDITIONAL INFORMATION FOR THE PURPOSE OF FINNISH INSTITUTIONS 1. The claimant wishes to have the decision in Finnish in Swedish ITEM 9 ‘ Insured person ’ 2. Is the claimant receiving or applying for any periodical pension-type benefits not reported in item 9 of E 204 form (for example benefits payable under compulsory motor insurance due to a road accident)? Yes No If in the affirmative, please specify:

2.1 Type of the benefit: … 2.2 Monthly gross amount of the benefit: … 2.3 Institution paying the benefit: ITEM 2 ‘ Insured person ’ 3. The claimant’s education and training 3.1 Basic education … 3.2 Further education and training (degrees, vocational training, courses; please give dates): 4. Employment — the latest contract of service 4.1 Primary occupation of the claimant: … 4.2 Length of service in primary occupation: … 4.3 Please check the alternatives that best characterise the claimant’s work: light part time; please indicate the number of hours per day … moderately hard full time sedentary work day work hard time wages standing work night work indoor work piece wages shift work outdoor work 4.4 Description of work (duties, working positions, tempo of work):

4.5 Description of work environment and circumstances (noise, dust, draught, heat, cold, potentially harmful substances, risk of accident, etc.): 4.6 Have the claimant’s duties undergone a change? No Yes. Please indicate when and in what way … E 204 additional page 3 FI (continued) 4.7 Has the claimant voluntarily taken a reduction in his or her working hours? No Yes Please indicate how and when the claimant’s occupational activity was reduced, as well as to what extent the claimant remains employed and what work he or she does (number of hours per week/month, amount of pay and fringe benefits):

4.8 Name and address of the claimant’s latest employer: … 4.9 Claimant’s duties in his or her latest occupation: … 4.10 When did the claimant’s latest contract of service begin? … 4.11 If the contract of service is still in force, please indicate when it is to end (if known): … 5. Self-employment 5.1 Has the claimant been self-employed? No → please go to item 6 Yes 5.2 If in the affirmative, please indicate since when: … 5.3 Is the claimant currently self-employed? No Yes 5.4 Ownership particulars business is still owned by the claimant or his/her spouse business has been sold business has been leased 6.

Unemployment 6.1 Has the claimant been unemployed during the last three years? No Yes 6.2 If in the affirmative, has the claimant received or applied for unemployment benefits during the last three years? No The claimant has received or is currently receiving unemployment benefits The claimant is applying for unemployment benefits; please indicate the benefit and the institution … … 7. Pensioners’ care allowance under the National Pensions Act The pensioners’ care allowance may be awarded to persons whose functional capacity has on account of an illness or injury diminished with the result that he or she is not capable of performing ordinary activities of everyday life unaided, or that the illness or injury imposes an added long-term financial strain.

7.1 Is the claimant applying for the pensioners’ care allowance? No Yes E 204 additional page 4 NO ADDITIONAL INFORMATION FOR THE PURPOSES OF NORWEGIAN INSTITUTIONS 1. The claimant 1.1 The claimant has been employed/self-employed. Income during the period immediately preceding present disability per year: … Weekly working hours preceding disability: … 1.2 The claimant has, during the period immediately preceding present disability, been occupied partly by domestic work, partly been employed/self-employed? 1.3 The claimant has applied for is receiving 1.3.1 Basic benefit covering extra expenses due to permanent illness 1.3.2 Assistance benefit 2.

The spouse has applied for a pension as a non-working person is receiving a pension as a non-working person is not receiving a pension as a non-working person 3. Children 3.1 Are all of the children supported by the claimant? Yes No If ‘ No ’ , state the name of the child (children) and the amount of the child’s income per year: … … 3.2 If the parents are married: Do all the children live with both parents? Yes No If ‘ No ’ , state which child (children): 3.3 If the parents are not married: Do ail the children live with both parents? Yes No If ‘ Yes ’ , give information about the other parent:

Name: … Date of birth: … Income per year (All kinds. Specify): … Name of the child (children) if not all children are concerned: … … … 4. Cohabiting partner 4.1 Has the claimant previously been married to the cohabiting partner? Yes No 4.2 Does the claimant have or has he/she had children by the cohabiting partner? Yes No E 204 additional page 5 CH ADDITIONAL INFORMATION FOR THE PURPOSE OF SWISS INSTITUTIONS 1. Information concerning the insured person Surname (point 2.1): … Forenames (point 2.3): … Date of birth (point 4.1): … 2. If the insured person is a Swiss national, please indicate the place of origin: … and the date of acquisition of the Swiss nationality: … 3.

Information concerning residence in Switzerland of the insured person Place: from (month/year): to (month/year): Type of residence permit: Please attach copies of certificates of residence or residence permits. 4. To be completed if the insured person is or has been married 1st marriage: 2nd marriage: 3rd marriage: 4.1 Marriage celebrated on: 4.2 Dissolved by divorce on: 4.3 Information concerning the spouse, ex-spouse or deceased spouse Surname and forenames: Surname at birth: Date of birth: Date of death: 5. Information concerning residence in Switzerland of the spouse, any ex-spouses or deceased spouses during marriage Surname and forenames:

Place of residence: to (month/year): from (month/year): Type of residence permit: Please attach copies of certificates of residence or residence permits. E 204 additional page 5 CH (continued) 6. To be completed for children of separated or divorced parents Surname: Forenames: Date of birth: Custody to: the father the mother joint other person the father the mother joint other person the father the mother joint other person the father the mother joint other person the father the mother joint other person E 204 additional page 6 LT ADDITIONAL INFORMATION FOR LITHUANIAN INSTITUTIONS 1. Lithuanian state social insurance certificate serial number and number 2.

The claimant was on military service in Lithuania or former USSR: Yes No If ‘ Yes ’ , indicate if he served as a conscript or as a reenlistee 3. The time of nursing/caring at home in Lithuania (filled in, if engaged in nursing before 1995-01-01): 3.1 For mothers — the time of caring for and nursing a disabled child under the age of 16? Yes No 3.2 For family members — the time of nursing the disabled of Group 1? Yes No 4. The claimant was: 4.1 Political prisoner? Yes No 4.2 Deportee? Yes No 4.3 Resistant? Yes No 4.4 Deported for forced works beyond former USSR border? Yes No 4.5 In ghettos, concentration camps and other types of places of forced confinement during the World War II? Yes No E 204 additional page 7 PL ADDITIONAL INFORMATION FOR THE PURPOSES OF POLISH INSTITUTIONS To be completed by claimant and added to the E 204 form 1.

Personal details of the claimant 1.1 Surname: … 1.2 Surname at birth: … 1.3 Forename(s): … 1.4 Date of birth: … 1.5 NIP number: … 2. In order to establish the amount of invalidity pension under the general social insurance scheme, the claimant applies for the following to be accepted as the basis for the benefit rate Average basis of contribution assessment for social insurance or old age and disability insurance according to Polish regulations, in the period of 10 subsequent calendar years, selected from the past 20 calendar years, immediately preceding the year in which the claim was submitted, i.e. from … until … (*) Average basis of contribution assessment for social insurance or old age and disability insurance according to Polish regulations, in the period of 20 calendar years prior to the year of application submission, selected from the whole period of insurance (*).

Average basis of contribution assessment for social insurance or old age and disability insurance according to Polish regulations, in the period of 10 subsequent calendar years immediately preceding the year in which the insurance started abroad for the first time, if there had not been an insurance in Poland during 20 calendar years, immediately preceding the year in which the claim was submitted. Assessment basis of contributions according to Polish regulations from the period of being actually subject to insurance (*). 3. In order to investigate the claim for policemen’s invalidity pension, the claimant should indicate the name of the unit where he/ she was on duty before exemption, type of duty and the date of exemption:

4. In order to investigate the claim for policemen’s pension, the claimant declares that he/she: receives, for period … to … does not receive remuneration or similar benefit in cash after duty’s exemption. receives does not receive Polish pension, pension for retired judge or prosecutor, survivor’s pension from retired judge or prosecutor, pre-retirement benefit, cash benefit financed by Unemployment Fund. If he/she ‘ receives ’ , please indicate the benefit number, date since this benefit has been paying and the name of paying institution is is not a member of an open pension fund.

E 204 additional page 7 PL (continued) 5. In order to investigate the claim for military invalidity pension, the claimant should indicate the name of the unit where the former professional soldier was on Army supply until the day of exemption from the professional military service and to indicate the date of exemption: 6. Was the claimant receiving sickness benefit or rehabilitation benefit or payment for the period of incapacity for work under social insurance when the claim was submitted? Yes No if ‘ Yes ’ , please indicate the date when you ceased to receive it: … 7. In order to establish the amount of the invalidity pension under social insurance for farmers, please state whether the claimant (his/ her spouse) is an owner (co-owner) or a holder of the farm.

Yes No if ‘ Yes ’ , please indicate the area of the farm (in hectares): … Date Signature of the claimant (*) In the case of persons employed, the certificate with the data about the assessment basis for social insurance contribution or for the old age and disability insurance or the certificate of remuneration issued by employer or successor to the rights, insurance card with the amount of the remuneration received should be enclosed. Originals of the abovementioned documents or copies certified by foreign insurance institution, notary or RP consul, are to be shown. In the case of self-employed persons, bank account number of the contribution payer is required or if the business activity was performed before social insurance was obligatory, certificate of professional and social organisation (e.g.

Guild of Crafts) is required. E 204 additional page 8 HU ADDITIONAL INFRORMATION FOR THE PURPOSES OF HUNGARIAN INSTITUTIONS To be completed by claimant and added to the E 204 form. 1.1 Surname (4): … 1.2 Surname at birth (4): … 1.3 Forenames (5): … 1.4 Previous names (6): … 1.5 Mother’s surname and forenames at birth (8): … 2. The amount of the claimant’s wage before invalidity: … 3. The stated working time for the last scope of activities before invalidity: … E 204 additional page 9 LV ADDITIONAL INFORMATION FOR THE PURPOSES OF LATVIAN INSTITUTIONS 1. The insured person belongs to one of the following categories? Politically prosecuted Student before 1991 Person has taken care of a I group invalid or a child who has been recognised as invalid from childhood — up to the age of 16, or a person aged over 80 before 1991 2.

In case the insured person was in military service in Latvia or the former USSR before 1996, indicate 2.1 the period: … 2.2 if he served as a conscript or as a reenlistee 3. Information concerning the insured person`s children in case the person has brought up 5 or more children or a child who has been recognised as invalid from childhood — up to age of 8 years Children: Surname: Forenames: Date of birth: Period of care: Remarks (*) 1. 2. 3. 4. 5. (*) Indicate whether the child is an invalid or deceased (date of death) or if the child was in custody of another person or in institutional care.

THE ADMINISTRATIVE COMMISSION FOR SOCIAL SECURITY FOR MIGRANT WORKERS See ‘ Instructions ’ on page 6 E 205 BE (8) CERTIFICATE CONCERNING INSURANCE HISTORY IN BELGIUM Regulation (EEC) No 1408/71; Article 38; Article 43a; Article 45; Article 48; Article 51a; Article 57(5) Regulation (EEC) No 574/72; Article 42(1); Article 43(1) to (3); Article 69 To be drawn up by the investigating institution for insurance periods completed under the legislation which it administers; where appropriate, to be attached to forms E 202, E 203 or E 204. Each institution concerned should draw up a form for the periods completed under the legislation which it administers and send it to the investigating institution.

1. Institution to which the form is addressed (institution concerned or investigating institution, as applicable) 1.1 Name: … … 1.2 Address (2): … … Information concerning the deceased insured person 2. Names 2.1 Surname (3): … 2.2 Surname at birth (3): … 2.3 Forenames (4): … 2.4 Previous names (5): … 2.5 Sex (6): … 2.6 Father’s surname and forenames (7): … 2.7 Mother’s surname and forenames (7): … 2.8 National social security number (NISS) (7a): … 3. Nationality (8): … 4. Details of birth 4.1 Date of birth (9): … 4.2 Place of birth (10): … 4.3 Province, department, county (11): … 4.4 Country (12): … 5.

Address (2): … … 6. 6.1 Insurance No at the investigating institution: … 6.2 Reference No of file at the investigating institution: … 6.3 Reference No of file at the institution concerned: … 7. Rightful claimant (13) 7.1 Surname (3): … 7.2 Forenames: … Surname at birth: … Place of birth (10): … 7.3 Date of birth: … Sex: … Nationality: … 7.4 Address (2): … … E 205 BE 8. Year from 1 January to 31 December (employed or non employed persons) Periods (non employed persons) Number of days From To Insurance periods Equivalent periods Occupation (15) (16) Remarks (14) (**) (17) Before 1926 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 E 205 BE 8.

(continued) Year from 1 January to 31 December (employed or non employed persons) Periods (non employed persons) Number of days From To Insurance periods Equivalent periods Occupation (15) (16) Remarks (14) (**) (17) 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 E 205 BE 8. (continued) Year from 1 January to 31 December (employed persons) Periods (non employed persons) Number of days From To Insurance periods Equivalent periods Occupation (15) (16) Remarks (14) (**) (17) 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 8.1 Total period of insurance under the Belgian social security scheme for employed persons — self-employed persons … notional additional days (*) 8.2 Remarks: … … … (*) Equivalent periods for which no dates are specified.

(**) Additional insurance periods, early retirement pension (Article 5a, Royal Decree No 50). E 205 BE 8a Admissible periods of service for the purpose of calculating pension under a special pension scheme in the public sector Period Number of months of effective service (18) Number of months of other admissible periods (19) Occupation Increment (20) Remarks (21) Total Total General remarks Remarks: Periods which do not open a right to pension year — from … to … 9. An insured person showing proof that he has completed an insurance period of less than one year may receive a pension under national legislation (Article 48(1) of Regulation (EEC) No 1408/71). may not receive 10.

Institution completing the form 10.1 Name: … … 10.2 Address (2): … … 10.3 Stamp 10.4 Date: … 10.5 Signature: E 205 BE INSTRUCTIONS Please complete this form in block letters, writing on the dotted lines only. It consists of six 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: B = Belgium. (2) Street, number, post code, town, country, telephone number. (3) For surname please state usual surname or surname acquired by marriage. The surname at birth must always be given; if same as current surname, put ‘ IDEM ’ .

Expressions such as ‘ called … ’ or ‘ alias … ’ and prefixes to surnames must be written in full in the order in which they appear on the birth certificate. In the case of Spanish nationals state both names at birth. In the case of Portuguese nationals state all names (forenames, surname, maiden name) in the order of civil status in which they appear on the identity card or passport. (4) Give all forenames in the order in which they appear on the birth certificate. (5) To be stated particularly in the case of adoption or in the case of other names in current use; expressions such as ‘ called … ’ or ‘ alias … ’ and prefixes to surnames must be written in full in the order in which they appear on the birth certificate.

(6) Put M for male and F for female. (7) This information is required when the worker is a Spanish national, or when the form is to be sent to a French institution, regardless of the worker’s nationality. (7a) For workers subject to Belgian legislation, State worker’s national social security number (NISS). (8) Where appropriate indicate the date of naturalisation. For the purpose of Spanish institutions in the case of Spanish nationals state the number appearing on the national identity card DNI (Documento Nacional de IdentidadI) or the NIE (Número de Identificación de Extranjeros) in the case of foreign people, for both cases if it exists, even if the identity card is out of date.

Failing this, state ‘ None ’ . For the purposes of Maltese Institutions, in the case of Maltese Nationals, state the identity card number, if not a Maltese national, state Maltese social security number. In the case of Slovene nationals, state the personal identification number EMŠO. (9) The day and the month should be shown by two digits each and the year by four digits (example: 1 August 1921 = 01.08.1921). (10) For French towns comprising several arrondissements, please give the number of the arrondissement (example: Paris 14). In the case of Portuguese districts state also the parish and the local authority.

(11) Must be stated for insured persons of Spanish, French or Italian nationality. Here, the territorial area or district in which the place of birth is located should be stated. (example: in the case of France if the place (commune) of birth is Lille, the department of birth should be shown as Nord followed by the area code if known to the insured person; in this case: 59. The complete entry should therefore read: Nord 59). In the case of persons born in Spain, state only the province. (12) The symbol of the insured person’s country of birth in accordance with ISO code 3166-1. (13) Complete where appropriate.

(14) In 8.2 indicate the nature of the periods treated as periods of employment. (15) In the case of persons who were employed in mines or in undertakings treated as such, for Austrian purposes add an E 205 A additional form. (16) For Belgian, Greek and Spanish institutions, specify where possible the type of activity in question. (17) For Spanish institutions, in the case of seamen a photocopy of the sailor’s book or books of the country issuing the certificate should be enclosed. (18) For part-time work, the time to be indicated is the reduced time. (19) Other periods actually taken into account in calculating the pension (including imputed periods for study and military service and periods counting for more than their simple duration).

(20) Increment: the denominator of the fraction assigned per year of service. The usual increment is 1/60 per year of service. (21) Any information which may be of interest to the foreign institution and which is not apparent from the other columns. THE ADMINISTRATIVE COMMISSION ON SOCIAL SECURITY FOR MIGRANT WORKERS See ‘ Instructions ’ on page 4 E 205 CZ (1) CERTIFICATE CONCERNING INSURANCE HISTORY IN THE CZECH REPUBLIC Regulation (EEC) No 1408/71; Article 38; Article 43a; Article 45; Article 48; Article 51a; Article 57(5) Regulation (EEC) No 574/72; Article 42(1); Article 43(1) to (3); Article 69 To be drawn up by the investigating institution for insurance periods completed under the legislation which it administers; where appropriate, to be attached to forms E 202, E 203 or E 204.

Each institution concerned should draw up a form for the periods completed under the legislation which it administers and send it to the investigating institution. 1. Institution to which the form is addressed (institution concerned or investigating institution, as applicable) 1.1 Name: … … 1.2 Address (2): … … Information concerning the insured person 2. Names 2.1 Surname (3): … 2.2 Surname at birth (3): … 2.3 Forenames(4): … 2.4 Previous names (5): … 2.5 Sex (6): … 2.6 Father’s surname and forenames (7): … 2.7 Mother’s surname and forenames (7): … 3. Nationality (8): … 4.

Details of birth 4.1 Date of birth (9): … 4.2 Place of birth (10): … 4.3 Province, department, county (11): … 4.4 Country (12): … 5. Address (2): … … 6. 6.1 Insurance No at the investigating institution: … 6.2 Reference No of file at the investigating institution: … 6.3 Reference No of file at the institution concerned: … 7. Rightful claimant (13) 7.1 Surname (3): … 7.2 Forenames: … Surname at birth(3): … Place of birth (10): … 7.3 Date of birth: … Sex: … Nationality (8): … 7.4 Address (2): … … E 205 CZ 8. Insurance periods and periods treated as insurance periods From To Number of days for waiting period amount of benefit Type (14) E 205 CZ 8.1 Total length of insurance under the Czech social security scheme: periods to be taken into account only for the acquisition of entitlement of benefits: days … periods to be taken into account only for the calculation of benefits: days … 8.2 Notes and comments: … … … 9.

An insured person showing proof that he has completed an insurance period of less than one year may receive may not receive a pension under national legislation (Article 48(1) of Regulation (EEC) No 1408/71). 10. Institution completing the form 10.1 Name: … … 10.2 Address (2): … … 10.3 Stamp 10.4 Date: … 10.5 Signature: E 205 CZ INSTRUCTIONS Please complete this form in block letters, writing on the dotted lines only. It consists of four pages, none of which may be left out even if it does not contain any relevant information. NOTES (1) Symbol of the country to which the institution completing the form belongs:

CZ = the Czech Republic. (2) Street, number, post code, town, country, telephone number. (3) For surname please state usual surname or surname acquired by marriage. The surname at birth must always be given; if same as current surname, put ‘ IDEM ’ . Expressions such as ‘ called … ’ or ‘ alias … ’ and prefixes to surnames must be written in full in the order in which they appear on the birth certificate. In the case of Spanish nationals state both names at birth. In the case of Portuguese nationals state all names (forenames, surname, maiden name) in the order of civil status in which they appear on the identity card or passport.

(4) Give all forenames in the order in which they appear on the birth certificate. (5) To be stated particularly in the case of adoption or in the case of other names in current use; expressions such as ‘ called … ’ or ‘ alias … ’ and prefixes to surnames must be written in full in the order in which they appear on the birth certificate. (6) Put M for male and F for female. (7) This information is required when the worker is a Spanish national, or when the form is to be sent to a French institution, regardless of the worker’s nationality. (8) Where appropriate, indicate the date of naturalisation.

For the purpose of Spanish institutions in the case of Spanish nationals state the number appearing on the national identity card DNI (Documento Nacional de IdentidadI) or the NIE (Número de Identificación de Extranjeros) in the case of foreign people, for both cases if it exists, even if the identity card is out of date. Failing this, state ‘ None ’ . For the purposes of Maltese Institutions, in the case of Maltese Nationals, state the identity card number, if not a Maltese national, state Maltese social security number. In the case of Slovene nationals, state the personal identification number EMŠO.

(9) The day and the month should be shown by two digits each and the year by four digits (example: 1 August 1921 = 01.08.1921). (10) For French towns comprising several arrondissements, please give the number of the arrondissement (example: Paris 14). In the case of Portuguese districts state also the parish and the local authority. (11) Must be stated for insured persons of Spanish, French or Italian nationality. Here, the territorial area or district in which the place of birth is located should be stated (example: in the case of France if the place (commune) of birth is Lille, the department of birth should be shown as Nord followed by the area code if known to the insured person; in this case:

59. The complete entry should therefore read: Nord 59). In the case of persons born in Spain, state only the province). (12) The symbol of the insured person ' s country of birth in accordance with ISO code 3166-1. (13) Complete where appropriate. (14) Put P — compulsory insurance D — voluntary insurance N — periods treated as insurance periods. For Spanish institutions, specify where possible the type of activity in question. For Spanish institutions, in the case of seamen a photocopy of the sailor’s book or books of the country issuing the certificate should be enclosed. THE ADMINISTRATIVE COMMISSION ON SOCIAL SECURITY FOR MIGRANT WORKERS See ‘ Instructions ’ on page 4 E 205 DK (1) CERTIFICATE CONCERNING PERIODS OF INSURANCE AND PERIODS OF RESIDENCE IN DENMARK Regulation (EEC) No 1408/71;

Article 38; Article. 43a; Article 45; Article 48; Article 51a; Article 57(5) Regulation (EEC) No 574/72; Article 42(1); Article 43(1) to (3); Article 69 To be drawn up by the investigating institution for insurance periods completed under the legislation which it administers; where appropriate, to be attached to forms E 202, E 203 or E 204. Each institution concerned should draw up a form for the periods completed under the legislation which it administers and send it to the investigating institution. 1. Institution to which the form is addressed (institution concerned or investigating institution, as applicable) 1.1 Name: … … 1.2 Address (2): … … Information concerning the insured person 2.

2.1 Surname (3): … 2.2 Surname at birth (3): … 2.3 Forenames (4): … 2.4 Previous names (5): … 2.5 Sex (6): … 2.6 Father’s surname and forenames (7): … 2.7 Mother’s surname and forenames (7): … 3. Nationality (8): … 4. Details of birth 4.1 Date of birth (9): … 4.2 Place of birth (10): … 4.3 Province, department, county (11): … 4.4 Country (12): … 5. Address (2): … 6. 6.1 Insurance No at the investigating institution: … 6.2 Reference No of file at the investigating institution: … 6.3 Reference No of file at the institution concerned: … 7. Rightful claimant (13) 7.1 Surname (3): … 7.2 Forenames: … Surname at birth (3): … Place of birth (10): … 7.3 Date of birth: … Sex: … Nationality (8): … 7.4 Address (2): … … E 205 DK 8.

Periods during which periods of residence and periods treated as such were completed under the law on social pensions Periods of residence Year From To Years Days Months E 205 DK 8.1 Total length of period of insurance under Danish social security schemes: … 8.2 Remarks (14) (15): … … … 9. An insured person giving proof that he has completed an insurance period of less than one year may receive may not receive a pension under national legislation (Article 48(1) of Regulation (EEC) No 1408/71). 10. Institution completing the form 10.1 Name: … … 10.2 Address (2): … … 10.3 Stamp 10.4 Date: … 10.5 Signature:

E 205 DK INSTRUCTIONS Please complete this form in block letters, writing on the dotted lines only. It consists of four pages, none of which may be left out even if it does not contain any relevant information. NOTES (1) Symbol of the country to which the institution completing the form belongs: DK = Denmark. (2) Street, number, post code, town, country, telephone number. (3) For surname please state usual surname or surname acquired by marriage. The surname at birth must always be given; if same as current surname, put ‘ IDEM ’ . Expressions such as ‘ called … ’ or ‘ alias … ’ and prefixes to surnames must be written in full in the order in which they appear on the birth certificate.

In the case of Spanish nationals state both names at birth. In the case of Portuguese nationals state all names (forenames, surname, maiden name) in the order of civil status in which they appear on the identity card or passport. (4) Give all forenames in the order in which they appear on the birth certificate. (5) To be stated particularly in the case of adoption or in the case of other names in current use; expressions such as ‘ called … ’ or ‘ alias … ’ and prefixes to surnames must be written in full in the order in which they appear on the birth certificate. (6) Put M for male and F for female.

(7) This information is required when the worker is a Spanish national, or when the form is to be sent to a French institution, regardless of the worker’s nationality. (8) Where appropriate, indicate the date of naturalisation. For the purpose of Spanish institutions in the case of Spanish nationals state the number appearing on the national identity card (DNI) or NIE in the case of foreign people, for both cases if it exists, even if the identity card is out of date. Failing this, state ‘ None ’ . For the purposes of Maltese Institutions, in the case of Maltese nationals, state the identity card number, if not a Maltese national, state Maltese social security number.

In the case of Slovene nationals, state the personal identification number EMŠO. (9) The day and the month should be shown by two digits each and the year by four digits (example: 1 August 1921 = 01.08.1921). (10) For French towns comprising several arrondissements, please give the number of the arrondissement (example: Paris 14). In the case of Portuguese districts state also the parish and the local authority. (11) Must be stated for insured persons of Spanish, French or Italian nationality. Here, the territorial area or district in which the place of birth is located should be stated (example: in the case of France if the place (commune) of birth is Lille, the department of birth should be shown as Nord followed by the area code if known to the insured person; in this case:

59. The complete entry should therefore read: Nord 59). In the case of persons born in Spain, state only the province. (12) The symbol of the insured person’s country of birth in accordance with ISO code 3166-1. (13) Complete where appropriate. (14) For Spanish institutions, in the case of seamen a photocopy of the sailor’s book or books of the country issuing the certificate should be enclosed. (15) For Belgian, Greek and Spanish institutions specify where possible the type of activity in question. THE ADMINISTRATIVE COMMISSION FOR SOCIAL SECURITY FOR MIGRANT WORKERS See ‘ Instructions ’ on page 4 E 205 DE (1) CERTIFICATE CONCERNING INSURANCE HISTORY IN GERMANY Regulation (EEC) No 1408/71;

Article 38; Article. 43a; Article 45; Article 48; Article 51a; Article 57(5) Regulation (EEC) No 574/72; Article 42(1); Article 43(1) to (3); Article 69 To be drawn up by the investigating institution for insurance periods completed under the legislation which it administers; where appropriate, to be attached to forms E 202, E 203 or E 204. Each institution concerned should draw up a form for the periods completed under the legislation which it administers and send it to the investigating institution. 1. Institution to which the form is addressed (institution concerned or investigating institution, as applicable) 1.1 Name: … … 1.2 Address (2): … … Information concerning the insured person (2a) 2.

2.1 Surname (3): … 2.2 Surname at birth (3): … 2.3 Forenames (4): … 2.4 Previous names (5): … 2.5 Sex (6): … 2.6 Father’s surname and forenames (7): … 2.7 Mother’s surname and forenames (7): … 3. Nationality (8): … 4. Details of birth 4.1 Date of birth (9): … 4.2 Place of birth (10): … 4.3 Province, department, county (11): … 4.4 Country (12): … 5. Address (2): … 6. 6.1 Insurance No at the investigating institution: … 6.2 Reference No of file at the investigating institution: … 6.3 Reference No of file at the institution concerned: … 7. Rightful claimant (13) 7.1 Surname (3): … 7.2 Forenames: … Surname at birth (3): … Place of birth (10): … 7.3 Date of birth: … Sex: … Nationality (8): … 7.4 Address (2): … … … E 205 DE 8.

Completed insurance periods and periods treated as such Insurance periods (14) Periods treated as such Scheme Year From To Years Months Days Years Months Days Employees Self-employed Civil servants Miners (15) Occupation (16) (17) E 205 DE Total insurance period: 8.1.1 for the acquisition of entitlement to all types of pension: … Years … Months … Days; 8.1.2 plus only for the acquisition of entitlement to early retirement pensions for the long-term insured: … Years … Months … Days; 8.2 for pension calculation: … Years … Months … Days. 9. An insured person showing proof that he has completed an insurance period of less than one year may receive may not receive a pension under national legislation (Article 48(1) of Regulation (EEC) No 1408/71).

10. Institution completing the form 10.1 Name: … … 10.2 Address (2): … … 10.3 Stamp 10.4 Date: … 10.5 Signature: E 205 DE INSTRUCTIONS Please complete this form in block letters, writing on the dotted lines only. It consists of four pages, none of which may be left out even if it does not contain any relevant information. NOTES (1) Symbol of the country to which the institution completing the form belongs: DE = Germany. (2) Street, number, post code, town, country, telephone number. (2bis) The term ‘ insured persons ’ encompasses individuals insured under the general social security scheme as well as civil servants and individuals treated as such who are insured under a special scheme.

(3) For surname please state usual surname or surname acquired by marriage. The surname at birth must always be given; if same as current surname, put ‘ IDEM ’ . Expressions such as ‘ called … ’ or ‘ alias … ’ and prefixes to surnames must be written in full in the order in which they appear on the birth certificate. In the case of Spanish nationals state both names at birth. In the case of Portuguese nationals state all names (forenames, surname, maiden name) in the order of civil status in which they appear on the identity card or passport. (4) Give all forenames in the order in which they appear on the birth certificate.

(5) To be stated particularly in the case of adoption or in the case of other names in current use; expressions such as ‘ called … ’ or ‘ alias … ’ and prefixes to surnames must be written in full in the order in which they appear on the birth certificate. (6) Put M for male and F for female. (7) This information is required when the worker is a Spanish national, or when the form is to be sent to a French institution, regardless of the worker’s nationality. (8) Where appropriate, indicate the date of naturalisation. For the purpose of Spanish institutions in the case of Spanish nationals state the number appearing on the national identity card DNI (Documento Nacional de IdentidadI) or the NIE (Número de Identificación de Extranjeros) in the case of foreign people, for both cases if it exists, even if the identity card is out of date.

Failing this, state ‘ None ’ . For the purposes of Maltese institutions, in the case of Maltese nationals, state the identity card number, if not a Maltese national, state Maltese social security number. In the case of Slovene nationals, state the personal identification number EMŠO. (9) The day and the month should be shown by two digits each and the year by four digits (example: 1 August 1921 = 01.08.1921). (10) For French towns comprising several arrondissements, please give the number of the arrondissement (example: Paris 14). In the case of Portuguese districts state also the parish and the local authority.

(11) Must be stated for insured persons of Spanish, French or Italian nationality. Here, the territorial area or district in which the place of birth is located should be stated (example: in the case of France if the place (commune) of birth is Lille, the department of birth should be shown as Nord followed by the area code if known to the insured person; in this case: 59. The complete entry should therefore read: Nord 59). In the case of persons born in Spain, state only the province. (12) The symbol of the insured person’s country of birth in accordance with ISO code 3166-1. (13) Complete where appropriate.

(14) After the number of insurance months put ‘ F ’ (voluntary) for periods of voluntary insurance in order to avoid any confusion with compulsory insurance. (15) In the case of workers who were employed in mines or in undertakings treated as such, add the following Codes: 1 = activity above ground, 2 = activity underground, 3 = activity not specified. (16) For Belgian, Greek and Spanish institutions, specify where possible the type of activity in question. (17) For Spanish institutions, in the case of seamen a photocopy of the sailor’s book or books of the country issuing the certificate should be enclosed.

THE ADMINISTRATIVE COMMISSION ON SOCIAL SECURITY FOR MIGRANT WORKERS See ‘ Instructions ’ on page 4 E 205 EE (1) CERTIFICATE CONCERNING INSURANCE HISTORY IN THE ESTONIAN REPUBLIC Regulation (EEC) No 1408/71: Article 38; Article 43a; Article 45; Article 48; Article 51a; Article 57(5) Regulation (EEC) No 574/72; Art. 42(1); Article 43(1) to (3); Article 69 To be drawn up by the investigating institution for insurance periods completed under the legislation which it administers; where appropriate, to be attached to forms E 202, E 203 or E 204. Each institution concerned should draw up a form for the periods completed under the legislation which it administers and send it to the investigating institution.

1. Institution to which the form is addressed (institution concerned or investigating institution, as applicable) 1.1 Name: … … 1.2 Address (2): … … Information concerning the insured person 2. Names 2.1 Surname (3): … 2.2 Surname at birth (3): … 2.3 Forenames (4): … 2.4 Previous names (5): … 2.5 Sex (6): … 2.6 Father ' s surname and forenames (7): … 2.7 Mother ' s surname and forenames (7): … 3. Nationality (8): … 4. Details of birth 4.1 Date of birth (9): … 4.2 Place of birth: … 4.3 Country: … 5. Address (2): … … 6. 6.1 Reference No of file at the investigating institution: … 6.2 Reference No of file at the institution concerned: … 7.

Rightful claimant (10) 7.1 Surname (3): … 7.2 Forenames: … Surname at birth (3): … Place of birth: … 7.3 Date of birth: … Sex: … Nationality (8): … 7.4 Address (2): … … E 205 EE 8. Insurance periods and periods treated as insurance periods Length of pensionable insurance from 1.1.1999 (11) From To Length of service Year Accumulation period (11) Remarks: special pension schemes, occupation, unspecified periods of insurance, etc. (12) E 205 EE 8.1 Total length of period of insurance under Estonian social security schemes: … 8.2 Comments: … … … may receive may not receive a pension under national legislation (Article 48(1) of Regulation (EEC) No 1408/71).

9. An insured person showing proof that he has completed an insurance period of less than one year 10. Institution completing the form 10.1 Name: … … 10.2 Address (2): … 10.3 Stamp 10.4 Date: … 10.5 Signature: E 205 EE INSTRUCTIONS Please complete this form in block letters, writing on the dotted lines only. It consists of four pages, none of which may be left out even if it does not contain any relevant information. NOTES (1) Symbol of the country to which the institution completing the form belongs: EE = Estonia. (2) Street, number, post code, town, country, telephone number. (3) For surname please state usual surname or surname acquired by marriage.

The surname at birth must always be given; if same as current surname, put ‘ IDEM ’ . Expressions such as ‘ called … ’ or ‘ alias … ’ and prefixes to surnames must be written in full in the order in which they appear on the birth certificate. In the case of Spanish nationals state both names at birth. In the case of Portuguese nationals state all names (forenames, surname, maiden name) in the order of civil status in which they appear on the identity card or passport. (4) Give all forenames in the order in which they appear on the birth certificate. (5) This information is required when the worker is a Spanish national, or when the form is to be sent to a French institution, regardless of the worker ' s nationality.

(6) Put M for male and F for female. (7) This information is required when the worker is a Spanish national, or when the form is to be sent to a French institution, regardless of the worker ' s nationality. (8) Where appropriate, indicate the date of naturalisation. For the purpose of Spanish institutions in the case of Spanish nationals state the number appearing on the national identity card DNI (Documento Nacional de IdentidadI) or the NIE (Número de Identificación de Extranjeros) in the case of foreign people, for both cases if it exists, even if the identity card is out of date. Failing this, state ‘ None ’ .

For the purposes of Maltese Institutions, in the case of Maltese Nationals, state the identity card number, if not a Maltese national, state Maltese social security number. In the case of Slovene nationals, state the personal identification number EMŠO. (9) The day and the month should be shown by two digits each and the year by four digits (example: 1 August 1921 = 01.08.1921). (10) Complete where appropriate. (11) In Estonia from 01.01.1999 length of insurance is measured in so-called ‘ insurance years ’ (iy). Accumulation period of one year is calculated for a person for whom the social tax has been paid in an amount equal to social tax calculated on the basis of at least 12 minimum monthly wages for that year.

For the insurance periods completed after 1 January 1999 in occupation which is subject to a special scheme for miners or to the Law on Superannuated Pensions, both columns of the table are to be filled in: length of service and accumulation period. (12) For Belgian, Greek and Spanish institutions specify where possible the type of activity in question. For Spanish institutions, in the case of seamen a photocopy of the sailor’s books or books of the country issuing the certificate should be enclosed. THE ADMINISTRATIVE COMMISSION ON SOCIAL SECURITY FOR MIGRANT WORKERS See ‘ Instructions ’ on page 4 E 205 GR (1) CERTIFICATE CONCERNING INSURANCE HISTORY IN GREECE Regulation (EEC) No 1408/71;

Article 38; Article 43a; Article 45; Article 48; Article 51a; Article 57(5) Regulation (EEC) No 574/72; Article 42(1); Article 43(1) to (3); Article 69 To be drawn up by the investigating institution for insurance periods completed under the legislation which it administers; where appropriate, to be attached to forms E 202, E 203 or E 204. Each institution concerned should draw up a form for the periods completed under the legislation which it administers and send it to the investigating institution. 1. Institution to which the form is addressed (institution concerned or investigating institution, as applicable) 1.1 Name: … … 1.2 Address (2): … … Information concerning the insured person 2.

Names 2.1 Surname (3): … 2.2 Surname at birth (3): … 2.3 Forenames (4): … 2.4 Previous names (5): … 2.5 Sex (6): … 2.6 Father’s surname and forenames (7): … 2.7 Mother’s surname and forenames (7): … 3. Nationality (8): … 4. Details of birth 4.1 Date of birth (9): … 4.2 Place of birth (10): … 4.3 Province, department, county (11): … 4.4 Country (12): … 5. Address (2): … … 6. 6.1 Insurance No at the investigating institution: … 6.2 Reference No of file at the investigating institution: … 6.3 Reference No of file at the institution concerned: … 7. Rightful claimant (13) 7.1 Surname (3): … 7.2 Forenames: … Surname at birth: … Place of birth (10): … 7.3 Date of birth: … Sex: … Nationality (8): … 7.4 Address (2): … … E 205 GR 8.

Periods during which periods of insurance and periods treated as such were completed Periods of insurance (14) Periods treated as periods of insurance (15) Year From To Years Months Days Years Months Days Occupation — type of work (16) (17) (18) E 205 GR 8.1 Total length of period of insurance under Greek social security schemes: … years … months … days; of which period to be taken into account for the acquisition of entitlement: … years … months …days; period to be taken into account for the calculation of benefits: … years … months … days; 8.2 Remarks (15): … … … 9. An insured person showing proof that he has completed an insurance period of less than one year may receive may not receive a pension under national legislation (Article 48(1) of Regulation (EEC) No 1408/71).

10. Institution completing the form 10.1 Name: … … 10.2 Address (2): … … 10.3 Stamp 10.4 Date: … 10.5 Signature: E 205 GR INSTRUCTIONS Please complete this form in block letters, writing on the dotted lines only. It consists of four pages, none of which may be left out even if it does not contain any relevant information. NOTES (1) Symbol of the country to which the institution completing the form belongs: GR = Greece. (2) Street, number, post code, town, country, telephone number. (3) For surname please state usual surname or surname acquired by marriage. The surname at birth must always be given; if same as current surname, put ‘ IDEM ’ .

Expressions such as ‘ called … ’ or ‘ alias … ’ and prefixes to surnames must be written in full in the order in which they appear on the birth certificate. In the case of Spanish nationals state both names at birth. In the case of Portuguese nationals state all names (forenames, surname, maiden name) in the order of civil status in which they appear on the identity card or passport. (4) Give all forenames in the order in which they appear on the birth certificate. (5) To be stated particularly in the case of adoption or in the case of other names in current use; expressions such as ‘ called … ’ or ‘ alias … ’ and prefixes to surnames must be written in full in the order in which they appear on the birth certificate.

(6) Put M for male and F for female. (7) This information is required when the worker is a Spanish national, or when the form is to be sent to a French institution, regardless of the worker’s nationality. (8) Where appropriate, indicate the date of naturalisation. For the purpose of Spanish institutions in the case of Spanish nationals state the number appearing on the national identity card (DNI) or NIE in the case of foreign people, for both cases if it exists, even if the identity card is out of date. Failing this, state ‘ None ’ . For the purposes of Maltese Institutions, in the case of Maltese Nationals, state the identity card number, if not a Maltese national, state Maltese social security number.

In the case of Slovene nationals, state the personal identification number EMŠO. (9) The day and the month should be shown by two digits each and the year by four digits (example: 1 August 1921 = 01.08.1921). (10) For French towns comprising several arrondissements, please give the number of the arrondissement (example: Paris 14). In the case of Portuguese districts state also the parish and the local authority. (11) Must be stated for insured persons of Spanish, French or Italian nationality. Here, the territorial area or district in which the place of birth is located should be stated (example: in the case of France if the place (commune) of birth is Lille, the department of birth should be shown as Nord followed by the area code if known to the insured person; in this case:

59. The complete entry should therefore read: Nord 59). In the case of persons born in Spain, state only the province. (12) The symbol of the insured person’s country of birth in accordance with ISO code 3166-1. (13) Complete where appropriate. (14) After the period of voluntary insurance, put ‘ V ’ for voluntary insurance in order to avoid any confusion with compulsory insurance. (15) In 8.2 indicate the nature of the periods treated as insurance periods. (16) In the case of workers who were employed in mines or in undertakings treated as such, for Austrian purposes add an E 205A additional form.

(17) Specify the type of activity and indicate the category. (18) For Spanish institutions, in the case of seamen a photocopy of the sailor’s book or books of the country issuing the certificate should be enclosed. THE ADMINISTRATIVE COMMISSION ON SOCIAL SECURITY FOR MIGRANT WORKERS See ‘ Instructions ’ on page 4 E 205 ES (1) CERTIFICATE CONCERNING INSURANCE HISTORY IN SPAIN Regulation (EEC) No 1408/71; Article 38; Article 43a; Article 45; Article 48; Article 51a; Article 57(5) Regulation (EEC) No 574/72; Article 42(1); Article 43(1) to (3); Article 69 To be drawn up by the investigating institution for insurance periods completed under the legislation which it administers; where appropriate, to be attached to forms E 202, E 203 or E 204.

Each institution concerned should draw up a form for the periods completed under the legislation which it administers and send it to the investigating institution. 1. Institution to which the form is addressed (institution concerned or investigating institution, as applicable) 1.1 Name: … … 1.2 Address (2): … … Information concerning the insured person 2. 2.1 Surname (3): … 2.2 Surname at birth (3): … 2.3 Forenames (4): … 2.4 Previous names (5): … 2.5 Sex (6): … 2.6 Father’s surname and forenames (7): … 2.7 Mother’s surname and forenames (7): … 3. Nationality (8): … 4.

Details of birth 4.1 Date of birth (9): … 4.2 Place of birth (10): … 4.3 Province, department, county (11): … 4.4 Country (12): … 5. Address (2): … 6. 6.1 Insurance No at the investigating institution: … 6.2 Reference No of file at the investigating institution: … 6.3 Reference No of file at the institution concerned: … 7. Rightful claimant (13) 7.1 Surname (3): … 7.2 Forenames: … Surname at birth: … Place of birth (10): … 7.3 Date of birth: … Sex: … Nationality: … 7.4 Address (2): … … E 205 ES 8. Periods during which insurance periods and periods treated as such were completed Insurance periods (14) Periods treated as insurance periods Year from to Years Months Days Years Months Days Schemes Occupation (15) (16) (17) 8a.

Mines Periods Year To Months Insurance Periods Periods treated as insurance periods From Years Days Years Months Days Type of undertakings (18) Profession (19) Underground work (20) Surface (20) Periods of interruption From To Day Month Year Day Month Year Reason for the interruption (21) Total Years Months Days Total length of activity Total length of underground activity E 205 ES 8.1 Total length of period of insurance under Spanish social security schemes for employed persons: period to be taken into account for the acquisition of entitlement and for calculation of benefits: … years … months … days periods to be taken into account only for the acquisition of entitlement: … years … months … days periods to be taken for calculation of benefits: … years … months … days 8.2 Total length of period of insurance under Spanish social security schemes for self-employed persons: periods to be taken into account for the acquisition of entitlement and for calculation of benefits: … years … months … days periods to be taken into account only for the acquisition of entitlement: … years … months … days periods to be taken for calculation benefits: … years … months … days 8.3 Remarks: … … … 9.

An insured person showing proof that he has completed an insurance period of less than one year may receive may not receive a pension under national legislation (Article 48(1) of Regulation (EEC) No 1408/71). 10. Institution completing the form 10.1 Name: … … 10.2 Address (2): … … 10.3 Stamp 10.4 Date: … 10.5 Signature: E 205 ES INSTRUCTIONS Please complete this form in block letters, writing on the dotted lines only. It consists of four pages, none of which may be left out even if it does not contain any relevant information. NOTES (1) Symbol of the country to which the institution completing the form belongs:

ES = Spain. (2) Street, number, post code, town, country, telephone number. (3) For surname please state usual surname or surname acquired by marriage. The surname at birth must always be given; if same as current surname, put ‘ IDEM ’ . Expressions such as ‘ called … ’ or ‘ alias … ’ and prefixes to surnames must be written in full in the order in which they appear on the birth certificate. In the case of Spanish nationals state both names at birth. In the case of Portuguese nationals state all names (forenames, surname, maiden name) in the order of civil status in which they appear on the identity card or passport.

(4) Give all forenames in the order in which they appear on the birth certificate. (5) To be stated particularly in the case of adoption or in the case of other names in current use; expressions such as ‘ called … ’ or ‘ alias … ’ and prefixes to surnames must be written in full in the order in which they appear on the birth certificate. (6) Put M for male and F for female. (7) This information is required when the worker is a Spanish national, or when the form is to be sent to a French institution, regardless of the worker’s nationality. (8) Where appropriate, indicate the date of naturalisation.

For the purpose of Spanish institutions in the case of Spanish nationals state the number appearing on the national identity card (DNI) or NIE, in the case of foreigners, for both cases if it exists, even if the identity card is out of date. Failing this, state “ None ” . For the purposes of Maltese institutions, in the case of Maltese nationals, state the identity card number, if not a Maltese national, state Maltese social security number. In the case of Slovene nationals, state the personal identification number EMŠO. (9) The day and the month should be shown by two digits each and the year by four digits (example:

1 August 1921 = 01.08.1921). (10) For French towns comprising several arrondissements, please give the number of the arrondissement (example: Paris 14). In the case of Portuguese districts state also the parish and the local authority. (11) Must be stated for insured persons of Spanish, French or Italian nationality. Here, the territorial area or district in which the place of birth is located should be stated (example: in the case of France if the place (commune) of birth is Lille, the department of birth should be shown as ‘ Nord ’ followed by the area code if known to the insured person; in this case:

59. The complete entry should therefore read: ‘ Nord 59 ’ ). In the case of persons born in Spain, state only the province. (12) The symbol of the insured person’s country of birth in accordance with ISO code 3166-1. (13) Complete where appropriate. (14) After the number of voluntary insurance years or days put " V in order to avoid any confusion with compulsory insurance. (15) In the case of workers who were employed in mines or in undertakings treated as such, for Austrian purposes add an E 205A additional form. (16) For Belgian, Greek and Spanish institutions, specify where possible the type of work in question.

(17) For Spanish institutions, in the case of seamen a photocopy of the sailor ' s book or books of the country issuing the certificate should be enclosed. (18) Indicate the substance extracted or processed (coal, copper, etc…). (19) Specify type of work performed in mines. (20) Put a cross (X) in the suitable square, whether the activity is performed at the surface or underground. (21) Specify the reason for interruption (sickness, leave, unemployment, etc.). THE ADMINISTRATIVE COMMISSION ON SOCIAL SECURITY FOR MIGRANT WORKERS See ‘ Instructions ’ on page 4 E 205 FR (1) CERTIFICATE CONCERNING INSURANCE HISTORY IN FRANCE Regulation (EEC) No 1408/71;

Article 38; Article 43a; Article 45; Article 48; Article 51a; Article 57(5) Regulation (EEC) No 574/72; Article 42(1); Article 43(1) to (3); Article 69 To be drawn up by the investigating institution for insurance periods completed under the legislation which it administers; where appropriate, to be attached to forms E 202, E 203 or E 204. Each institution concerned should draw up a form for the periods completed under the legislation which it administers and send it to the investigating institution. 1. Institution to which the form is addressed (institution concerned or investigating institution, as applicable) 1.1 Name: … … 1.2 Address (2): … … Information concerning the insured person 2.

Names 2.1 Surname (3): … 2.2 Surname at birth (3): … 2.3 Forenames (4): … 2.4 Previous names (5): … 2.5 Sex (6): … 2.6 Father’s surname and forenames (7): … 2.7 Mother’s surname and forenames (7): … 3. Nationality (8): … 4. Details of birth 4.1 Date of birth (9): … 4.2 Place of birth (10): … 4.3 Province, department, county (11): … 4.4 Country (12): … 5. Address (2): … … 6. 6.1 Insurance No at the investigating institution: … 6.2 Reference No of file at the investigating institution: … 6.3 File at the institution concerned: … 7. Rightful claimant (13) 7.1 Surname (3): … 7.2 Forenames: … Surname at birth (3): … Place of birth (10): … 7.3 Date of birth: … Sex: … Nationality (8): … 7.4 Address (2): … … E 205 FR 8.

Periods during which insurance periods and periods treated as such were completed Insurance periods (14) Periods treated as insurance periods (15) Insurance schemes Year From To (quarters) (quarters) Employed person Self-employed person Occupation (16) (17) (18) Benefit increase for mothers E 205 FR 8.1 Total length of period of insurance under French social security schemes for employed and self-employed persons: … 8.2 Comments (15): … … … 9. An insured person showing proof that he has completed an insurance period of less than one year may receive may not receive a pension under national legislation (Article 48(1) of Regulation (EEC) No 1408/71).

10. Institution completing the form 10.1 Name: … … 10.2 Address (2): … … 10.3 Stamp 10.4 Date: … 10.5 Signature: E 205 FR INSTRUCTIONS Please complete this form in block letters, writing on the dotted lines only. It consists of four pages, none of which may be left out even if it does not contain any relevant information. NOTES (1) Symbol of the country to which the institution completing the form belongs: FR = France. (2) Street, number, post code, town, country, telephone number. (3) For surname please state usual surname or surname acquired by marriage. The surname at birth must always be given; if same as current surname, put ‘ IDEM ’ .

Expressions such as ‘ called … ’ or ‘ alias … ’ and prefixes to surnames must be written in full in the order in which they appear on the birth certificate. In the case of Spanish nationals state both names at birth. In the case of Portuguese nationals state all names (forenames, surname, maiden name) in the order of civil status in which they appear on the identity card or passport. (4) Give all forenames in the order in which they appear on the birth certificate. (5) To be stated particularly in the case of adoption or in the case of other names in current use; expressions such as ‘ called … ’ or ‘ alias … ’ and prefixes to surnames must be written in full in the order in which they appear on the birth certificate.

(6) Put M for male and F for female. (7) This information is required when the worker is a Spanish national, or when the form is to be sent to a French institution, regardless of the worker’s nationality. (8) Where appropriate, indicate the date of naturalisation. For the purpose of Spanish institutions in the case of Spanish nationals state the number appearing on the national identity card DNI (Documento Nacional de IdentidadI) or the NIE (Número de Identificación de Extranjeros) in the case of foreigners, for both cases if it exists, even if the identity card is out of date. Failing this, state ‘ None ’ .

For the purposes of Maltese institutions, in the case of Maltese nationals, state the identity card number, if not a Maltese national, state Maltese social security number. In the case of Slovene nationals, state the personal identification number EMŠO. (9) The day and the month should be shown by two digits each and the year by four digits (example: 1 August 1921 = 01.08.1921). (10) For French towns comprising several arrondissements, please give the number of the arrondissement (example: Paris 14). In the case of Portuguese districts state also the parish and the local authority. (11) Must be stated for insured persons of Spanish, French or Italian nationality.

Here, the territorial area or district in which the place of birth is located should be stated (example: in the case of France if the place (commune) of birth is Lille, the department of birth should be shown as ‘ Nord ’ followed by the area code if known to the insured person; in this case: 59. The complete entry should therefore read: ‘ Nord 59 ’ . In the case of persons born in Spain, state only the province. (12) The symbol of the insured person’s country of birth in accordance with ISO code 3166-1. (13) Complete where appropriate. (14) After the periods of voluntary insurance, put ‘ V ’ for voluntary insurance in order to avoid any confusion with compulsory insurance.

After periods referred to in Article 15(2) of Regulation 574/72 put ‘ S ’ . (15) In 8.2 indicate the nature of the periods treated as insurance periods. (16) In the case of workers who were employed in mines or in undertakings treated as such, add the following codes: 1 = activity above ground, 2 = activity underground, 3 = activity not specified. (17) For Belgian, Greek and Spanish institutions, specify where possible the type of activity in question. (18) For Spanish institutions, in the case of seamen a photocopy of the sailor’s book or books of the country issuing the certificate should be enclosed.

THE ADMINISTRATIVE COMMISSION ON SOCIAL SECURITY FOR MIGRANT WORKERS See ‘ Instructions ’ on page 4 E 205 IE (1) CERTIFICATE CONCERNING INSURANCE HISTORY IN IRELAND Regulation (EEC) No 1408/71; Article 38; Article 43a; Article 45; Article 48; Article 51a; Article 57(5) Regulation (EEC) No 574/72; Article 42(1); Article 43(1) to (3); Article 69 To be drawn up by the investigating institution for insurance periods completed under the legislation which it administers; where appropriate, to be attached to forms E 202, E 203 or E 204. Each institution concerned should draw up a form for the periods completed under the legislation which it administers and send it to the investigating institution.

1. Institution to which the form is addressed (institution concerned or investigating institution, as applicable) 1.1 Name: … … 1.2 Address (2): … … Information concerning the in sured person 2. Names 2.1 Surname (3): … 2.2 Surname at birth (3): … 2.3 Forenames (4): … 2.4 Previous names (5): … 2.5 Sex (6): … 2.6 Father’s surname and forenames (7): … 2.7 Mother’s surname and forenames (7): … 3. Nationality (8): … 4. Details of birth 4.1 Date of birth (9): … 4.2 Place of birth (10): … 4.3 Province, department, county (11): … 4.4 Country (12): … 5. Address (2): … … 6.

6.1 Insurance No at the investigating institution: … 6.2 Reference No of file at the investigating institution: … 6.3 Reference No of file at the institution concerned: … 7. Rightful claimant (13) 7.1 Surname (3): … 7.2 Forenames: … Surname at birth: … Place of birth (10): … 7.3 Date of birth: … Sex: … Nationality: … 7.4 Address (2): … E 205 IE 8. Periods during which insurance periods and periods treated as such were completed Insurance periods (14) Periods treated as insurance period Year From To (weeks) (weeks) Reason for treating these periods as insurance periods (15) Occupation (16) (17) (18) E 205 IE 8.1 Total length of period of insurance under the Irish social security shemes for employed persons: … 8.2 Comments: … … … … 9.

An insured person showing proof that he has completed an insurance period of less than one year may receive may not receive a pension under national legislation (Article 48(1) of Regulation (EEC) No 1408/71). 10. Institution completing the form 10.1 Name: … … 10.2 Address (2): … … 10.3 Stamp 10.4 Date: … 10.5 Signature: E 205 IE INSTRUCTIONS Please complete this form in block letters, writing on the dotted lines only. It consists of four pages, none of which may be left out even if it does not contain any relevant information. NOTES (1) Symbol of the country to which the institution completing the form belongs:

IE = Ireland. (2) Street, number, post code, town, country, telephone number. (3) For surname please state usual surname or surname acquired by marriage. The surname at birth must always be given; if same as current surname, put ‘ IDEM ’ . Expressions such as ‘ called … ’ or ‘ alias … ’ and prefixes to surnames must be written in full in the order in which they appear on the birth certificate. In the case of Spanish nationals state both names at birth. In the case of Portuguese nationals state all names (forenames, surname, maiden name) in the order of civil status in which they appear on the identity card or passport.

(4) Give all forenames in the order in which they appear on the birth certificate. (5) To be stated particularly in the case of adoption or in the case of other names in current use; expressions such as ‘ called … ’ or ‘ alias … ’ and prefixes to surnames must be written in full in the order in which they appear on the birth certificate. (6) Put M for male and F for female. (7) This information is required when the worker is a Spanish national, or when the form is to be sent to a French institution, regardless of the worker’s nationality. (8) Where appropriate, indicate the date of naturalisation.

For the purpose of Spanish institutions in the case of Spanish nationals state the number appearing on the national identity card DNI (Documento Nacional de IdentidadI) or the NIE (Número de Identificación de Extranjeros) in the case of foreigners, for both cases if it exists, even if the identity card is out of date. Failing this, state ‘ None ’ . For the purposes of Maltese Institutions, in the case of Maltese nationals, state the identity card number. If not a Maltese national, state Maltese social security number. In the case of Slovene nationals, state the personal identification number EMŠO.

(9) The day and the month should be shown by two digits each and the year by four digits (example: 1 August 1921 = 01.08.1921). (10) For French towns comprising several arrondissements, please give the number of the arrondissement (example: Paris 14). In the case of Portuguese districts state also the parish and the local authority. (11) Must be stated for insured persons of Spanish, French or Italian nationality. Here, the territorial area or district in which the place of birth is located should be stated (example: in the case of France if the place (commune) of birth is Lille, the department of birth should be shown as ‘ Nord ’ followed by the area code if known to the insured person; in this case:

59. The complete entry should therefore read: ‘ Nord 59 ’ ). In the case of persons born in Spain, state only the province. (12) The symbol of the insured person’s country of birth in accordance with the international motor vehicle registration code. (13) Complete where appropriate. (14) After the number of weeks put ‘ V ’ where the periods in question are periods of voluntary insurance. (15) Indicate whether the period in question are periods of illness, unemployment, etc. (16) In the case of insured persons who were employed in mines or in undertakings treated as such, this data may be issued only on the basis of information supplied by the employee.

(17) For Belgian, Greek and Spanish institutions, specify where possible the type of activity in question. (18) For Spanish institutions, in the case of seamen a photocopy of the sailor’s book or books of the country issuing the certificate should be enclosed. THE ADMINISTRATIVE COMMISSION ON SOCIAL SECURITY FOR MIGRANT WORKERS See ‘ Instructions ’ on page 4 E 205 IT (1) CERTIFICATE CONCERNING INSURANCE HISTORY IN ITALY Regulation (EEC) No 1408/71; Article 38; Article 43a; Article 45; Article 48; Article 51a; Article 57(5) Regulation (EEC) No 574/72; Article 42(1); Article 43(1) to (3); Article 69 To be drawn up by the investigating institution for insurance periods completed under the legislation which it administers; where appropriate, to be attached to forms E 202, E 203 or E 204.

Each institution concerned should draw up a form for the periods completed under the legislation which it administers and send it to the investigating institution. 1. Institution to which the form is addressed (institution concerned or investigating institution, as applicable) 1.1 Name: … … 1.2 Address (2): … … Information concerning the insured person 2. Names 2.1 Surname (3): … 2.2 Surname at birth (3): … 2.3 Forenames (4): … 2.4 Previous names (5): … 2.5 Sex (6): … 2.6 Father’s surname and forenames (7): … 2.7 Mother’s surname and forenames (7): … 3. Nationality (8): … 4.

Details of birth 4.1 Date of birth (9): … 4.2 Place of birth (10): … 4.3 Province, department, county (11): … 4.4 Country (12): … 5. Address (2): … … 6. 6.1 Insurance No at the investigating institution: … 6.2 Reference No of file at the investigating institution: … 6.3 Reference No of file at the institution concerned: … 7. Rightful claimant (13) 7.1 Surname (3): … 7.2 Forenames (4): … Surname at birth (3): … Place of birth (10): … 7.3 Date of birth: … Sex: … Nationality (8): … 7.4 Address (2): … … E 205 IT 8. Periods during which insurance periods and periods treated as such were completed Insurance periods (14) Periods treated as insurance periods (15) Insurance scheme Year From To Weeks Months Weeks Months Employed persons Self-employed persons Occupation (16) (17) (18) E 205 IT 8.1 Total length of period of insurance under Italian social security schemes for employed persons and self-employed persons treated as such: periods to be taken into account for the acquisition of entitlement and for calculation of benefits: … weeks … months periods to be taken into account only for the calculation of benefits: … weeks … months periods to be taken into account only for the acquisition of entitlement to benefits: … weeks … months The periods of … up to … are converted into benefits with effect from … 8.2 Comments (15): … … … 9.

An insured person showing proof that he has completed an insurance period of less than one year may receive may not receive a pension under national legislation (Article 48(1) of Regulation (EEC) No 1408/71). 10. Institution completing the form 10.1 Name: … 10.2 Address (2): … … 10.4 Date: … 10.3 Stamp 10.5 Signature: E 205 IT INSTRUCTIONS Please complete this form in block letters, writing on the dotted lines only. It consists of four pages, none of which may be left out even if it does not contain any relevant information. NOTES (1) Symbol of the country to which the institution completing the form belongs:

IT = Italy. (2) Street, number, post code, town, country, telephone number. (3) For surname please state usual surname or surname acquired by marriage. The surname at birth must always be given; if same as current surname, put ‘ IDEM ’ . Expressions such as ‘ called … ’ or ‘ alias … ’ and prefixes to surnames must be written in full in the order in which they appear on the birth certificate. In the case of Spanish nationals state both names at birth. In the case of Portuguese nationals state all names (forenames, surname, maiden name) in the order of civil status in which they appear on the identity card or passport.

(4) Give all forenames in the order in which they appear on the birth certificate. (5) To be stated particularly in the case of adoption or in the case of other names in current use; expressions such as ‘ called … ’ or ‘ alias … ’ and prefixes to surnames must be written in full in the order in which they appear on the birth certificate. (6) Put M for male and F for female. (7) This information is required when the worker is a Spanish national, or when the form is to be sent to a French institution, regardless of the worker’s nationality. (8) Where appropriate, indicate the date of naturalisation.

For the purpose of Spanish institutions in the case of Spanish nationals state the number appearing on the national identity card DNI (Documento Nacional de IdentidadI) or the NIE (Número de Identificación de Extranjeros) in the case of foreigners, for both cases if it exists, even if the identity card is out of date. Failing this, state ‘ None ’ . For the purposes of Maltese institutions, in the case of Maltese nationals, state the identity card number. If not a Maltese national, state Maltese social security number. In the case of Slovene nationals, state the personal identification number EMŠO.

(9) The day and the month should be shown by two digits each and the year by four digits (example: 1 August 1921 = 01:08.1921). (10) For French towns comprising several arrondissements, please give the number of the arrondissement (example: Paris 14). In the case of Portuguese districts state also the parish and the local authority. (11) Must be stated for insured persons of Spanish, French or Italian nationality. Here, the territorial area or district in which the place of birth is located should be stated (example: in the case of France if the place (commune) of birth is Lille, the department of birth should be shown as ‘ Nord ’ followed by the area code if known to the insured person; in this case:

59. The complete entry should therefore read: ‘ Nord 59 ’ . In the case of persons born in Spain, state only the province. (12) The symbol of the insured person’s country of birth in accordance with ISO code 3166-1. (13) Complete where appropriate. (14) After the number of weeks or months put ‘ P ’ for periods of compulsory insurance in order to avoid any confusion with periods of voluntary insurance. (15) In 8.2 indicate the nature of the periods treated as insurance periods. (16) In the case of workers who were employed in mines or in undertakings treated as such, for Austrian purposes add an E 205A additional form.

(17) For Belgian, Greek and Spanish institutions, specify where possible the type of activity in question. (18) For Spanish institutions, in the case of seamen a photocopy of the sailor’s book or books of the country issuing the certificate should be enclosed. THE ADMINISTRATIVE COMMISSION ON SOCIAL SECURITY FOR MIGRANT WORKERS See ‘ Instructions ’ on page 4 E 205 CY (1) CERTIFICATE CONCERNING INSURANCE HISTORY IN CYPRUS Regulation (EEC) No 1408/71: Article 38; Article 45; Article 48; Article 57(5) Regulation (EEC) No 574/72: Article 42(1); Article 43(1) to (3); Article 69 To be drawn up by the investigating institution for insurance periods completed under the legislation which it administers; where appropriate, to be attached to forms E 202, E 203 or E 204.

Each institution concerned should draw up a form for the periods completed under the legislation which it administers and send it to the investigating institution. 1. Institution to which the form is addressed (institution concerned or investigating institution, as applicable) 1.1 Name: … … 1.2 Code No: … 1.3 Address (2): … … Information concerning the insured person 2. Names 2.1 Surname (3): … 2.2 Surname at birth (3): … 2.3 Forenames (4): … 2.4 Previous name: … 2.5 Sex (6): … 2.6 Father’s surname and forenames (7): … 2.7 Mother’s surname and forenames (7): … 3. Nationality (8): … 4.

Details of birth 4.1 Date of birth (9): … 4.2 Place of birth (10): … 4.3 Province, department (11): … 4.4 Country (12): … 5. Address (2): … … 6. 6.1 Insurance No at the investigating institution: … 6.2 Reference No of file at the investigating institution: … 6.3 Reference No of file at the institution concerned: … 7. Rightful claimant (13) 7.1 Surname (3): … 7.2 Forenames: … Surname at birth (3): … Place of birth (10): … 7.3 Date of birth: … Sex: … Nationality (8): … 7.4 Address (2): … … E 205 CY 8. Periods during which insurance periods and periods as such were completed (14) Employed Persons Self-employed Persons Voluntary insurance Year From To Weeks Weeks Weeks 8.1 Total length of period of insurance under Cyprus social security scheme for employed and self-employed persons: … 8.2 Comments: … … … Insurance periods Periods treated as Insurance Periods (15) Weeks Occupation (16) (17) (18) E 205 CY 9.

An insured person showing proof that he has completed an insurance period of less than one year may receive may not receive a pension under national legislation (Article 48(1) of Regulation (EEC) No 1408/71). 10. Institution completing the form 10.1 Name: … 10.2 Address (2): … … 10.3 Stamp 10.4 Date: … 10.5 Signature: E 205 CY INSTRUCTIONS Please complete this form in block letters, writing on the dotted lines only. It consists of four pages, none of which may be left out even if it does not contain any relevant information. NOTES (1) Symbol of the country to which the institution completing the form belongs:

CY = Cyprus. (2) Street, number, post code, town, country, telephone number. (3) For surname please state usual surname or surname acquired by marriage. The ‘ surname at birth ’ must always be given; if same as current surname, put ‘ IDEM ’ . Expressions such as ‘ called … ’ or ‘ alias … ’ and prefixes to surnames must be written in full in the order in which they appear on the birth certificate. If the form is being completed by a Netherlands institution, in cases where the insured person or the rightful claimant is a married woman or a woman who was married before, put the present or last husband’s surname for current surname and the maiden name for surname at birth.

In the case of Spanish nationals state both names at birth. In the case of Portuguese nationals state all names (forenames, surname, maiden name) in the order of civil status in which they appear on the identity card or passport. (4) Give all forenames in the order in which they appear on birth certificate. (5) To be stated particularly in the case of adoption or in the case of other names in current use; expressions such as ‘ called … ’ or ‘ alias … ’ and prefixes to surnames must be written in full in the order in which they appear on the birth certificate. (6) Put M for male and F for female.

(7) This information is required when the worker is a Spanish national, or when the form is to be sent to a French institution, regardless of the worker’s nationality. (8) Where appropriate, indicate the date of naturalisation. For the purpose of Spanish institutions in the case of Spanish nationals state the number appearing on the national identity card (DNI) or NIE in the case of foreigners, for both cases if it exists, even if the identity card is out of date. Failing this, state ‘ None ’ . For the purposes of Maltese Institutions, in the case of Maltese Nationals, state the identity card number.

If not a maltese national, state maltese social security number. In the case of Slovene nationals, state the personal identification number EMŠO. (9) The day and the month should be shown by two digits each and the year by four digits (example: 1 August 1921. = 01.08.1921). (10) For French towns comprising several arrondissements, please give the number of the arrondissement (example: Paris 14). In the case of Portuguese districts state also the parish and the local authority. (11) Must be stated for insured persons of Spanish, French or Italian nationality. Here, the territorial area or district in which the place of birth is located should be stated (example: in the case of France if the place (commune) of birth is Lille, the department of birth should be shown as ‘ Nord ’ followed by the area code if known to the insured person; in this case:

59. The complete entry should therefore read: ‘ Nord 59 ’ ). In the case of persons born in Spain, state only the province. (12) The symbol of the insured person’s country of birth in accordance with ISO code 3166-1. (13) Complete where appropriate. (14) Insurance periods from 1 January 1957. (15) In 8.2 indicate the nature of the periods treated as periods of employment/illness unemployment etc. (16) In the case of workers who were employed in mines or in undertakings treated as such for Cyprus institutions, specify the type of activity in question. (17) For Belgian, Greek and Spanish institutions, specify where possible the type of activity in question.

(18) For Spanish institutions, in the case of seamen a photocopy of the sailor’s book or books of the country issuing the certificate should be enclosed. THE ADMINISTRATIVE COMMISSION ON SOCIAL SECURITY FOR MIGRANT WORKERS See ‘ Instructions ’ on page 4 E 205 LV (1) CERTIFICATE CONCERNING INSURANCE HISTORY IN LATVIA Regulation (EEC) No 1408/71: Article 38; Article 43a; Article 45; Article 48; Article 51a; Article 57(5) Regulation (EEC) No 574/72; Article 42(1); Article 43(1) to (3); Article 69 To be drawn up by the investigating institution for insurance periods completed under the legislation which it administers; where appropriate, to be attached to forms E 202, E 203 or E 204.

Each institution concerned should draw up a form for the periods completed under the legislation which it administers and send it to the investigating institution. 1. Institution to which the form is addressed (institution concerned or investigating institution, as applicable) 1.1 Name: … … 1.2 Address (2): … … Information concerning the insured person 2. Names 2.1 Surname (3): … 2.2 Surname at birth (3): … 2.3 Forenames (4): … 2.4 Previous names (5): … 2.5 Sex (6): … 2.6 Father ' s surname and forenames (7): … 2.7 Mother ' s surname and forenames (7): … 3. Nationality (8): … 4.

Details of birth 4.1 Date of birth (9): … 4.2 Place of birth (10): … 4.3 Province, department, county (11): … 4.4 Country (12): … 5. Address (2): … … 6. 6.1 Insurance No at the investigating institution: … 6.2 Reference No of file at the investigating institution: … 6.3 Reference No of file at the institution concerned: … 7. Rightful claimant (13) 7.1 Surname (3): … 7.2 Forenames: … Surname at birth (3): … Place of birth (10): … 7.3 Date of birth (9): … Sex: … Nationality (8): … 7.4 Address (2): … … E 205 LV 8. Periods during which periods of insurance and periods treated as such were completed Periods of insurance (14) (15) Periods treated as periods of insurance (until 1991) From To Years Months Days Years Months Days Remarks (16) E 205 LV 8.1 Total length of periods of insurance under Latvian social security scheme to be taken into account for the acquisition of entitlement and for calculation of benefits: … years … months … days 8.2 Remarks: … … … 9.

An insured person showing proof that he has completed an insurance period of less than one year may receive may not receive a pension under national legislation (Article 48(1) of Regulation (EEC) No 1408/71). 10. Institution completing the form 10.1 Name: … … 10.2 Address (2): … … 10.3 Stamp 10.4 Date: … 10.5 Signature: E 205 LV INSTRUCTIONS Please complete this form in block letters, writing on the dotted lines only. It consists of four pages, none of which may be left out even if it does not contain any relevant information. NOTES (1) Symbol of the country to which the institution completing the form belongs:

LV = Latvia. (2) Street, number, post code, town, country, telephone number. (3) For surname please state usual surname or surname acquired by marriage. The surname at birth must always be given; if same as current surname put ‘ IDEM ’ . Expressions such as ‘ called … ’ or ‘ alias … ’ and prefixes to surnames must be written in full in the order in which they appear on the birth certificate. In the case of Spanish nationals state both names at birth. In the case of Portuguese nationals state all names (forenames, surname, maiden name) in the order of civil status in which they appear on the identity card or passport.

(4) Give all forenames in the order in which they appear on the birth certificate. (5) To be stated particularly in the case of adoption or in the case of other names in current use; expressions such as ‘ called … ’ or ‘ alias … ’ and prefixes to surnames must be written in full in the order in which they appear on the birth certificate. (6) Put M for male and F for female. (7) This information is required when the worker is a Spanish national, or when the form is to be sent to a French institution, regardless of the worker’s nationality. (8) Where appropriate, indicate the date of naturalisation.

For the purpose of Spanish institutions in the case of Spanish nationals state the number appearing on the national identity card DNI (Documento Nacional de IdentidadI) or the NIE (Número de Identificación de Extranjeros) in the case of foreigners, in both cases if it exists, even if the identity card is out of date. Failing this, state ‘ None ’ . For the purposes of Maltese Institutions, in the case of Maltese Nationals, state the identity card number, if not a Maltese national, state Maltese social security number. In the case of Slovene nationals, state the personal identification number EMŠO.

(9) The day and the month should be shown by two digits each and the year by four digits (example: 1 August 1921 = 01.08.1921). (10) For French towns comprising several arrondissements, please give the number of the arrondissement (example: Paris 14). In the case of Portuguese districts state also the parish and the local authority. (11) Must be stated for insured persons of Spanish, French or Italian nationality. Here, the territorial area or district in which the place of birth is located should be stated (example: in the case of France if the place (commune) of birth is Lille, the department of birth should be shown as Nord followed by the area code if known to the insured person; in this case:

59. The complete entry should therefore read: Nord 59). In the case of persons born in Spain, state only the province. (12) The symbol of the insured person’s country of birth in accordance with ISO code 3166-1. (13) Complete where appropriate. (14) Periods of insurance must be multiplied for politically repressed persons. (15) Periods of insurance must be stated in full years and months since 1 January 1996. (16) For Belgian, Greek and Spanish institutions, specify where possible the type of activity in question. For Spanish institutions, in the case of seamen a photocopy of the sailor’s book or books of the country issuing the certificate should be enclosed.

THE ADMINISTRATIVE COMMISSION ON SOCIAL SECURITY FOR MIGRANT WORKERS See ‘ Instructions ’ on page 4 E 205 LT (1) CERTIFICATE CONCERNING INSURANCE HISTORY IN LITHUANIA Regulation (EEC) No 1408/71: Article 38; Article 43a; Article 45; Article 48; Article 51a; Article 57(5) Regulation (EEC) No 574/72: Article 42(1); Article 43(1) to (3); Article 69 To be drawn up by the investigating institution for insurance periods completed under the legislation which it administers; to be attached to forms E 202, E 203 or E 204, as appropriate. Each institution concerned should draw up a form for the periods completed under the legislation which it administers and send it to the investigating institution.

1. Institution to which the form is addressed (institution concerned or institution investigating, as applicable) 1.1 Name: … … 1.2 Address (2): … … Information concerning the insured person 2. Names 2.1 Surname (3): … 2.2 Surname at birth (3): … 2.3 Forenames (4): … 2.4 Previous names (5): … 2.5 Sex (6): … 2.6 Father’s surname and forenames (7): … 2.7 Mother’s surname and forenames (7): … 3. Nationality (8): … 4. Details of birth 4.1 Date of birth (9): … 4.2 Place of birth (10): … 4.3 Province, department, county (11): … 4.4 Country (12): … 5. Address (2): … … 6.

6.1 Registration No at the investigating institution: … 6.2 Reference No of the file at the investigating institution: … 6.3 Reference No of the file at the institution concerned: … 7. Rightful claimant (13) 7.1 Surname (3): … 7.2 Forenames: … Surname at birth (3): … Place of birth (10): … 7.3 Date of birth: … Sex: … Nationality (8): … 7.4 Address (2): … … E 205 LT 8. Periods during which insurance periods and periods treated as such were completed From To Years Months Days Kind of period (14) Reason for treating equivalent periods as insurance periods Occupation (16) (17) or other remarks E 205 LT 8.1 Total length of periods (15) Kind of period Years Months Days 100 200 300 8.2 Comments: … … … may receive may not receive 9.

An insured person providing proof that he has completed an insurance period of less than one year a pension under national legislation (Article 48(1) of Regulation (EEC) No 1408/71). 10. Institution completing the form 10.1 Name: … … 10.2 Address (2): … … 10.3 Stamp 10.4 Date: … 10.5 Signature: E 205 LT INSTRUCTIONS Please complete this form in block letters, writing on the dotted lines only. It consists of four pages, none of which may be left out even if it does not contain any relevant information. NOTES (1) Symbol of the country to which the institution completing the form belongs:

LT = Lithuania. (2) Street, number, post code, town, country, telephone number. (3) For surname please state usual surname or surname acquired by marriage. The surname at birth must always be given; if same as current surname, put ‘ IDEM ’ . Expressions such as ‘ called … ’ or ‘ alias … ’ and prefixes to surnames must be written in full in the order in which they appear on the birth certificate. In the case of Spanish nationals state both names at birth. In the case of Portuguese nationals state all names (forenames, surname, maiden name) in the order of civil status in which they appear on the identity card or passport.

(4) Give all forenames in the order in which they appear on the birth certificate. (5) To be stated particularly in the case of adoption or in the case of other names in current use; expressions such as ‘ called … ’ or ‘ alias … ’ and prefixes to surnames must be written in full in the order in which they appear on the birth certificate. (6) Put M for male and F for female. (7) This information is required when the worker is a Spanish national, or when the form is to be sent to a French institution, regardless of the worker’s nationality. (8) Where appropriate, indicate the date of naturalisation.

For the purpose of Spanish institutions in the case of Spanish nationals state the number appearing on the national identity card DNI (Documento Nacional de IdentidadI) or the NIE (Número de Identificación de Extranjeros) in the case of foreigners, for both cases if it exists, even if the identity card is out of date. Failing this, state ‘ None ’ . For the purposes of Maltese institutions, in the case of Maltese nationals, state the identity card number, if not a Maltese national, state Maltese social security number. (9) The day and the month should be shown by two digits each and the year by four digits (example:

1 August 1921 = 01.08.1921). (10) For French towns comprising several arrondissements, please give the number of the arrondissement (example: Paris 14). In the case of Portuguese districts state also the parish and the local authority. (11) Must be stated for insured persons of Spanish, French or Italian nationality. Here, the territorial area or district in which the place of birth is located should be stated (example: in the case of France if the place (commune) of birth is Lille, the department of birth should be shown as Nord followed by the area code if known to the insured person; in this case:

59. The complete entry should therefore read: Nord 59). In the case of persons born in Spain, state only the province. (12) The symbol of the insured person’s country of birth in accordance with the international motor vehicle registration code. (13) Complete where appropriate. (14) Key to codes used in E 205 LT KIND OF PERIOD 10 — Periods of insurance of employed persons and other persons insured in the same manner like employees (for the acquisition of entitlement to benefits and for the calculation of full pension (both for the main and supplementary parts of the pension). 11 — Equivalent periods of employed persons and other persons insured in the same manner like employees (for the acquisition of entitlement to benefits and for the calculation of full pension (both for the main and supplementary parts of the pension).

20 — Periods of insurance of self-employed persons (for the acquisition of entitlement to pension and for the calculation of main part of the pension). (15) Key to codes used in E 205 LT TOTAL LENGTH OF PERIODS 100 — Periods of insurance and equivalent periods of employed persons and other persons insured in the same manner like employees (for the acquisition of entitlement of benefits and for the calculation of full pension); sum of periods 10 and 11. 200 — Periods of insurance and equivalent periods of self-employed persons (for the acquisition of entitlement to pension and for the calculation of main part of the pension); sum of periods 20 and 21.

300 — Total length of periods for the acquisition of entitlement to pension; sum of periods 100 and 200. (16) For Belgian, Greek and Spanish institutions, specify where possible the type of activity in question. (17) For Spanish institutions, in the case of seamen a photocopy of the sailor’s book or books of the country issuing the certificate should be enclosed. THE ADMINISTRATIVE COMMISSION ON SOCIAL SECURITY FOR MIGRANT WORKERS See ‘ Instructions ’ on page 4 E 205 LU (1) CERTIFICATE CONCERNING INSURANCE HISTORY IN LUXEMBOURG Regulation (EEC) No 1408/71; Article 38; Article 43a; Article 45;

Article 48; Article. 51a; Article. 57(5) Regulation (EEC) No 574/72; Article 42(1); Article 43(1) to (3); Article 69 To be drawn up by the investigating institution for insurance periods completed under the legislation which it administers; where appropriate, to be attached to forms E 202, E 203 or E 204. Each institution concerned should draw up a form for the periods completed under the legislation which it administers and send it to the investigating institution. 1. Institution to which the form is addressed (institution concerned or investigating institution, as applicable) 1.1 Name: … … 1.2 Address (2): … … Information concerning the insured person 2.

Names 2.1 Surname (3): … 2.2 Surname at birth (3): … 2.3 Forenames (4): … 2.4 Previous names (5): … 2.5 Sex (6): … 2.6 Father’s surname and forenames (7): … 2.7 Mother’s surname and forenames (7): … 3. Nationality (8): … 4. Details of birth 4.1 Date of birth (9): … 4.2 Place of birth (10): … 4.3 Province, department, county (11): … 4.4 Country (12): … 5. Address (2): … … 6. 6.1 Insurance No at the investigating institution: … 6.2 Reference No of file at the investigating institution: … 6.3 Reference No of file at the institution concerned: … 7. Rightful claimant (13) 7.1 Surname (3): … 7.2 Forenames: … Surname at birth (3): … Place of birth (10): … 7.3 Date of birth: … Sex: … Nationality (8): … 7.4 Address (2): … … E 205 LU 8.

From To Days Months Days Months Insurance periods Periods during which insurance periods and periods treated as such were completed Periods treated as insurance periods (14) Year Insurance scheme Occupation (15) (16) (17) E 205 LU 8.1 Total length of period of insurance under Luxembourg social security schemes: … 8.2 Comments (14): … … … 9. An insured person showing proof that he has completed an insurance period of less than one year may receive may not receive a pension under national legislation (Article 48(1) of Regulation (EEC) No 1408/71). 10. Institution completing the form 10.1 Name: … … 10.2 Address (2): … … 10.3 Stamp 10.4 Date: … 10.5 Signature:

E 205 LU INSTRUCTIONS Please complete this form in block letters, writing on the dotted lines only. It consists of four pages, none of which may be left out even if it does not contain any relevant information. NOTES (1) Symbol of the country to which the institution completing the form belongs: LU = Luxembourg. (2) Street, number, post code, town, country, telephone number. (3) For surname please state usual surname or surname acquired by marriage. The surname at birth must always be given; if same as current surname, put ‘ IDEM ’ . Expressions such as ‘ called … ’ or ‘ alias … ’ and prefixes to surnames must be written in full in the order in which they appear on the birth certificate.

In the case of Spanish nationals state both names at birth. In the case of Portuguese nationals state all names (forenames, surname, maiden name) in the order of civil status in which they appear on the identity card or passport. (4) Give all forenames in the order in which they appear on the birth certificate. (5) To be stated particularly in the case of adoption or in the case of other names in current use; expressions such as ‘ called … ’ or ‘ alias … ’ and prefixes to surnames must be written in full in the order in which they appear on the birth certificate. (6) Put M for male and F for female.

(7) This information is required when the worker is a Spanish national, or when the form is to be sent to a French institution, regardless of the worker’s nationality. (8) Where appropriate, indicate the date of naturalisation. For the purpose of Spanish institutions in the case of Spanish nationals state the number appearing on the national identity card DNI (Documento Nacional de IdentidadI) or the NIE (Número de Identificación de Extranjeros) in the case of foreigners, for both cases if it exists, even if the identity card is out of date. Failing this, state ‘ None ’ . For the purposes of Maltese Institutions, in the case of Maltese Nationals, state the identity card number.

If not a Maltese national, state Maltese social security number. In the case of Slovene nationals, state the personal identification number EMŠO. (9) The day and the month should be shown by two digits each and the year by four digits (example: 1 August 1921 = 01.08.1921). (10) For French towns comprising several arrondissements, please give the number of the arrondissement (example: Paris 14). In the case of Portuguese districts state also the parish and the local authority. (11) Must be stated for insured persons of Spanish, French or Italian nationality. Here, the territorial area or district in which the place of birth is located should be stated (example: in the case of France if the place (commune) of birth is Lille, the department of birth should be shown as Nord followed by the area code if known to the insured person; in this case:

59. The complete entry should therefore read: Nord 59). In the case of persons born in Spain, state only the province. (12) The symbol of the insured person’s country of birth in accordance with ISO code 3166-1. (13) Complete where appropriate. (14) In 8.2 indicate the nature of the periods treated as periods of employment. (15) In the case of persons who were employed in mines or in undertakings treated as such, for Austrian purposes add an E 205A additional form. (16) For Belgian, Greek and Spanish institutions, specify where possible the type of activity in question. (17) For Spanish institutions, in the case of seamen a photocopy of the sailor’s book or books of the country issuing the certificate should be enclosed.

THE ADMINISTRATIVE COMMISSION ON SOCIAL SECURITY FOR MIGRANT WORKERS See ’Instructions’ on page 4 E 205 HU (1) CERTIFICATE CONCERNING INSURANCE HISTORY IN HUNGARY Regulation (EEC) No 1408/71; Article 38; Article 43a; Article 45; Article 48; Article. 51a; Article. 57(5) Regulation (EEC) No 574/72; Article 42(1); Article 43(1) to (3); Article 69 To be drawn up by the investigating institution for insurance periods completed under the legislation which it administers; where appropriate, to be attached to forms E 202, E 203 or E 204. Each institution concerned should draw up a form for the periods completed under the legislation which it administers and send it to the investigating institution.

1. Institution to which the form is addressed (institution concerned or investigating institution, as applicable) 1.1 Name: … … 1.2 Address (2): … … Information concerning insured persons 2. Names 2.1 Surname (3): … 2.2 Surname at birth (3): … 2.3 Forenames (4): … 2.4 Previous names (5): … 2.5 Sex (6): … 2.6 Father’s surname and forenames (7): … 2.7 Mother’s surname and forenames at birth (7): … 3. Nationality (8): … 4. Details of birth 4.1 Date of birth (9): … 4.2 Place of birth (10): … 4.3 Province, department, county (11): … 4.4 Country (12): … 5. Address (2): … … 6.

6.1 Insurance No at the investigating institution: … 6.2 Reference No of file at the investigating institution: … 6.3 Reference No of file at the institution concerned: … 7. Rightful claimant (13) 7.1 Surname (3): … 7.2 Forenames: … Surname at birth: … Place of birth (10): … 7.3 Date of birth: … Sex: … Nationality: … 7.4 Address (2): … … E 205 HU 8. Insurance periods and periods treated as such From To Year Month Year Day Month Day Total number of insured days Type of insurance (14) (15) (16) E 205 HU 8.1 Total length of insurance period in the Hungarian social security system: …year … day(s) 8.2 Insurance period to be taken into account exclusively for the purpose of entitlement to early old-age pension and reduced early old-age pension benefits: … year … day(s) 9.

An insured person giving proof that he has completed an insurance period of less than one year may receive may not receive a pension under national legislation (Article 48(1) of Regulation (EEC) No 1408/71). 10. Institution completing the form 10.1 Name: … … 10.2 Address (2): … … 10.3 Stamp 10.4 Date: … 10.5 Signature: E 205 HU INSTRUCTIONS Please complete this form in block letters, writing on the dotted lines only. It consists of four pages, none of which may be left out even if it does not contain any relevant information. NOTES (1) Symbol of the country to which the institution completing the form belongs:

HU = Hungary. (2) Street, number, post code, town, country, telephone number. (3) For surname please state usual surname or surname acquired by marriage. The surname at birth must always be given; if same as current surname, put ‘ IDEM ’ . Expressions such as ‘ called … ’ or ‘ alias … ’ and prefixes to surnames must be written in full in the order in which they appear on the birth certificate. In the case of Spanish nationals state both names at birth. In the case of Portuguese nationals state all names (forenames, surname, maiden name) in the order of civil status in which they appear on the identity card or passport.

(4) Give all forenames in the order in which they appear on the birth certificate. (5) To be stated particularly in the case of adoption or in the case of other names in current use; expressions such as ‘ called … ’ or ‘ alias … ’ and prefixes to surnames must be written in full in the order in which they appear on the birth certificate. (6) Put M for male and F for female. (7) This information is required when the worker is a Spanish national, or when the form is to be sent to a French institution, regardless of the worker’s nationality. For Hungarian purposes the mother’s surname and forename(s) at birth are required.

(8) Where appropriate, indicate the date of naturalisation. For the purpose of Spanish institutions in the case of Spanish nationals state the number appearing on the national identity card DNI (Documento Nacional de IdentidadI) or the NIE (Número de Identificación de Extranjeros) in the case of foreigners, for both cases if it exists, even if the identity card is out of date. Failing this, state ‘ None ’ . For the purposes of Maltese Institutions, in the case of Maltese Nationals, state the identity card number. If not a Maltese national, state Maltese social security number. In the case of Slovene nationals, state the personal identification number EMŠO.

(9) The day and the month should be shown by two digits each and the year by four digits (example: 1 August 1921 = 01.08.1921). (10) For French towns comprising several arrondissements, please give the number of the arrondissement (example: Paris 14). In the case of Portuguese districts state also the parish and the local authority. (11) Must be stated for insured persons of Spanish, French or Italian nationality. Here, the territorial area or district in which the place of birth is located should be stated (example: in the case of France if the place (commune) of birth is Lille, the department of birth should be shown as Nord followed by the area code if known to the insured person; in this case:

59. The complete entry should therefore read: Nord 59). In the case of persons born in Spain, state only the province. (12) The symbol of the insured person’s country of birth in accordance with ISO code 3166-1. (13) Complete where appropriate. (14) For Hungarian purposes please use the following codes to indicate the type of insurance: 1. Compulsory insurance. 2. Voluntary insurance. 3. Other type of insurance. (15) For Belgian, Greek and Spanish institutions specify where possible the type of activity in question. (16) For Spanish institutions, in the case of seamen a photocopy of the sailor’s book or books of the country issuing the certificate should be enclosed.

E 205 additional page HU ADDITIONAL INFORMATION FOR THE PURPOSES OF THE HUNGARIAN INSTITUTIONS Regulation (EEC) No 1408/71; Article 38; Article 43a; Article 45; Article 48; Article 51a; Article 57(5) Regulation (EEC) No 574/72; Article 42(1); Article 43(1) to (3); Article 69 1. Information concerning insured persons Undertakings (1) Type of work performed (2) Periods of employment or periods treated as such Length of each period Overall Underground work From To Years Months Days Years Months Days (1) (2) Indicate the undertakings in which the person concerned was employed and the substance extracted or processed.

Specify type of work and indicate whether performed at the surface or underground, or whether it concerns periods treated as periods of employment. E 205 additional page HU (continued) 2. The periods of employment shown in Item 1 were interrupted as follows Periods of interruption Day/Month/Year Day/Month/Year Reason for interruption (sickness, leave, military service, active service, unemployment, medical treatment, rehabilitation, unpaid leave, etc.) THE ADMINISTRATIVE COMMISSION ON SOCIAL SECURITY FOR MIGRANT WORKERS See ‘ instructions ’ on page 4 E 205 MT (1) CERTIFICATE CONCERNING INSURANCE HISTORY IN MALTA Regulation (EEC) No 1408/71;

Article 38; Article 43a; Article 45; Article 48; Article 51a; Article 57(5) Regulation (EEC) No 574/72; Article 42(1); Article 43(1) to (3); Article 69 To be drawn up by the investigating institution for insurance periods completed under the legislation which it administers; where appropriate, to be attached to forms E 202, E 203 or E 204. Each institution concerned should draw up a form for the periods completed under the legislation which it administers and send it to the investigating institution. 1. Institution to which the form is addressed (institution concerned or investigating institution, as applicable) 1.1 Name: … … 1.2 Address (2): … … Information concerning insured person (2a) 2.

Names 2.1 Surname (3): … 2.2 Surname at birth (3): … 2.3 Forenames (4): … 2.4 Previous names (5): … 2.5 Sex (6): … 2.6 Father’s surname and forenames (7): … 2.7 Mother’s surname and forenames (7): … 2.8 Maltese social security number (7a): … 3. Nationality (8): … 4. Details of birth 4.1 Date of birth (9): … 4.2 Place of birth (10): … 4.3 Province, department, county (11): … 4.4 Country (12): … 5. Address (2): … … 6. 6.1 Insurance No at the investigating institution: … 6.2 Reference No of file at the investigating institution: … 6.3 Reference No of file at the institution concerned: … 7.

Rightful claimant (13) 7.1 Surname (3): … Forenames: … 7.2 Surname at birth (3): … Place of birth (10): … Date of birth (9): … 7.3 Sex: … Nationality (8): … 7.4 Address (2): … … E 205 MT 8. Insurance history 8.1 From To As an employed person As a self-employed or non employed person As a voluntary contributor Contribution Years Number of Weekly Contributions Contributions Paid Credits E 205 MT 8.2 Remarks (14): … … … 9. An insured person showing proof that he has completed an insurance period of less than one year may receive may not receive a pension under national legislation (Article 48(1) of Regulation (EEC) No 1408/71).

10. Institution completing the form 10.1 Name: … … 10.2 Address (2): … … 10.3 Stamp 10.4 Date: … 10.5 Signature: E 205 MT INSTRUCTIONS Please complete this form in block letters or typewriting, writing on the dotted lines only. It consists of four pages, none of which may be left out even if it does not contain any relevant information. NOTES (1) Symbol of the country to which the institution completing the form belongs: MT = Malta. (2) Street, number, post code, town, country, telephone number. (2a) If attached to E203, details should be those of the deceased spouse. (3) For surname please state usual surname or surname acquired by marriage.

The surname at birth must always be given; if same as current surname, put ‘ IDEM ’ . Expressions such as ‘ called … ’ or ‘ alias … ’ and prefixes to surnames must be written in full in the order in which they appear on the birth certificate. In the case of Spanish nationals state both names at birth. In the case of Portuguese nationals state all names (forenames, surname, maiden name) in the order of civil status in which they appear on the identity card or passport. (4) Give all forenames in the order in which they appear on the birth certificate. (5) To be stated particularly in the case of adoption or in the case of other names in current use; expressions such as ‘ called … ’ or ‘ alias … ’ and prefixes to surnames must be written in full in the order in which they appear on the birth certificate.

(6) Put M for male and F for female. (7) This information is required when the worker is a Spanish national, or when the form is to be sent to a French institution, regardless of the worker’s nationality. (7a) For workers subject to Maltese legislation, state worker’s Maltese social security number (e.g. A 123456 or B 123456 - 78). (8) Where appropriate indicate the date of naturalisation. For the purpose of Spanish institutions, in the case of Spanish nationals state the number appearing on the national identity card DNI (Documento Nacional de IdentidadI) or the NIE (Número de Identificación de Extranjeros) in the case of foreigners, for both cases if it exists, even if the identity card is out of date.

Failing this, state ‘ None ’ . For the purposes of Maltese institutions, in the case of Maltese nationals, state the identity card number (e.g. 123456M or 012345G). If not a Maltese national, state Maltese social security number. In the case of Slovene nationals, state the personal identification number EMŠO. (9) The day and the month should be shown by two digits each and the year by four digits (example: 1 August 1921 = 01.08.1921). (10) For French towns comprising several arrondissements, please give the number of the arrondissement (example: Paris 14). In the case of Portuguese districts state also the parish and the local authority.

(11) Must be stated for insured persons of Spanish, French or Italian nationality. Here, the territorial area or district in which the place of birth is located should be stated (example: in the case of France if the place (commune) of birth is Lille, the department of birth should be shown as ‘ Nord ’ followed by the area code if known to the insured person, in this case of persons born in Spain, state only the province. (12) The symbol of the insured person’s country of birth in accordance with ISO code 3166-1. (13) Complete where appropriate. (14) For Spanish institutions, specify where possible the type of activity in question.

For Spanish institutions, in the case of seamen a photocopy of the sailor’s book or books of the country issuing the certificate should be enclosed. THE ADMINISTRATIVE COMMISSION ON SOCIAL SECURITY FOR MIGRANT WORKERS See ‘ Instructions ’ on page 4 E 205 NL (1) CERTIFICATE CONCERNING INSURANCE HISTORY IN THE NETHERLANDS Regulation (EEC) No 1408/71; Article 38; Article 43a; Article 45; Article 48; Article 51a; Article 57(5) Regulation (EEC) No 574/72; Article 42(1); Article 43(1) to (3); Article 69 To be drawn up by the investigating institution for insurance periods completed under the legislation which it administers; where appropriate, to be attached to forms E 202, E 203 or E 204.

Each institution concerned should draw up a form for the periods completed under the legislation which it administers and send it to the investigating institution. 1. Institution to which the form is addressed (institution concerned or investigating institution, as applicable) 1.1 Name … … 1.2 Address (2): … … Information concerning the insured person 2. Names 2.1 Surname (3): … 2.2 Surname at birth (3): … 2.3 Forenames (4): … 2.4 Previous names (5): … 2.5 Sex (6): … 2.6 Father’s surname and forenames (7): … 2.7 Mother’s surname and forenames (7): … 3. Nationality (8): … 4.

Details of birth 4.1 Date of birth (9): … 4.2 Place of birth (10): … 4.3 Province, department, county (11): … 4.4 Country (12): … 5. Address (2): … … 6. 6.1 Insurance No at the investigating institution: … 6.2 Reference No of file at the investigating institution: … 6.3 Reference No of file at the institution concerned: … 7. Rightful claimant (13) 7.1 Surname (3): … 7.2 Forenames: … Surname at birth (3): … Place of birth (10): … 7.3 Date of birth (9): … Sex: … Nationality (8): … 7.4 Address (2): … … E 205 NL 8. Insurance periods under AOW/ANW (14) (17) Insurance periods under WAO/AAW/WAZ (14) Number of From To From Months To Years Days Type (15) (16) (17) E 205 NL 8.1 Total length of period of insurance in the Netherlands (17) under AOW ANW WAO/AAW/WAZ … months … days. may receive may not receive a pension under national legislation (Article 48(1) of Regulation (EEC) No 1408/71).

9. An insured person showing proof that he has completed an insurance period of less than one year 10. Institution completing the form 10.1 Name: … … 10.2 Address (2): … … 10.3 Stamp 10.4 Date: … 10.5 Signature: E 205 NL INSTRUCTIONS Please complete this form in block letters, writing on the dotted lines only. It consists of four pages, none of which may be left out even if it does not contain any relevant information. NOTES (1) Symbol of the country to which the institution completing the form belongs: NL = the Netherlands. (2) Street, number, post code, town, country, telephone number.

(3) For surname please state usual surname of surname acquired by marriage. The surname at birth must always be given; if same as current surname, put ‘ IDEM ’ . Expressions such as ‘ called … ’ or ‘ alias … ’ and prefixes to surnames must be written in full in the order in which they appear on the birth certificate. In the case of Spanish nationals state both names at birth. In the case of Portuguese nationals state all names (forenames, surname, maiden name) in the order of civil status in which they appear on the identity card or passport. (4) Give all forenames in the order in which they appear on the birth certificate.

(5) To be stated particularly in the case of adoption or in the case of other names in current use; expressions such as ‘ called … ’ or ‘ alias … ’ and prefixes to surnames must be written in full in the order in which they appear on the birth certificate. (6) Put M for male and F for female. (7) This information is required when the worker is a Spanish national, or when the form is to be sent to a French institution, regardless of the worker’s nationality. (8) Where appropriate, indicate the date of naturalisation. For the purpose of Spanish institutions in the case of Spanish nationals state the number appearing on the national identity card DNI (Documento Nacional de IdentidadI) or the NIE (Número de Identificación de Extranjeros) in the case of foreigners, for both cases if it exists, even if the identity card is out of date.

Failing this, state ‘ None ’ . For the purposes of Maltese institutions, in the case of Maltese nationals, state the identity card number. If not a Maltese national, state Maltese social security number. (9) The day and the month should be shown by two digits each and the year by four digits (example: 1 August 1921 = 01.08.1921). (10) 1.1 For French towns comprising several arrondissements, please give the number of the arrondissement (example: Paris 14). In the case of Portuguese districts state also the parish and the local authority. (11) Must be stated for insured persons of Spanish, French or Italian nationality.

Here, the territorial area or district in which the place of birth is located should be stated (example: in the case of France if the place (commune) of birth is Lille, the department of birth should be shown as ‘ Nord ’ followed by the area code if known to the insured person; in this case: 59. The complete entry should therefore read: ‘ Nord 59 ’ ). In the case of persons born in Spain state only the province. (12) The symbol of the insured person’s country of birth in accordance with ISO code 3166-1. (13) Complete where appropriate. (14) AOW = General Old-age Pensions Act ANW = General Surviving Relatives Act WAO = Disablement Benefits Act AAW = General Incapacity for Work Act WAZ = Self-employed Disablement Benefits Act (15) Use the following symbols in order to indicate the type of insurance period:

P = compulsory insurance, V = voluntary insurance, G = periods treated as periods of insurance. (16) For Greek and Spanish institutions, specify where possible the type of activity in question. (17) Since the Netherlands insurance scheme does not provide for registration of the insured person, it may happen that our statistics may contain references to periods in respect of which it can only be assumed that the person concerned was insured in the Netherlands. In the case where it is established that the person concerned was insured during the period of insurance stated by us in the Netherlands under the legislation of your country, you should, without consulting us, deduct the periods in question from the total number of periods of insurance stated in point 8.1 of this form.

(18) For Spanish institutions, in the case of seamen a photocopy of the sailor’s book or books of the country issuing the certificate should be enclosed. THE ADMINISTRATIVE COMMISSION ON SOCIAL SECURITY FOR MIGRANT WORKERS See ‘ Instructions ’ on page 4 E 205 AT (1) CERTIFICATE CONCERNING INSURANCE HISTORY IN AUSTRIA Regulaltion (EEC) No 1408/71; Article 38; Article 43a; Article 45; Article 48; Article 51a; Article 57(5) Regulation (EEC) No 574/72; Article 42(1); Article 43(1) to (3); Article 69 To be drawn up by the investigating institution for insurance periods completed under the legislation which it administers; where appropriate, to be attached to forms E 202, E 203 or E 204.

Each institution concerned should draw up a form for the periods completed under the legislation which it administers and send it to the investigating institution. 1. Institution to which the form is addressed (institution concerned or investigating institution, as applicable) 1.1 Name: … … 1.2 Address (2): … … Information concerning insured person 2. Names 2.1 Surname (3): … 2.2 Surname at birth (3): … 2.3 Forenames (4): … 2.4 Previous names (5): … 2.5 Sex (6): … 2.6 Father’s surname and forenames (7): … 2.7 Mother’s surname and forenames: … 3. Nationality (8): … 4.

Details of birth 4.1 Date of birth (9): … 4.2 Place of birth (10): … 4.3 Province, department, county (11): … 4.4 Country (12): … 5. Address (2): … … 6. 6.1 Insurance No at the investigating institution: … 6.2 Reference No of file at the investigating institution: … 6.3 Reference No of File at the institution concerned: … 7. Rightful claimant (13) 7.1 Surname (3): … 7.2 Forenames (4): … Surname at birth (3): … Place of birth (10): … 7.3 Date of birth (9): … Sex (6): … Nationality (8): … 7.4 Address (2): … … E 205 AT 8. Insurance schemes Year From Periods during which insurance periods and periods treated as such were completed Insurance periods (14) Periods treated as insurance periods (15) To Years Months Days Years Months Days Employed person Self-employed person Civil servants Occupation (16) (17) (18) E 205 AT Sum total of periods 8.1.

Total length of period of insurance under the social security schemes for employed and for self-employed persons and civil servants in Austria: periods to be taken into account only for the acquisition of entitlement of benefits: … years … months … days; periods to be taken into account only for calculation of benefits: …years … months … days. 8.2 Remarks (15): … … … 9. An insured person showing proof that he has completed an insurance period of less than one year may receive may not receive a pension under national legislation (Article 48(1) of Regulation (EEC) No 1408/71). 10.

Institution completing the form 10.1 Name: … … 10.2 Address (2): … … 10.3 Stamp 10.4 Date: … 10.5 Signature E 205 AT INSTRUCTIONS Please complete this form in block letters, writing on the dotted lines only. It consists of four pages, none of which may be left out even if it does not contain any relevant information. NOTES (1) Symbol of the country to which the institution completing the form belongs: AT = Austria. (2) Street, number, post code, town, country, telephone number. (3) For surname please state usual surname or surname acquired by marriage. The surname at birth must always be given; if same as current surname, put ‘ IDEM ’ .

Expressions such as ‘ called … ’ or ‘ alias … ’ and prefixes to surnames must be written in full in the order in which they appear on the birth certificate. In the case of Spanish nationals state both names at birth. In the case of Portuguese nationals state all names (forenames, surname, maiden name) in the order of civil status in which they appear on the identity card or passport. (4) Give all forenames in the order in which they appear on the birth certificate. (5) To be stated particularly in the case of adoption or in the case of other names in current use; expressions such as ‘ called … ’ or ‘ alias … ’ and prefixes to surnames must be written in full in the order in which they appear on the birth certificate.

(6) Put M for male and F for female. (7) This information is required when the worker is a Spanish national, or when the form is to be sent to a French institution, regardless of the worker’s nationality. (8) Where appropriate, indicate the date of naturalisation. For the purpose of Spanish institutions in the case of Spanish nationals state the number appearing on the national identity card DNI (Documento Nacional de IdentidadI) or the NIE (número de Identificación de Extranjeros) in the case of foreigners, for both cases if it exists, even if the identity card is out of date. Failing this, state ‘ None ’ .

For the purposes of Maltese institutions, in the case of Maltese nationals, state the identity card number. If not a Maltese national, state Maltese social security number. In the case of Slovene nationals, state the personal identification number EMŠO. (9) The day and the month should be shown by two digits each and the year by four digits (example: 1 August 1921 = 01.08.1921). (10) For French towns comprising several arrondissements, please give the number of the arrondissement (example: Paris 14). In the case of Portuguese districts state also the parish and the local authority. (11) Must be stated for insured persons of Spanish, French or Italian nationality.

Here, the territorial area or district in which the place of birth is located should be stated (example: in the case of France if the place (commune) of birth is Lille, the department of birth should be shown as ‘ Nord ’ followed by the area code if known to the insured person; in this case: 59. The complete entry should therefore read: ‘ Nord 59 ’ ). In the case of persons born in Spain state only the province. (12) The symbol of the insured person’s country of birth in accordance with the international motor vehicle registration code. (13) Complete where appropriate. (14) After the number of insurance months put ‘ F ’ (voluntary) for periods of voluntary insurance in order to avoid any confusion with compulsory insurance.

Furthermore, put ‘ FS ’ for periods of self-insurance, which are taken into account for the calculation of the amount of the benefit, but not for the acquisition of the right. (15) After the number of months treated a such put ‘ E ’ for periods treated as periods of insurance which are taken into account for the acquisition of the right, but not for the calculation of the amount of the benefit. Furthermore, the nature of the periods treated as such (Ersatzzeiten) must be indicated in 8.2 (Remarks). (16) In the case of workers who were employed in mines or in undertakings treated as such, for Austrian purposes add an E 205A additional form.

(17) For Belgian, Greek and Spanish institutions, specify where possible the type of activity in question. (18) For Spanish institutions, in the case of seamen a photocopy of the sailor’s book or books of the country issuing the certificate should be enclosed. E 205 additional page AT COMPLEMENTARY DATA CONCERNING PERIODS OF EMPLOYMENT IN MINES AND SIMILAR UNDERTAKINGS Regulation (EEC) No 1408/71: Article 38; Article 43a; Article 45; Article 48; Article 51a; Article 57(5) Regulation (EEC) No 574/72: Article 42(1); Article 43(1)(2) and (3); Article 69 1. Undertakings (1) Type of work performed (2) Periods of employment or periods treated as such Overall Length of each period Underground work From To Years Months Days Years Months Days Total (1) Indicate the undertakings in which the person concerned was employed and the substance extracted or processed.

(2) Specify type of work and indicate whether performed at the surface or underground, or whether it concerns periods treated as periods of employment. E 205 additional page AT (continued) 2. The periods of employment shown in field 1 were interrupted as follows (3) Periods of interruption From To Day/Month/Year Day/Month/Year Reason for interruption (sickness, leave, military service, active service, unemployment, medical treatment, rehabilitation, unpaid leave, etc.) (3) Complete only if the form is to be sent to German and Spanish institutions. THE ADMINISTRATIVE COMMISSION ON SOCIAL SECURITY FOR MIGRANT WORKERS See ‘ Instruction ’ page 4 E 205 PL (1) CERTIFICATE CONCERNING INSURANCE HISTORY IN POLAND Regulation (EEC) No 1408/71:

Article 38; Article 43(a); Article 45; Article 48; Article 51(a); Article 57(5) Regulation (EEC) No 574/72: Article 42(1); Article 43(1) to (3); Article 69 To be drawn up by the investigating institution for insurance periods completed under the legislation which it administers; where appropriate, to be attached to forms E 202, E 203 or E 204. Each institution concerned should draw up a form for the periods completed under the legislation which it administers and send it to the investigating institution. 1. Institution to which the form is addressed (institution concerned or investigating institution, as applicable) 1.1 Name: … … 1.2 Address (2): … … Information concerning insured person (2a) 2.

Surname (3) 2.1 Surname (3): … 2.2 Surname: … 2.3 Forename(s) (4): … 2.4 Previous names (5): … 2.5 Sex (6): … 2.6 Father’s surname and forenames (7): … 2.7 Mother’s surname and forenames (7): … 2.8 PESEL No (8): … 2.9 NIP No: … 3. Nationality (9): … 4. Details of birth 4.1 Date (10): … 4.2 Place (11): … 4.3 Province, department, county (12): … 4.4 Country (13): … 5. Address (2): … … 6. 6.1 Insurance No at the investigating institution: … 6.2 Reference No of file at the investigating institution: … 6.3 Reference No of file at the institution concerned: … 7.

Rightful claimant (14) 7.1 Surname (3): … 7.2 Forename(s): … Surname at birth: … Place of birth (11): … 7.3 Date of birth: … Sex: … Nationality (9): … 7.4 Address(2): … … E 205 PL 8. Months Days Months Days For employed and self-employed persons P For civil servants (17) S Periods of insurance and periods treated as periods of insurance Periods of insurance (15) Periods treated as periods of insurance (16) System From (day, month, year) Until (day, month, year) Occupation (18) (19) (20) E 205 PL 8.1 Periods of insurance and periods treated as periods of insurance taken into account for the acquisition of entitlement of benefits: … months … days.

8.2 Periods of insurance and periods treated as periods of insurance taken into account for the calculation of benefits: … months … days. 8.3 Remarks (16): … … … 9. An insured person showing proof that he has completed an insurance period of less than one year may receive may not receive a pension under national legislation (Article 48(1) Regulation (EEC) No 1408/71). 10. Institution completing the form 10.1 Name: … … 10.2 Address (2): … … 10.3 Stamp 10.4 Date: … 10.5 Signature: E 205 PL INSTRUCTIONS Please complete this form in block letters; writing on the dotted lines only.

It consists of four pages, none of which may be left out even if it does not contain any relevant information. NOTES (1) Symbol of the country to which the institution completing the form belongs: PL = Poland. (2) Street, number, post code, town, country, telephone number. (2a) The term ‘ insured person ’ refers to the persons insured under the general schemes (ZUS, KRUS) also under special schemes for officers of the police, State security Office, internal security agency, intelligence agency (public security services), border guards, government security bureau, national Fire Brigades, prison guards and professional soldiers as well as persons working as judges and prosecutors.

(3) In point, ‘ Surname ’ please state usual surname or surname acquired by marriage. The point: ‘ The surname at birth ’ must always be given; if same as current surname, put ‘ IDEM ’ . Expressions such as ‘ called … ’ or ‘ alias … ’ and all prefixes to surnames must be written in full in order in which they appear in the birth certificate. In the case of Spanish nationals state both names at birth. In the case of Portuguese nationals state all names (forenames, surname, maiden name) in the order of civil status in which they appear on the identity card or passport. (4) Give all forenames in the order in which they appear on the birth certificate.

(5) To be stated particularly in the case of adoption or in the case of other names in current use; expressions such as ‘ called … ’ or ‘ alias … ’ and prefixes to names must be written in full in the order ain which they appear in the birth certificate. (6) Put M for male or F for female. (7) This information is required where the worker is a Spanish national, or a French national born outside metropolitan France. (8) State PESEL number or NKP number if the person concerned is subject to social insurance for farmers. If there is no such number state the series and number of identity card or passport.

(9) Where appropriate, indicate the date of naturalisation. For the purpose of Spanish institutions in the case of Spanish nationals state the number appearing on the national identity card DNI (Documento Nacional de IdentidadI) or the NIE (Número de Identificación de Extranjeros) in the case of foreign people, for both cases if it exists, even if the identity card is out of date. Failing this, state ‘ None ’ . For the purposes of Maltese institutions, in the case of Maltese nationals, state the identity card number, if not a Maltese national, state Maltese social security number. In the case of Slovene nationals, state the personal identification number EMŠO.

(10) The day and the month should be shown by two digits each and the year by four digits (example: 1 August 1921 = 01.08.1921). (11) For French towns comprising several arrondissements, please give the number of the arrondissement (example: Paris 14). In the case of Portuguese districts state also the parish and the local authority. (12) Must be stated for persons of Spanish, French or Italian nationality. Here, the territorial area or district in which the place of birth is located should be stated (example: in the case of France if the place (commune) of birth is Lille, the department of the birth should be shown as ‘ Nord ’ followed by the area code, if known to the insured person; in this case, 59.

The complete entry should therefore read ‘ Nord 59 ’ ). In the case of persons born in Spain, state only the province. (13) The symbol of the insured person’s country of birth in accordance with ISO code 3166-1. (14) Please, indicate it, if applicable. (15) Please indicate the contributory periods completed under the general schemes (ZUS, KRUS) and periods of service completed under special schemes for officers of the Police, the Citizens’ Militia, State Security Office, Internal Security Agency, Intelligence Agency (public security services), Border Guard, Government Security Bureau, National Fire Brigades, Prison Guard and professional soldiers as well as persons working as judges and prosecutors.

In the case of the periods of voluntary insurance write the letter ‘ D ’ (voluntary) after the number of months and days of periods of insurance so as not to confuse them with the obligatory insurance. (16) Please indicate the non-contributory periods limited to 1/3 of contributory periods. In the case of calculating benefits from special schemes please, indicate the non-contributory periods actually completed. In point 8.3, please indicate the character of periods treated as periods of insurance, e.g. the period of sickness benefit, period of attending high schools. (17) It concerns the periods of service of: professional soldiers, the Police officers, the Citizens’ Militia officers, State Protection Office officers, Internal Security Agency officers, Foreign Intelligence Agency officers (public security services), Border Guard officers, Government Security Bureau officers and National Fire Brigades officers, Prison Guard officers and also judges and prosecutors.

(18) In the case of workers who were employed in mines or in undertakings treated as such, fill in the additional page. (19) For the purposes of Belgian, Greek and Spanish institutions please indicate the type of activity, if possible. (20) For Spanish institutions, in the case of seamen a photocopy of the sailor’s book or books of the country issuing the certificate should be enclosed. E 205 additional page PL ADDITIONAL INFORMATIONS FOR PURPOSES OF POLISH INSTITUTIONS (To be completed if worker was employed in mines or undertakings treated as such) Undertakings (1) Type of work performed (2) Periods of employment or periods treated as such Length of each period overall underground work from to Years Months Days Years Months Days Total (1) Indicate the undertakings in which the person concerned was employed and the substance extracted or processed.

(2) Specify type of work and indicate whether performed on the surface or underground, or whether it concerns periods treated as periods of employment and if performed in full time. THE ADMINISTRATIVE COMMISSION ON SOCIAL SECURITY FOR MIGRANT WORKERS See ‘ Instructions ’ on page 4 E 205 PT (1) CERTIFICATE CONCERNING INSURANCE HISTORY IN PORTUGAL Regulation (EEC) No 1408/71; Article 38; Article 43a; Article 45; Article 48; Article 51a; Article 57(5) Regulation (EEC) No 574/72; Article 42(1); Article 43(1) to (3); Article 69 To be drawn up by the investigating institution for insurance periods completed under the legislation which it administers; where appropriate, to be attached to forms E 202, E 203 or E 204.

Each institution concerned should draw up a form for the periods completed under the legislation which it administers and send it to the investigating institution. 1. Institution to which the form is addressed (institution concerned or investigating institution, as applicable) 1.1 Name: … … 1.2 Address (2): … … Information concerning the insured person 2. Names 2.1 Surname (3): … 2.2 Surname at birth (3): … 2.3 Forenames (4): … 2.4 Previous names (5): … 2.5 Sex (6): … 2.6 Father’s surname and forenames (7): … 2.7 Mother’s surname and forenames (7): … 3. Nationality (8): … 4.

Details of birth 4.1 Date of birth (9): … 4.2 Place of birth (10): … 4.3 Province, department, county (11): … 4.4 Country (12): … 5. Address (2): … … 6. 6.1 Insurance No at the investigating institution: … 6.2 Reference No of file at the investigating institution: … 6.3 Reference No of file at the institution concerned: … 7. Rightful claimant (13) 7.1 Surname (3): … 7.2 Forenames: … Surname at birth (3): … Place of birth (10): … 7.3 Date of birth(9): … Sex: … Nationality (8): … 7.4 Address (2): … … E 205 PT 8. Years Insurance periods Periods treated as insurance periods From To From To Occupation (14) (15) (16) (17) E 205 PT 8.1 Length of periods of insurance under Portuguese social security schemes (periods of insurance prior to 1994 are registered in months or years; periods of insurance since 1994 are registered in years):

8.1.1 — period to be taken into account for the acquisition of entitlement: months period do be taken into account for the acquisition of entitlement: years period to be taken in account for the calculation of benefits: years 8.1.2 Length of additional periods (periods treated as insurance periods, regardless of calendar months or years, that must be added to periods mentioned in 8.1.1): period to be taken into account for the acquisition of entitlement: months period to be taken into account for the acquisition of entitlement: years period to be taken in account for the calculation of benefits: years 8.2 Remarks: … … … 9.

An insured person showing proof that he has completed an insurance period of less than one year may receive may not receive a pension under national legislation (Article 48(1) of Regulation (EEC) No 1408/71). 10. Institution completing the form 10.1 Name: … … 10.2 Address (2): … … 10.3 Stamp 10.4 Date: … 10.5 Signature: E 205 PT INSTRUCTIONS Please complete this form in block letters, writing on the dotted lines only. It consists of four pages, none of which may be left out even if it does not contain any relevant information. NOTES (1) Symbol of the country to which the institution completing the form belongs:

PT = Portugal. (2) Street, number, post code, town, country, telephone number. (3) For surname please state usual surname or surname acquired by marriage. The surname at birth must always be given; if same as current surname, put ‘ IDEM ’ . Expressions such as ‘ called … ’ or ‘ alias … ’ and prefixes to surnames must be written in full in the order in which they appear on the birth certificate. In the case of Spanish nationals state both names at birth. In the case of Portuguese nationals state all names (forenames, surname, maiden name) in the order of civil status in which they appear on the identity card or passport.

(4) Give all forenames in the order in which they appear on the birth certificate. (5) To be stated particularly in the case of adoption or in the case of other names in current use; expressions such as ‘ called … ’ or ‘ alias … ’ and prefixes to surnames must be written in full in the order in which they appear on the birth certificate. (6) Put M for male and F for female. (7) This information is required when the worker is a Spanish national, or when the form is to be sent to a French institution, regardless of the worker’s nationality. (8) Where appropriate, indicate the date of naturalisation.

For the purpose of Spanish institutions in the case of Spanish nationals state the number appearing on the national identity card DNI (Documento Nacional de IdentidadI) or the NIE (Número de Identificación de Extranjeros) in the case of foreign people, for both cases if it exists, even if the identity card is out of date. Failing this, state ‘ None ’ . For the purposes of Maltese institutions, in the case of Maltese nationals, state the identity card number, if not a Maltese national, state Maltese social security number. In the case of Slovene nationals, state the personal identification number EMŠO.

(9) The day and the month should be shown by two digits each and the year by four digits (example: 1 August 1921 = 01.08.1921). (10) For French towns comprising several arrondissements, please give the number of the arrondissement (example: Paris 14). In the case of Portuguese districts state also the parish and the local authority. (11) Must be stated for insured persons of Spanish, French or Italian nationality. Here, the territorial area or district in which the place of birth is located should be stated (example: in the case of France if the place (commune) of birth is Lille, the department of birth should be shown as ‘ Nord ’ followed by the area code if known to the insured person; in this case:

59. The complete entry should therefore read: ‘ Nord 59 ’ ). In the case of persons born in Spain state only the province. (12) The symbol of the insured person’s country of birth in accordance with ISO code 3166-1. (13) Complete where appropriate. (14) Indicate the nature of the periods treated as periods of employment. (15) This information is given on the basis of particulars provided by the worker. (16) After periods referred to in Article 15(2) of Regulation (EEC) No 574/72 put ‘ S ’ . (In the case of workers who were employed in mines or in undertakings treated as such, add the following Codes:

1 = acitivity above ground, 2 = activity underground, 3 = activity not specified. (17) For Belgian, Greek and Spanish institutions, specify where possible the type of activity in question. For Spanish institutions, in the case of seamen a photocopy of the sailor’s book or books of the country issuing the certificate should be enclosed. THE ADMINISTRATIVE COMMISSION ON SOCIAL SECURITY FOR MIGRANT WORKERS See ‘ Instructions ’ on page 4 E 205 SI (1) CERTIFICATE CONCERNING INSURANCE HISTORY IN THE REPUBLIC OF SLOVENIA Regulation (EEC) No 1408/71: Article 38; Article 43a ; Article 45; Article 48;

Article 51a; Article 57(5) Regulation (EEC) No 574/72: Article 42(1);. Article 43(1) to (3); Article 69 To be completed by the investigating institution in accordance with legislation administered and to be attached, if necessary, to forms E 202, E 203, or E 204. Each institution concerned should complete the form for insurance periods completed under applicable legislation and send it to the investigating institution. 1. Institution to which the form is addressed (competent institution or investigating institution, as appropriate) 1.1 Name: … … 1.2 Address (2): … … Information concerning the insured person 2.

Names 2.1 Surname (3): … 2.2 Surname at birth (3): … 2.3 Forenames (4): … 2.4 Previous names (5): … 2.5 Sex (6): … 2.6 Father’s surname and forenames (7): … 2.7 Mother’s surname and forenames (7): … 3. Nationality (8): … 4. Details of birth 4.1 Date of birth (9): … 4.2 Place of birth (10): … 4.3 Province, department, county(11): … 4.4 Country (12): … 5. Address (2): … … 6. 6.1 Insurance No at the investigating institution: … 6.2 Reference No of file at the investigating institution: … 6.3 Reference No of file at the institution concerned: … 7. Rightful claimant(13) 7.1 Surname (3): … 7.2 Forenames: … Surname at birth: … Place of birth (10): … 7.3 Date of birth (9): … Sex: … Nationality (8): … 7.4 Address (2): … … E 205 SI 8.

Completed insurance periods and periods treated as such Insurance periods Periods treated as insurance periods From To Years Years Months Months Days Days Occupation (15) (16) (17) Remarks (14) (18) (19) (20) (21) E 205 SI Total 8.1 — periods taken into account for the acquisition of a right to all pensions: … years … months … days additional periods taken into account only for the acquisition of a right to an old-age pension: … years … months … days 8.2 periods taken into account for the calculation of a pension: … years … months … days 9. An insured person showing proof that he has completed an insurance period of less than one year may receive may not receive a pension under national legislation (Article 48(1) of Regulation (EEC) No 1408/71).

10. Institution completing the form 10.1 Name: … … 10.2 Address (2): … … 10.3 Stamp 10.4 Date: … 10.5 Signature: E 205 SI INSTRUCTIONS Please complete this form in block letters, writing on the dotted lines only. It consists of four pages, none of which may be left out even if it does not contain any relevant information. NOTES (1) Symbol of the country to which the institution completing the form belongs: SI = Republic of Slovenia. (2) Street, number, post code, town, country, telephone number. (3) For surname please state usual surname or surname acquired by marriage. The surname at birth must always be given; if same as current surname put ‘ IDEM ’ .

Expressions such as ‘ called … ’ or ‘ alias … ’ and prefixes to surnames must be written in full in the order in which they appear on the birth certificate. In the case of Spanish nationals state both names at birth. In the case of Portuguese nationals state all names (forenames, surname, maiden name) in the order of civil status in which they appear on the identity card or passport. (4) Give all forenames in the order in which they appear on the birth certificate. (5) To be stated particularly in the case of adoption or in the case of other names in current use; expressions such as ‘ called … ’ or ‘ alias … ’ and prefixes to surnames must be written in full in the order in which they appear on the birth certificate.

(6) Put M for male and F for female. (7) This information is required when the worker is a Spanish national, or when the form is to be sent to a French institution, regardless of the worker’s nationality. (8) Where appropriate, indicate the date of naturalisation. For the purpose of Spanish institutions in the case of Spanish nationals state the number appearing on the national identity card DNI (Documento Nacional de Identidad) or the NIE (Número de Identificación de Extranjeros) in the case of foreign people, for both cases if it exists, even if the identity card is out of date. Failing this, state ‘ None ’ .

For the purposes of Maltese institutions, in the case of Maltese nationals, state the identity card number, if not a Maltese national, state Maltese social security number. In the case of Slovene nationals, state the personal identification number EMŠO. (9) The day and the month should be shown as two digits each and the year by four digits (example: 1 August 1921 = 01.08.1921). (10) For French towns comprising several arrondissements, please give the number of the arrondissement (example: Paris 14). In the case of Portuguese districts state also the parish and the local authority. (11) Must be stated for insured persons of Spanish, French or Italian nationality.

Here, the territorial area or district in which the place of birth is located should be stated (example: in the case of France if the place (commune) of birth is Lille, the department of birth should be shown as ‘ Nord ’ followed by the area code if known to the insured person; in this case: 59. The complete entry should therefore read: ‘ Nord 59 ’ ). In the case of persons born in Spain, state only the province. (12) The symbol of the insured person’s country of birth in accordance with ISO code 3166-1. (13) Complete where appropriate. (14) Periods taken into account only for the entitlement to old-age pension, but not for the calculation of a pension, are indicated by number (14).

(15) In the case of persons who were employed in mines or in undertakings treated as such, attach additional page indicating employment in mines or similar undertakings. (16) For Belgian Greek and Spanish institutions, specify where possible the type of activity in question. (17) For Spanish institutions, in the case of seamen a photocopy of the sailor’s book or book of the country issuing the certificate should be enclosed. (18) Periods which count double under Slovenian legislation are indicated by number (18). (19) After periods with bonus, number (19) as well as the rate of increase (12/14, 12/15, 12/16, 12/17, 12/18) are put.

(20) Periods which are taken into account by virtue of personal circumstances are indicated by number (20). (21) Purchased periods which are taken into account as insurance periods (abstract periods which cannot be allocated) are indicated by number (21). E 205 additional page SI COMPLEMENTARY DATA CONCERNING PERIODS OF EMPLOYMENT IN MINES AND SIMILAR UNDERTAKINGS Regulation (EEC) No 1408/71: Article 38; Article 43a; Article 45; Article 48; Article 51a; Article 57(5) Regulation (EEC) No 574/72: Article 42(1); Article 43(1) to (3); Article 69 1. Undertakings (1) Type of work performed (2) Periods of employment or periods treated as such Length of each period overall Underground work From To Years Months Days Years Months Days Total (1) Indicate the undertakings in which the person concerned was employed and the substance extracted or processed.

(2) Specify type of work and indicate whether performed at the surface or underground, or whether it concerns periods treated as periods of employment. E 205 additional page SI (continued) 2. The periods of employment shown in item 1 were interrupted as follows (3) Periods of interruption From To Day/Month/Year Day/Month/Year Reason for interruption (sickness, leave, military service, active service, unemployment, medical treatment, rehabilitation, unpaid leave, etc.) (3) Complete only if the form is to be sent to German, Spanish and Austrian institutions. THE ADMINISTRATIVE COMMISSION ON SOCIAL SECURITY FOR MIGRANT WORKERS See ‘ Instructions ’ on page 4 E 205 SK (1) CERTIFICATE CONCERNING INSURANCE HISTORY IN THE SLOVAK REPUBLIC Regulation (EEC) No 1408/71:

Article 38; Article 43a; Article 45; Article 48; Article 51a; Article 57(5) Regulation 574/72: Article 42(1) ; Article 43(1) to (3) ; Article 69 To be drawn up by the investigating institution for insurance periods completed under the legislation which it administers; to be attached to forms E 202, E 203 or E 204, as appropriate. Each institution concerned should draw up a form for the periods completed under the legislation which it administers and send it to the investigating institution. 1. Institution to which the form is addressed (institution concerned or institution investigating, as applicable) 1.1 Name: … … 1.2 Address (2): … … Information concerning the insured person 2.

Names 2.1 Surname (3): … 2.2 Surname at birth (3): … 2.3 Forenames (4): … 2.4 Previous names (5): … 2.5 Sex (6): … 2.6 Father’s surname and forenames (7): … 2.7 Mother’s surname and forenames (7): … 3. Nationality (8): … 4. Details of birth 4.1 Date of birth (9): … 4.2 Place of birth (10): … 4.3 Province, department, county (11): … 4.4 Country (12): … 5. Address (2): … … 6. 6.1 Registration No at the investigating institution: … 6.2 Reference No of the file at the investigating institution: … 6.3 Reference No of the file at the institution concerned: … 7. Rightful claimant (13) 7.1 Surname (3): … 7.2 Forenames: … Surnames at birth (3): … Place of birth (10): … 7.3 Date of birth (9): … Sex: … Nationality (8): … 7.4 Address (2): … … E 205 SK 8.

1. Periods of insurance 2. Periods treated as such From To From To 3. Number of days 4. Type of occupation (14) E 205 SK 8.1 Total length of insurance under the Slovak social security scheme: periods to be taken into account only for the acquisition of entitlement of benefits: days; periods to be taken into account only for the calculation of benefits: days; 8.2 Notes and comments: … … … 9. An insured person providing proof that he has completed an insurance period of less than one year may receive may not receive a pension under national legislation (Article 48(1) of Regulation (EEC) No 1408/71).

10. Institution completing the form 10.1 Name: … … 10.2 Address (2): … … 10.3 Stamp 10.4 Date: … 10.5 Signature: E 205 SK INSTRUCTIONS Please complete this form in block letters, writing on the dotted lines only. It consists of four pages, none of which may be left out even if it does not contain any relevant information. NOTES (1) Symbol of the country to which the institution completing the form belongs: SK = Slovakia. (2) Street, number, post code, town, country, telephone number. (3) For surname please state usual surname or surname acquired by marriage. The surname at birth must always be given; if same as current surname, put ‘ IDEM ’ .

Expressions such as ‘ called … ’ or ‘ alias … ’ and prefixes to surnames must be written in full in the order in which they appear on the birth certificate. In the case of Spanish nationals state both names at birth. In the case of Portuguese nationals state all names (forenames, surname, maiden name) in the order of civil status in which they appear on the identity card or passport. (4) Give all forenames in the order in which they appear on the birth certificate. (5) To be stated particularly in the case of adoption or in the case of other names in current use; expressions such as ‘ called … ’ or ‘ alias … ’ and prefixes to surnames must be written in full in the order in which they appear on the birth certificate.

(6) Put M for male and F for female. (7) This information is required when the worker is a Spanish national, or when the form is to be sent to a French institution, regardless of the worker’s nationality. (8) Where appropriate, indicate the date of naturalisation. For the purpose of Spanish institutions in the case of Spanish nationals state the number appearing on the national identity card DNI (Documento Nacional de IdentidadI) or the NIE (Número de Identificación de Extranjeros) in the case of foreign people, for both cases if it exists, even if the identity card is out of date. Failing this, state ‘ None ’ .

For the purposes of Maltese institutions, in the case of Maltese nationals, state the identity card number, if not a Maltese national, state Maltese social security number. (9) The day and the month should be shown by two digits each and the year by four digits (example: 1 August 1921 = 01.08.1921). (10) For French towns comprising several arrondissements, please give the number of the arrondissement (example: Paris 14). In the case of Portuguese districts state also the parish and the local authority. (11) Must be stated for insured persons of Spanish, French or Italian nationality. Here, the territorial area or district in which the place of birth is located should be stated (example: in the case of France if the place (commune) of birth is Lille, the department of birth should be shown as Nord followed by the area code if known to the insured person; in this case:

59. The complete entry should therefore read: Nord 59). In the case of persons born in Spain, state only the province. (12) The symbol of the insured person’s country of birth in accordance with ISO code 3166-1. (13) Complete where appropriate. (14) In the case of workers who were employed in mines or in undertakings treated as such, add the following Codes: 1 = acitivity above ground, 2 = activity underground, 3 = activity not specified. For Spanish institutions, in the case of seamen a photocopy of the sailor’s book or books of the country issuing the certificate should be enclosed. For Belgian, Greek and Spanish institutions specify where possible the type of activity in question.

THE ADMINISTRATIVE COMMISSION ON SOCIAL SECURITY FOR MIGRANT WORKERS See ‘ Instructions ’ on pages 4 E 205 FI (1) CERTIFICATE CONCERNING INSURANCE HISTORY IN FINLAND Regulation (EEC) No 1408/71; Article 38; Article 43a; Article 45; Article 48; Article 51a; Article 57(5) Regulation (EEC) No 574/72; Article 42(1); Article 43(1) to (3); Article 69 To be drawn up by the investigating institution for insurance periods completed under the legislation which it administers; where appropriate, to be attached to forms E 202, E 203 or E 204. Each institution concerned should draw up a form for the periods completed under the legislation which it administers and send it to the investigating institution.

1. Institution to which the form is addressed (institution concerned or investigating institution, as applicable) 1.1 Name: … … 1.2 Address (2): … … Information concerning the insured person 2. Names 2.1 Surname (3): … 2.2 Surname at birth (3): … 2.3 Forenames (4): … 2.4 Previous names (5): … 2.5 Sex (6): … 2.6 Father’s surname and forenames (7): … 2.7 Mother’s surname and forenames (7): … 3. Nationality (8): … 4. Details of birth 4.1 Date of birth (9): … 4.2 Place of birth (10): … 4.3 Province, department, county (11): … 4.4 Country (12): … 5. Address (2): … … 6.

6.1 Insurance No at the investigating institution: … 6.2 Reference No of file at the investigating institution: … 6.3 Reference No of file at the institution concerned: … 7. Rightful claimant (13) 7.1 Surname (3): … 7.2 Forenames: … Surname at birth (3): … Place of birth (10): … 7.3 Date of birth: … Sex: … Nationality (8): … 7.4 Address (2): … … E 205 FI 8. Periods of insurance Kind of period (15) Year From To Years Quarters Months Weeks Days Type (20) Nature (21) Scheme (22) Remarks E 205 FI 8.1 Totals by contribution type (15): … years … quarters … months … weeks … days 8.2 Remarks (14): … … … 9.

An insured person showing proof that he has completed an insurance period of less than one year may receive may not receive a pension under national legislation (Article 48(1) of Regulation (EEC) No 1408/71). 10. Institution completing the form 10.1 Name: … … 10.2 Address (2): … … 10.3 Stamp 10.4 Date: … 10.5 Signature: E 205 FI INSTRUCTIONS Please complete this form in block letters, writing on the dotted lines only. It consists of four pages, none of which may be left out even if it does not contain any relevant information. NOTES (1) Symbol of the country to which the institution completing the form belongs:

FI = Finland. (2) Street, number, post code, town, country, telephone number. (3) For surname please state usual surname or surname acquired by marriage. The surname at birth must always be given; if same as current surname, put ‘ IDEM ’ . Expressions such as ‘ called … ’ or ‘ alias … ’ and prefixes to surnames must be written in full in the order in which they appear on the birth certificate. In the case of Spanish nationals state both names at birth. In the case of Portuguese nationals state all names (forenames, surname, maiden name) in the order of civil status in which they appear on the identity card or passport.

(4) Give all forenames in the order in which they appear on the birth certificate. (5) To be stated particularly in the case of adoption or in the case of other names in current use; expressions such as ‘ called … ’ or ‘ alias … ’ and prefixes to surnames must be written in full in the order in which they appear on the birth certificate. (6) Put M for male and F for female. (7) This information is required when the worker is a Spanish national, or when the form is to be sent to a French institution, regardless of the worker’s nationality. (8) Where appropriate, indicate the date of naturalisation.

For the purpose of Spanish institutions in the case of Spanish nationals state the number appearing on the national identity card (DNI) or NIE in the case of foreign people, for both cases if it exists, even if the identity card is out of date. Failing this, state ‘ None ’ . For the purposes of Maltese Institutions, in the case of Maltese nationals, state the identity card number, if not a Maltese national, state Maltese social security number. In the case of Slovene nationals, state the personal identification number EMŠO. (9) The day and the month should be shown by two digits each and the year by four digits (example:

1 August 1921 - 01.08.1921). (10) For French towns comprising several arrondissements, please give the number of the arrondissement (example: Paris 14). In the case of Portuguese districts state also the parish and the local authority. (11) Must be stated for insured persons of Spanish, French or Italian nationality. Here, the territorial area or district in which the place of birth is located should be stated (example: in the case of France if the place (commune) of birth is Lille, the department of birth should be shown as Nord followed by the area code if known to the insured person; in this case:

59. The complete entry should therefore read: Nord 59). In the case of persons born in Spain state only the province. (12) The symbol of the insured person’s country of birth in accordance with ISO code 3166-1. (13) Complete where appropriate. (14) For Belgian, Greek and Spanish institutions, specify where possible the type of activity in question and in the case of seamen a photocopy of the sailor’s book or books of the country issuing the certificate should be enclosed. (15) The classification variables for the insurance periods as expressed in the note CA.SS.TM 186/87 and in its later updates, and, as regards the total amount, in the specification of entry ‘ contribution type 5049 ’ in the code list for message SSRECH used in the technical data exchange.

Key to contribution codes used in form E 205: COLUMN 20 — TYPE OF PERIOD 00 Period of compulsory in insurance (for the acquisition of entitlement and the calculation) 03 Equivalent period (for the acquisition of entitlement and the calculation) 40 Period of compulsory insurance (for the purposes of acquiring entitlement) COLUMN 21 — NATURE 00 Period of insurance based on residence 10 Period of employment 20 Period of parental benefits 30 Period of unemployment benefits 40 Period of rehabilitation and sickness benefit 50 Period of vocational and higher education 70 Period of pension time accruing pension COLUMN 22 — TYPE OF INSURANCE SCHEME 00 The pension schemes for residence based pension 10 The pension schemes for employed pensions 20 The pension schemes for self-employed persons 90 The pension schemes for employed persons as well as self-employed persons TOTALS BY CONTRIBUTION TYPE 107 Periods of residence for calculation and entitlement 108 Periods of residence for entitlement only 109 Periods of employment for calculation and entitlement 111 Periods of employment for entitlement only.

THE ADMINISTRATIVE COMMISSION ON SOCIAL SECURITY FOR MIGRANT WORKERS See ‘ Instructions ’ on page 4 E 205 SE (1) CERTIFICATE CONCERNING INSURANCE HISTORY IN SWEDEN Regulation (EEC) No 1408/71; Article 38; Article 43a; Article 45; Article 48; Article 51a; Article 57(5) Regulation (EEC) No 574/72; Article 42(1); Article 43(1) to (3); Article 69 This form must be completed by the investigating institution in respect of the insurance periods completed under the legislation it applies. It should be attached to forms E 202, E 203 or E 204 as appropriate. Each competent institution should complete a form for the periods completed under the legislation it applies and send it to the investigating institution.

1. Institution to which the form is addressed (competent institution or investigating institution, as appropriate) 1.1 Name: … … 1.2 Address (2): … … Information concerning insured person 2. Names 2.1 Surname (3): … 2.2 Surname at birth (3): … 2.3 All forenames (4): … 2.4 Previous surname (5): … 2.5 Sex (6): … 2.6 Father’s surname and all forenames (7): … 2.7 Mother’s surname and all forenames (7): … 3. Nationality (8): … 4. Details of birth 4.1 Date of birth (9): … 4.2 Place of birth (10): … 4.3 Province, county, town (11): … 4.4 Country (12): … 5. Address (2): … … 6.

6.1 Insurance No at the investigating institution: … 6.2 Reference No of file at the investigating institution: … 6.3 Reference No of file at the competent institution: … 7. Rightful claimant: (13) 7.1 Surname (3): … 7.2 All forenames: … Surname at birth: … Place of birth (10): … 7.3 Date of birth (9): … Sex: … Nationality (8): … 7.4 Address (2): … … E 205 SE 8. 1. Periods of insurance giving entitlement to income-based pensions/sickness compensation 2. Periods treated as insurance periods 3. Periods of residence giving entitlement to a guaranteed compensation/ guaranteed pension Number of From From To To From To Years Months Days E 205 SE 8.1 Insurance periods in Sweden … years 8.2 Periods treated as insurance periods in Sweden … years 8.3 Residence periods in Sweden … years … months … days 8.4 Remarks (14): … … … 9.

An insured person providing proof that he or she has completed an insurance period of less than one year may receive may not receive a pension under national legislation (Article 48(1) of Regulation (EEC) No 1408/71). 10. Institution completing the form 10.1 Name: … … 10.2 Address (2): … … Tel.: … Fax: … 10.3 Stamp 10.4 Date: … 10.5 Signature: E 205 SE INSTRUCTIONS Please complete the form in block letters, writing on the dotted lines only. The form consists of four pages, of which none should be omitted. NOTES (1) Symbol of the country to which the institution completing the form belongs:

SE = Sweden. (2) Street, number, post code, town, country, telephone number. (3) For surname please state usual surname or surname acquired by marriage. The surname at birth must always be given; if same as current surname, put ‘ IDEM ’ . Expressions such as ‘ called … ’ or ‘ alias … ’ and all prefixes to surnames must be written in full in the order in which they appear on the birth certificate. In the case of Spanish nationals state both surnames at birth. In the case of Portuguese nationals state all names (forenames, surname, maiden name) in the order of civil status in which they appear on the identity card or passport.

(4) Give all forenames in the order in which they appear on the birth certificate. (5) To be stated particularly in the case of adoption or in the case of other names in current use; expressions such as ‘ called … ’ or ‘ alias … ’ and all prefixes to surnames must be written in full in the order in which they appear on the birth certificate. (6) Put M for male and F for female. (7) This information is required when the worker is a Spanish national, or when the form is to be sent to a French institution, regardless of the worker’s nationality. (8) Where appropriate, indicate the date of naturalisation.

For the purpose of Spanish institutions in the case of Spanish nationals state the number appearing on the national identity card DNI (Documento Nacional de Identidad) or the NIE (Número de Identificación de Extranjeros) in the case of foreign people, for both cases if it exists, even if the identity card is out of date. Failing this, state ‘ None ’ . For the purposes of Maltese Institutions, in the case of Maltese nationals, state the identity card number, if not a Maltese national, state Maltese social security number. In the case of Slovene nationals, state the personal identification number EMŠO.

(9) The day and the month should be shown by two digits each and the year by four digits (example: 1 August 1921 = 01.08.1921). (10) For French towns comprising several arrondissements, please give the number of the arrondissement (example: Paris 14). In the case of Portuguese districts state also the parish and the local authority. (11) Must be stated for insured persons of Spanish, French or Italian nationality. Here, the territorial area or district in which the place of birth is located should be stated (example: in the case of France if the place (commune) of birth is Lille, the department of birth should be shown as Nord followed by the area code if known to the insured person; in this case:

59. The complete entry should therefore read: Nord 59). In the case of persons born in Spain, state only the province. (12) The symbol of the insured person’s country of birth in accordance with ISO code 3166-1. (13) Complete where appropriate. (14) For Spanish institutions specify where possible the type of work in question. For Spanish institutions, in the case of seamen a photocopy of the sailor’s book or books of the country issuing the certificate should be enclosed. THE ADMINISTRATIVE COMMISSION ON SOCIAL SECURITY FOR MIGRANT WORKERS See ‘ Instructions ’ on page 4 E 205 UK (1) CERTIFICATE CONCERNING INSURANCE HISTORY IN THE UNITED KINGDOM Regulation (EEC) No 1408/71;

Article 38; Article 43a; Article 45; Article 48; Article 51a; Article 57(5) Regulation (EEC) No 574/72; Article 42(1); Article 43(1) to (3); Article 69 To be drawn up by the investigating institution for insurance periods completed under the legislation which it administers; where appropriate, to be attached to forms E 202, E 203 or E 204. Each institution concerned should draw up a form for the periods completed under the legislation which it administers and send it to the investigating institution. 1. Institution to which the form is addressed (institution concerned or investigating institution, as applicable) 1.1 Name: … … 1.2 Address (2): … … Information concerning the insured person 2.

Names 2.1 Surname (3): … 2.2 Surname at birth (3): … 2.3 Forenames (4): … 2.4 Previous names (5): … 2.5 Sex (6): … 2.6 Father’s surname and forenames (7): … 2.7 Mother’s surname and forenames (7): … 3. Nationality (8): … 4. Details of birth 4.1 Date of birth (9): … 4.2 Place of birth (10): … 4.3 Province, department, county (11): … 4.4 Country (12): … 5. Address (2): … … 6. 6.1 Insurance No at the investigating institution: … 6.2 Reference No of file at the investigating institution: … 6.3 Reference No of file at the institution concerned: … 7. Rightful claimant (13) 7.1 Surname (3): … 7.2 Forenames: … Surname at birth: … Place of birth (10): … 7.3 Date of birth: … Sex: … Nationality: … 7.4 Address (2): … … E 205 UK 8.

Periods during which insurance periods and periods treated as such were completed Insurance periods (14) Employed persons Self-employed persons Voluntary insurance Periods treated as insurance periods Year From To Weeks Weeks Weeks Weeks Occupation (15) (16) (17) E 205 UK 8.1 Total length of period of insurance under the United Kingdom social security scheme for employed and self-employed persons: … 8.2 Comments: … … … 9. An insured person showing proof that he has completed an insurance period of less than one year may receive may not receive a pension under national legislation (Article 48(1) of Regulation (EEC) No 1408/71).

10. Institution completing the form 10.1 Name: … … 10.2 Address (2): … … 10.3 Stamp 10.4 Date: … 10.5 Signature: E 205 UK INSTRUCTIONS Please complete this form in block letters, writing on the dotted lines only. It consists of four pages, none of which may be left out even if it does not contain any relevant information. NOTES (1) Symbol of the country to which the institution completing the form belongs: UK = United Kingdom. (2) Street, number, post code, town, country, telephone number. (3) For surname please state usual surname or surname acquired by marriage. The surname at birth must always be given; if same as current surname, put ‘ IDEM ’ .

Expressions such as ‘ called … ’ or ‘ alias … ’ and prefixes to surnames must be written in full in the order in which they appear on the birth certificate. In the case of Spanish nationals state both names at birth. In the case of Portuguese nationals state all names (forenames, surname, maiden name) in the order of civil status in which they appear on the identity card or passport. (4) Give all forenames in the order in which they appear on birth certificate. (5) To be stated particularly in the case of adoption or in the case of other names in current use; expressions such as ‘ called … ’ or ‘ alias … ’ and prefixes to surnames must be written in full in the order in which they appear on the birth certificate.

(6) Put M for male and F for female. (7) This information is required when the worker is a Spanish national, or when the form is to be sent to a French institution, regardless of the worker’s nationality. (8) Where appropriate, indicate the date of naturalisation. For the purpose of Spanish institutions in the case of Spanish nationals state the number appearing on the national identity card DNI (Documento Nacional de IdentidadI) or the NIE (Número de Identificación de Extranjeros) in the case of foreigners, for both cases if it exists, even if the identity card is out of date. Failing this, state ‘ None ’ .

For the purposes of Maltese institutions, in the case of Maltese nationals, state the identity card number, if not a Maltese national, state Maltese social security number. In the case of Slovene nationals, state the personal identification number EMŠO. (9) The day and the month should be shown by two digits each and the year by four digits (example: 1 August 1921. = 01.08.1921). (10) For French towns comprising several arrondissements, please give the number of the arrondissement (example: Paris 14). In the case of Portuguese districts state also the parish and the local authority. (11) Must be stated for insured persons of Spanish, French or Italian nationality.

Here, the territorial area or district in which the place of birth is located should be stated (example: in the case of France if the place (commune) of birth is Lille, the department of birth should be shown as Nord followed by the area code if known to the insured person; in this case: 59. The complete entry should therefore read: Nord 59). In the case of persons born in Spain, state only the province. (12) The symbol of the insured person’s country of birth in accordance with ISO code 3166-1. (13) Complete where appropriate. (14) Indicate the period of voluntary insurance in the next column.

(15) In the case of workers who were employed in mines or in undertakings treated as such, add the following Codes: 1 = acitivity above ground, 2 = activity underground, 3 = activity not specified. These data may be issued only on the basis of information supplied by the employee. (16) For Belgian, Greek and Spanish institutions, specify where possible the type of activity in question. (17) For Spanish institutions, in the case of seamen a photocopy of the sailor’s book or books of the country issuing the certificate should be enclosed. THE ADMINISTRATIVE COMMISSION ON SOCIAL SECURITY FOR MIGRANT WORKERS See ‘ Instructions ’ on page 4 E 205 IS (1) CERTIFICATE CONCERNING INSURANCE HISTORY IN ICELAND Regulation (EEC) No 1408/71;

Article 38; Article 43a; Article 45; Article 48; Article 51a; Art. 57(5) Regulation (EEC) No 574/72; Article 42(1); Article 43(1) to (3); Article 69 To be drawn up by the investigating institution for insurance periods completed under the legislation which it administers; where appropriate, to be attached to forms E 202, E 203 or E 204. Each institution concerned should draw up a form for the periods completed under the legislation which it administers and send it to the investigating institution. 1. Institution to which the form is addressed (institution concerned or investigating institution, as applicable) 1.1 Name: … … 1.2 Address (2): … … Information concerning insured person 2.

Names 2.1 Surname (3): … 2.2 Surname at birth (3): … 2.3 Forenames (4): … 2.4 Previous names (5): … 2.5 Sex (6): … 2.6 Father’s surname and forenames (7): … 2.7 Mother’s surname and forenames (7): … 3. Nationality (8): … 4. Details of birth 4.1 Date of birth (9): … 4.2 Place of birth (10): … 4.3 Province, department, county (11): … 4.4 Country (12): … 5. Address (2): … … 6. 6.1 Insurance No at the investigating institution Reference: … 6.2 Reference No of file at the investigating institution: … 6.3 Reference No of file at the institution concerned: … 7. Rightful claimant (13) 7.1 Surname (3): … 7.2 Forenames: … Surname at birth (3): … Place of birth (10): … 7.3 Date of birth: … Sex: … Nationality (8): … 7.4 Address (2): … … E 205 IS 8.

1. Periods under employment pension schemes establishing right to supplementary pensions 2. Periods of residence establishing right to basic pension 3. Sum of periods of employment 4. Sum of periods of residence From To From To Years Months Days Years Months Days E 205 IS 8.1 Total length of periods under employment pension schemes … years … months … days 8.2 Total length of periods of residence … years … months … days 8.3. Remarks (14) (15): … … … 9. An insured person showing proof that he has completed an insurance period of less than one year may receive may not receive a pension under national legislation (Article 48(1) of Regulation (EEC) No 1408/71).

10. Institution completing the form 10.1 Name: … … 10.2 Address (2): … … 10.3 Stamp 10.4 Date: … 10.5 Signature: E 205 IS INSTRUCTIONS Please complete this form in block letters, writing on the dotted lines only. It consists of four pages, none of which may be left out even if it does not contain any relevant information. NOTES (1) Symbol of the country to which the institution completing the form belongs: IS = Iceland. (2) Street, number, post code, town, country, telephone number. (3) For surname please state usual surname or surname acquired by marriage. The surname at birth must always be given; if same as current surname, put ‘ IDEM ’ .

Expressions such as ‘ called … ’ or ‘ alias … ’ and prefixes to surnames must be written in full in the order in which they appear on the birth certificate. In the case of Spanish nationals state both names at birth. In the case of Portuguese nationals state all names (forenames, surname, maiden name) in the order of civil status in which they appear on the identity card or passport. (4) Give all forenames in the order in which they appear on birth certificate. (5) To be stated particularly in the case of adoption or in the case of other names in current use; expressions such as ‘ called … ’ or ‘ alias … ’ and prefixes to surnames must be written in full in the order in which they appear on the birth certificate.

(6) Put M for male and F for female. (7) This information is required when the worker is a Spanish national, or when the form is to be sent to a French institution, regardless of the worker’s nationality. (8) Where appropriate, indicate the date of naturalisation. For the purpose of Spanish institutions in the case of Spanish nationals state the number appearing on the national identity card DNI (Documento Nacional de IdentidadI) or the NIE (Número de Identificación de Extranjeros) in the case of foreign people, for both cases if it exists, even if the identity card is out of date. Failing this, state ‘ None ’ .

For the purposes of Maltese institutions, in the case of Maltese nationals, state the identity card number, if not a Maltese national, state Maltese social security number. In the case of Slovene nationals, state the personal identification number EMŠO. (9) The day and the month should be shown by two digits each and the year by four digits (example: 1 August 1921 = 01.08.1921). (10) For French towns comprising several arrondissements, please give the number of the arrondissement (example: Paris 14). In the case of Portuguese districts state also the parish and the local authority. (11) Must be stated for insured persons of Spanish, French or Italian nationality.

Here, the territorial area or district in which the place of birth is located should be stated (example: in the case of France if the place commun of birth is Lille, the department of birth should be shown as ‘ Nord ’ followed by the area code if known to the insured person; in this case: 59. The complete entry should therefore read: ‘ Nord 59 ’ ). In the case of persons bom in Spain, state only the province. (12) The symbol of the insured person’s country of birth in accordance with ISO code 3166-1. (13) Complete where appropriate. (14) For Spanish institutions, in the case of seamen a photocopy of the sailor’s book or books of the country issuing the certificate should be enclosed.

(15) For Belgian, Greek and Spanish institutions specify where possible the type of activity in question. THE ADMINISTRATIVE COMMISSION ON SOCIAL SECURITY FOR MIGRANT WORKERS See ‘ Instructions ’ on page 5 E 205 LI (8) CERTIFICATE CONCERNING INSURANCE HISTORY IN LIECHTENSTEIN Regulation (EEC) No 1408/71; Article 38; Article 43a; Article 45; Article 48; Article 51a; Article 57(5) Regulation (EEC) No 574/72; Article 42(1); Article 43(1) to (3); Article 69 To be drawn up by the investigating institution for insurance periods completed under the legislation which it administers; where appropriate, to be attached to forms E 202, E 203 or E 204.

Each institution concerned should draw up a form for the periods completed under the legislation which it administers and send it to the investigating institution. 1. Institution to which the form is addressed (institution concerned or investigating institution, as applicable) 1.1 Name: … … 1.2 Address (2): … … Information concerning the insured person 2. Names 2.1 Surname (3): … 2.2 Surname at birth (3): … 2.3 Forenames (4): … 2.4 Previous names (5): … 2.5 Sex (6): … 2.6 Father’s surname and forenames (7): … 2.7 Mother’s surname and forenames (7): … 3. Nationality (8): … 4.

Details of birth 4.1 Date of birth (9): … 4.2 Place of birth (10): … 4.3 Province, department, county (11): … 4.4 Country (12): … 5. Address (2): … … 6. 6.1 Insurance No at the investigating institution: … 6.2 Reference No of file at the investigating institution: … 6.3 Reference No of file at the institution concerned: … 7. Rightful claimant (13) 7.1 Surname (3): … 7.2 Forenames: … Surname at birth (3): … Place of birth (10): … 7.3 Date of birth: … Sex: … Nationality (8): … 7.4 Address (2): … … E 205 LI 8. Year from 1 January to 31 December Number of months Type of insurance periods Type of contributions (15) Remarks (17) 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 E 205 LI 8.

(continued) Year from 1 January to 31 December Number of months Type of insurance periods Type of contributions (15) Remarks (17) 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2011 2012 2013 2014 2015 2016 2017 2005 2006 2007 2008 2009 2010 E 205 LI 8.1 Total period of insurance: months 8.2 Remarks: … … … 9. An insured person showing proof that he has completed an insurance period of less than one year may receive may not receive a pension under national legislation (Article 48(1) of Regulation (EEC) No 1408/71). 10. Institution completing the form 10.1 Name: … … 10.2 Address (2): … … 10.3 Stamp 10.4 Date: … 10.5 Signature:

E 205 LI INSTRUCTIONS 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: LI = Liechtenstein. (2) Street, number, post code, town, country, telephone number. (3) For surname please state usual surname or surname acquired by marriage. The surname at birth must always be given; if same as current surname, put ‘ IDEM ’ . Expressions such as ‘ called … ’ or ‘ alias … ’ and prefixes to surnames must be written in full in the order in which they appear on the birth certificate.

In the case of Spanish nationals state both names at birth. In the case of Portuguese nationals state all names (forenames, surname, maiden name) in the order of civil status in which they appear on the identity card or passport. (4) Give all forenames in the order in which they appear on birth certificate. (5) To be stated particularly in the case of adoption or in the case of other names in current use; expressions such as ‘ called … ’ or ‘ alias … ’ and prefixes to surnames must be written in full in the order in which they appear on the birth certificate. (6) Put M for male and F for female.

(7) This information is required when the worker is a Spanish national, or when the form is to be sent to a French institution, regardless of the worker’s nationality. (8) Where appropriate, indicate the date of naturalisation. For the purpose of Spanish institutions in the case of Spanish nationals state the number appearing on the national identity card (DNI) or NIE in the case of foreign people, for both cases if it exists, even if the identity card is out of date. Failing this, state ‘ None ’ . For the purposes of Maltese institutions, in the case of Maltese nationals, state the identity card number, if not a Maltese national, state Maltese social security number.

In the case of Slovene nationals, state the personal identification number EMŠO. (9) The day and the month should be shown by two digits each and the year by four digits (example: 1 August 1921 = 01.08.1921). (10) For French towns comprising several arrondissements, please give the number of the arrondissement (example: Paris 14). In the case of Portuguese districts state also the parish and the local authority. (11) Must be stated for insured persons of Spanish, French or Italian nationality. Here, the territorial area or district in which the place of birth is located should be stated (example: in the case of France if the place (commune) of birth is Lille, the department of birth should be shown as Nord followed by the area code if known to the insured person; in this case:

59. The complete entry should therefore read: Nord 59). In the case of persons born in Spain, state only the province. (12) The symbol of the insured person’s country of birth in accordance with ISO code 3166-1. (13) Complete where appropriate. (14) In 8.2 indicate the nature of the periods treated as periods of employment. (15) Kind of insurance periods/kind of contribution: 1 — contributions from employment 2 — contributions from a voluntary-insured person 3 — contributions from self-employment 4 — contributions from non-active persons 10 — periods of insurance without contribution obligation.

(16) For Belgian, Greek and Spanish institutions, specify where possible the type of activity in question. (17) For Spanish institutions, in the case of seamen a photocopy of the sailor’s book or books of the country issuing the certificate should be enclosed. THE ADMINISTRATIVE COMMISSION ON SOCIAL SECURITY FOR MIGRANT WORKERS See ‘ Instructions ’ on page 4 E 205 NO (1) CERTIFICATE CONCERNING INSURANCE HISTORY IN NORWAY Regulation (EEC) No 1408/71; Article 38; Article 43a; Article 45; Article 48; Article 51a; Article 57(5) Regulation (EEC) No 574/72; Article 42(1); Article 43(1) to (3); Article 69 To be drawn up by the investigating institution for insurance periods completed under the legislation which it administers; where appropriate, to be attached to forms E 202, E 203 or E 204.

Each institution concerned should draw up a form for the periods completed under the legislation which it administers and send it to the investigating institution. 1. Institution to which the form is addressed (institution concerned or investigating institution, as applicable) 1.1 Name: … … 1.2 Address (2): … … Information concerning the insured person 2. Names 2.1 Surname (3): … 2.2 Surname at birth (3): … 2.3 Forenames (4): … 2.4 Previous names (5): … 2.5 Sex (6): … 2.6 Father’s surname and forenames (7): … 2.7 Mother’s surname and forenames (7): … 3. Nationality (8): … 4.

Details of birth 4.1 Date of birth (9): … 4.2 Place of birth (10): … 4.3 Province, department, county (11): … 4.4 Country (12): … 5. Address (2): … … 6. 6.1 Insurance No at the investigating institution: … 6.2 Reference No of file at the investigating institution: … 6.3 Reference No of file at the institution concerned: … 7. Rightful claimant (13) 7.1 Surname (3): … 7.2 Forenames: … Surname at birth(3): … Place of birth (10): … 7.3 Date of birth (9): … Sex: … Nationality (8): … 7.4 Address (2): … … E 205 NO 8. Sum of each insurance period Insurance periods based on residence and periods treated as such Year from to Insurance years with income as employed or self-employed, giving points for supplementary pension Year Months Days E 205 NO 8.1 Total number of insurance years as employed or self-employed, counting, as basis for calculation of supplementary pension … years 8.2 Total insurance period under the pension scheme in Norway … years … months … days Total insurance period, according to Norwegian legislation … years … months … days 8.3 Remarks (14) (15): … … … 9.

An insured person showing proof that he has completed an insurance period of less than one year may receive may not receive a pension under national legislation (Article 8(1) of Regulation (EEC) No 1408/71). 10. Institution completing the form 10.1 Name: … … 10.2 Address (2): … … 10.3 Stamp 10.4 Date: … 10.5 Signature: E 205 NO INSTRUCTIONS Please complete this form in block letters, writing on the dotted lines only. It consists of four pages, none of which may be left out even if it does not contain any relevant information. NOTES (1) Symbol of the country to which the institution completing the form belongs:

NO = Norway. (2) Street, number, post code, town, country, telephone number. (3) For surname please state usual surname or surname acquired by marriage. The surname at birth must always be given; if same as current surname, put ‘ IDEM ’ . Expressions such as ‘ called … ’ or ‘ alias … ’ and prefixes to surnames must be written in full in the order in which they appear on the birth certificate. In the case of Spanish nationals state both names at birth. In the case of Portuguese nationals state all names (forenames, surname, maiden name) in the order of civil status in which they appear on the identity card or passport.

(4) Give all forenames in the order in which they appear on the birth certificate. (5) To be stated particularly in the case of adoption or in the case of other names in current use; expressions such as ‘ called … ’ or ‘ alias … ’ and prefixes to surnames must be written in full in the order in which they appear on the birth certificate. (6) Put M for male and F for female. (7) This information is required when the worker is a Spanish national, or when the form is to be sent to a French institution, regardless of the worker’s nationality. (8) Where appropriate, indicate the date of naturalisation.

For the purpose of Spanish institutions in the case of Spanish nationals state the number appearing on the national identity card DNI (Documento Nacional de IdentidadI) or the NIE (Número de Identificación de Extranjeros) in the case of foreign people, for both cases if it exists, even if the identity card is out of date. Failing this, state ‘ None ’ . For the purposes of Maltese Institutions, in the case of Maltese nationals, state the identity card number, if not a Maltese national, state Maltese social security number. (9) The day and the month should be shown by two digits each and the year by four digits (example:

1 August 1921 = 01.08.1921). (10) For French towns comprising several arrondissements, please give the number of the arrondissement (example: Paris 14). In the case of Portuguese districts state also the parish and the local authority. (11) Must be stated for insured persons of Spanish, French or Italian nationality. Here, the territorial area or district in which the place of birth is located should be stated (example: in the case of France if the place (commune) of birth is Lille, the department of birth should be shown as ‘ Nord ’ followed by the area code if known to the insured person; in this case:

59. The complete entry should therefore read: ‘ Nord 59 ’ ). In the case of persons born in Spain, state only the province. (12) The symbol of the insured person’s country of birth in accordance with ISO code 3166-1. (13) Complete where appropriate. (14) For Spanish institutions, in the case of seamen a photocopy of the sailor’s book or books of the country issuing the certificate should be enclosed. (15) For Belgian, Greek and Spanish institutions specify where possible the type of activity in question. THE ADMINISTRATIVE COMMISSION ON SOCIAL SECURITY FOR MIGRANT WORKERS See ‘ Instructions ’ on page 4 E 205 CH (1) CERTIFICATE CONCERNING INSURANCE HISTORY IN SWITZERLAND Regulation (EEC) No 1408/71:

Article 38; Article 45; Article 48; Article 57(5) Regulation (EEC) No 574/72: Article 42(1); Article 43(1) to (3); Article 69 To be drawn up by the investigating institution for insurance periods completed under the legislation which it administers; where appropriate, to be attached to forms E 202, E 203 or E 204. Each institution concerned should draw up a form for the periods completed under the legislation which it administers and send it to the investigating institution. 1. Institution to which the form is addressed (institution concerned or investigating institution, as applicable) 1.1 Name: … … 1.2 Address (2): … … Information concerning the insured person 2.

Names 2.1 Surname (3): … 2.2 Surname at birth (3): … 2.3 Forenames (4): … 2.4 Previous names (5): … 2.5 Sex (6): … 2.6 Father’s surname and forenames (7): … 2.7 Mother’s surname and forenames (7): … 3. Nationality (8) (9): … 4. Details of birth 4.1 Date of birth (10): … 4.2 Place of birth (11): … 4.3 Province, department, county (12): … 4.4 Country (13): … 5. Address (2): … … 6. 6.1 Insurance No at the investigating institution: … 6.2 Reference No of file at the investigating institution: … 6.3 Reference No of file at the institution concerned: … 7. Rightful claimant (14) 7.1 Surname (3): … 7.2 Forenames: … Surname at birth: … Place of birth (11): … 7.3 Date of birth: … Sex: … Nationality (8) (9): … 7.4 Address (2): … … E 205 CH 8.

Year (from 1 January to 31 December) Months of contributions J F M A M J J A S O N D Number of months Periods without correlation to months Periods treated as insurance periods Total number of months Type of insurance periods Type of contributions (15) E 205 CH 8.1 Total period of insurance … months 8.2 Remarks (16): … … … 9. An insured person showing proof that he has completed an insurance period of less than one year may receive may not receive a pension under national legislation (Article 48(1) of Regulation (EEC) No 1408/71). 10. Institution completing the form 10.1 Name: … … 10.2 Address (2): … … 10.3 Stamp 10.4 Date: … 10.5 Signature:

E 205 CH INSTRUCTIONS Please complete this form in block letters, writing on the dotted lines only. It consists of four pages, none of which may be left out even if it does not contain any relevant information. NOTES (1) Symbol of the country to which the institution completing the form belongs: CH = Switzerland. (2) Street, number, post code, town, country, telephone number. (3) For surname please state usual surname or surname acquired by marriage. The surname at birth must always be given; if same as current surname put ‘ IDEM ’ . Expressions such as ‘ called … ’ or ‘ alias … ’ and prefixes to surnames must be written in full in the order in which they appear on the birth certificate.

In the case of Spanish nationals state both names at birth. In the case of Portuguese nationals state all names (forenames, surname, maiden name) in the order of civil status in which they appear on the identity card or passport. (4) Give all forenames in the order in which they appear on the birth certificate. (5) To be stated particularly in the case of adoption or in the case of other names in current use; expressions such as ‘ called … ’ or ‘ alias … ’ and prefixes to surnames must be written in full in the order in which they appear on the birth certificate. (6) Put M for male and F for female.

(7) This information is required where the worker is a Spanish national, or when the form is to be sent to a French institution, regardless of the worker’s nationality. (8) Where appropriate, indicate the date of naturalisation. (9) For the purpose of Spanish institutions in the case of Spanish nationals state the number appearing on the national identity card DNI (Documento Nacional de IdentidadI) or the NIE (Número de Identificación de Extranjeros) in the case of foreign people, for both cases if it exists, even if the identity card is out of date. Failing this, state ‘ None ’ . For the purposes of Maltese institutions, in the case of Maltese nationals, state the identity card number, if not a Maltese national, state Maltese social security number.

In the case of Slovene nationals, state the personal identification number EMŠO. (10) The day and the month should be shown by two digits each and the year by four digits (example: 1 August 1921 = 01.08.1921). (11) For French towns comprising several arrondissements, please give the number of the arrondissement (example: Paris 14). In the case of Portuguese districts state also the parish and the local authority. (12) Must be stated for persons of Spanish, French or Italian nationality. Here, the territorial area or district in which the place of birth is located should be stated (example: in the case of France if the place (commune) of birth is Lille, the department of birth should be shown as ‘ Nord ’ followed by the area code if know to the insured person, in this case:

59. The complete entry should therefore read: ‘ Nord 59 ’ ). In the case of persons born in Spain state only the province. (13) The symbol of the insured person’s country of birth in accordance with ISO code 3166-1. (14) Complete where appropriate. (15) Kind of insurance periods/kind of contribution: 1 — contributions from employment 2 — voluntary insurance contributions 3 — contributions from self-employment 4 — contributions from non-active periods 10 — insurance periods with no obligation to contribute. (16) For the purpose of Belgian, Greek and Spanish institutions specify where possible the type of activity in question.

For Spanish institutions, in the case of seamen a photocopy of the sailor’s book or books of the country issuing the certificate should be enclosed. THE ADMINISTRATIVE COMMISSION ON SOCIAL SECURITY FOR MIGRANT WORKERS See ‘ Instructions ’ on pages 3 and 4 E 207 (1) CERTIFICATE CONCERNING THE INSURED PERSON’s INSURANCE HISTORY Regulation (EEC) No 1408/71: Article 38; Article 43a; Article 45; Article 48; Article 51a; Article 57(5) Regulation No 574/72: Article 42(1); Article 43(1) to (3); Article 69 To be completed by the investigating institution and to be attached to forms E 202, E 203 and E 204.

The information in box 7 has been obtained from the person concerned and will be sent to the institution concerned. Information concerning insured persons (2) 1. 1.1 Surname (3): … 1.2 Surname at birth (3): … 1.3 Forenames (4): … 1.4 Previous names (5): … 1.5 Sex (6): … 1.6 Father’s surname and forenames (7): … 1.7 Mother’s surname and forenames at birth (7): … 1.8 National social security number (7a): … 2. Nationality (8): … Identification No (20): … 3. Details of birth 3.1 Date of birth (9): … 3.2 Place of birth (10): … 3.3 Province, department, county (11): … 3.4 Country (12): … 4.

Address (13) (14): … … 5. 5.1 Identification No at the investigating institution (15) (20): … 5.2 Identification No at the institution concerned (15) (20): … 6. Investigating Institution 6.1 Name: … 6.2 Address (3): … 6.3 Stamp 6.4 Date: … 6.5 Signature: E 207 7. Information relating to all periods completed (periods as civil servant or periods of employment, self-employment, residence and training) (16) (16a) Periods (17) from to Type of periods (18) Name of employer and place of registered office or type of activity carried out as self-employed person Place and country where activity is carried out (19) (a) Insurance institution or scheme (15) (b) Identification number (20) (c) Type of insurance (21) Place of residence during period of employment (16) (22) 1 (a) … (b) … (c) … 2 (a) … (b) … (c) … 3 (a) … (b) … (c) … 4 (a) … (b) … (c) … 5 (a) … (b) … (c) … 6 (a) … (b) … (c) … 7 (a) … (b) … (c) … 8 (a) … (b) … (c) … 7.1 Stamp 7.2 Date: … 7.3 Signature:

(23) E 207 INSTRUCTIONS Please complete this form in block letters, writing on the dotted lines only. It consists of four pages, none of which may be left out even if it does not contain any relevant information. If the space provided on page 2 is not sufficient to indicate all stages of the insurance history of the person concerned, insert one or more identical pages, changing the numbers at the extreme left-hand side (Substituting 9, 10, 11 … for 1, 2, 3 …). 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. (2) For Germany and Austria, the term ‘ insured persons ’ encompasses individuals insured under the general social security scheme as well as civil servants and individuals treated as such who are insured under a special scheme.

In the case of Poland the term ‘ insured person ’ also refers to persons who are subject to special schemes. If the form is being sent to a Swedish institution, please complete additional page No 1. (3) For surname please state usual surname or surname acquired by marriage. The ‘ surname at birth ’ must always be given; if same as current surname, put ‘ IDEM ’ . Expressions such as ‘ called … ’ or ‘ alias … ’ and prefixes to surnames must be written in full in the order in which they appear on the birth certificate. If the form is being completed by a Netherlands institution, in cases where the insured person or the rightful claimant is a married woman or a woman who was married before, put the present or last husband’s surname for current surname and the maiden name for surname at birth.

In the case of Spanish nationals state both names at birth. In the case of Portuguese nationals state all names (forenames, surname, maiden name) in the order of civil status in which they appear on the identity card or passport. (4) Give all forenames in the order in which they appear on the birth certificate. (5) To be stated particularly in the case of adoption or in the case of other names in current use; expressions such as «called» or «alias» and prefixes to surnames must be written in full in the order in which they appear on the birth certificate. (6) Put M for male and F for female.

(7) This information is required when the worker is a Spanish national, or when the form is to be sent to a French or Hungarian institution, regardless of the worker’s nationality. (7 a) For workers subject to Belgian legislation, state worker’s national social security number (NISS); for the purposes of the Netherlands institutions, state the SOFI number. (8) Where appropriate, indicate the date of naturalisation. (9) The day and the month should be shown by two digits each and the year by four digits (example : 1 August 1921 = 01.08.1921). (10) For French towns comprising several arrondissements, please give the number of the arrondissement (example :

Paris 14). In the case of Portuguese districts, state also the parish and the local authority. (11) Must be stated for insured persons of Spanish, French or Italian nationality. Here, the territorial area or district in which the place of birth is located should be stated (example: in the case of France if the place (commune) of birth is Lille, the department of birth should be shown as ‘ Nord ’ followed by the area code if known to the insured person; in this case ‘ 59 ’ . The complete entry should therefore read ‘ Nord 59 ’ ). In the case of persons born in Spain, state only the province.

(12) The symbol of the insured person’s country of birth, in accordance with ISO code 3166-1. (13) Street, number, post code, town, country, telephone number. (14) For the purposes of Norwegian institutions, please state actual address and last address in Norway with date of emigration. (15) For Spanish institutions enclose a photocopy of the Spanish sailor’s book or books if the relevant institution is the ISM (Instituto Nacional de la Marina - Mariners’ Social Institute), or if the relevant scheme is the Special Scheme for Mariners. (16) Attach certified copies of documentary evidence for each period (e.g. pension cards, salary slips, contribution vouchers).

For Latvian institution attach the employment record (darba grāmatiņa) for the employment before 1996. For a Lithuanian institution attach, for employment before 1994, the employment record (darbo knygele), certificates of service and of income for 1984-1993. Applications for a Polish old-age pension under a special scheme, by persons who are entitled to have higher assessment of service counted towards seniority allowance, i.e. raise of old-age pension due to their service, should send appropriate certificates. For the purposes of Swiss institutions, attach a copy of all AVS/AI (AHV/IV) insurance certificates, AVS/AI (AHV/IV) insurance stamps, certificates of residence or residence permits and employment certificates obtained in Switzerland.

(16 a) In the case of Poland the term ‘ periods as civil servant ’ also refers to periods of service as officers of the Police, the Citizens’ Militia, state security, public order and security services, State Security Office, Internal Security Agency, Intelligence Agency, Border Guard, Government Security Bureau, National Fire Brigades and Prison Guard and periods of military service of professional soldiers as well as periods of working as a judge or a prosecutor. (17) If the form is being sent to a Danish, Netherlands, Finnish, Icelandic, Liechtenstein, Norwegian or Swiss institution, indicate also all periods of residence completed by the worker in Denmark, the Netherlands, Finland, Iceland, Liechtenstein, Norway or Switzerland.

For this purpose, give the exact address of the person in the corresponding State. E 207 (18) Indicate the type of work performed (employed or self-employed), e.g. mechanic, shop assistant, self-employed farmer. Where applicable: school or vocational training: (specify type of course and diplomas obtained); periods without paid employment (e.g. housewife, unemployed, sickness, etc.); military service (country). If the person concerned served in the Spanish armed forces, enclose a copy of the service record book (cartilla militar) with form E 207. Failing this, provide the following information: year of conscription, service branch, function, province of recruitment and place of residence immediately after discharge.

If the person concerned served in the armed forces in Italy, in Latvia or in Lithuania or the former USSR, or in Slovakia or the former Czechoslovakia a copy of his service book (for Italy: ‘ foglio matricolare ’ ) or of his service record (for Italy: ‘ stato di servizio ’ ) should be enclosed where possible with the E 207 form. (19) Where the activity is carried out in France, give the name of the department. (20) Where the form is being sent to a Czech institution, state the Czech 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 Liechtenstein institution, indicate the AHV insurance number; to a Lithuanian institution state the personal identification number; to a Latvian institution; state the identity 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 identification number (fødselsnummer); 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) and to an institution of the social security scheme for civil servants, indicate the personal identification number (PRS-Kenn-Nr); to an Austrian institution, state the Austrian insurance number (VSNR); for the purpose of Spanish institutions in the case of Spanish nationals state the number appearing on the national identity card DNI (Documento Nacional de IdentidadI) or the NIE (Número de Identificación de Extranjeros) in the case of foreign people, for both cases if it exists, even if the identity card is out of date.

Failing this, state ‘ None ’ ; to a Polish institution, state the reference number of the pension file for the person who applied for or had established the right to a pension from the Polish social security system, for a person applying for a Polish pension for the first time, state PESEL and NIP or NKP number (NKP number — if the person concerned is subject to social insurance for farmers), if there is no such number state the series and number of identity card or passport; to a Portuguese institution, indicate the registration number with the general insurance scheme, and if it is the case, 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.

The TAJ number or personal identification number is required when the form is being sent to Hungarian institutions. (21) Specify whether compulsory insurance, voluntary insurance, optional continued insurance or period uninsured. (22) For Greece, indicate the commune and department where the person concerned is insured with OGA. (23) If page 2 is completed by the claimant him/herself, the claimant’s signature and date must be given. In the case of Ireland, a copy of the national form completed by the claimant will be attached. E 207 additional page 1 SE ADDITIONAL INFORMATION FOR SWEDISH INSTITUTIONS Periods of residence between 16 and 65 years Periods under employment Duration from to from to years months days Addresses in Sweden In case of a survivor’s pension, the abovementioned periods refer to the deceased.

If the claimant/the deceased was employed/self-employed in Sweden before 1960, proof of employment should be enclosed if possible. THE ADMINISTRATIVE COMMISSION ON SOCIAL SECURITY FOR MIGRANT WORKERS E 210 (Symbol of the country) NOTIFICATION OF DECISION CONCERNING A CLAIM FOR A PENSION Application of Regulations (EEC) No 1408/71 and (EEC) No 574/72 Old age Invalidity Survivor Award or rejection Each of the institutions concerned should complete this form and send it to the investigating institution together with a copy of the formal decision. One extra copy should be added for any additional institution concerned.

1. Investigating institution to which the form is addressed 1.1 Name: … … 1.2 Address: … … 1.3 Number of insured person/reference number of file: … 2. Information concerning the insured person 2.1 Surname: … 2.2 Surname at birth: … 2.3 Forenames: … 2.4 Previous names: … 2.5 Date of birth: … 2.6 Identification No: … 3. Information concerning the entitled person 3.1 Surname: … 3.2 Surname at birth: … 3.3 Forenames: … 3.4 Previous names: … 3.5 Date of birth: … 3.6 Family relationship or other connection with the deceased insured person (box 2): … 4. Address: of insured person of entitled person … … 5.

The claim is rejected Reasons: … … … E 210 6. A pension is awarded 6.1 This benefit is awarded pursuant to: Article 46(1)(a)(i) of Regulation (EEC) No 1408/71 (national). Article 46(1)(a)(ii) of Regulation (EEC) No 1408/71 (pro rata). Article 46(2) of Regulation (EEC) No 1408/71 (pro rata). Article 51a(2) of Regulation (EEC) No 1408/71. 6.2 For the award of the benefit, a rule against overlapping was applied from , taking account of: benefit of the same kind: (state type of benefit) benefit of a different kind: (state type of benefit) other sources of income professional or trade activity/activity as a civil servant. other (state the income concerned):

6.3 The effect of the rule against overlapping was limited by the application of provisions of: Article 46a(3)(d) of Regulation (EEC) No 1408/71. Article 46c of Regulation (EEC) No 1408/71 because one or more institutions took account of: a benefit of a different kind: … other sources of income professional trade or activity/activity as a civil servant. other (please specify): Article 7(1) of Regulation (EEC) No 574/72. 6.4 Number of monthly payments per year 12 13 14 6.5 From: … 6.6 Monthly amount, where appropriate, for the application of Article 46a(3)(d), Article 46c of Regulation (EEC) No 1408/71, or Article 7(1) of Regulation (EEC) No 574/72: … 6.7 Part of the amount awarded on the basis of voluntary insurance (Article 46a(3)(c) of Regulation (EEC) No 1408/71) (to be completed only at the request of the investigating institution): … 6.8 Monthly amount before deduction of taxes, etc.

(Article 46a(3)(b) of Regulation (EEC) No 1408/71), where appropriate, following application of Article 46c of Regulation (EEC) No 1408/71 or of Article 7(1) of Regulation (EEC) No 574/72: … … 6.9 Monthly amount due (amount paid after deduction of taxes, etc.): … 6.10 To be filled in by Swedish institutions Monthly amount from the guaranteed pension/ compensation scheme: … Monthly amount from the income related pension/compensation scheme: … E 210 7. Appeals and periods allowed for appeals Procedure to follow: … Time limit: … 8. Institution concerned 8.1 Name: … … 8.2 Address: … … 8.3 Number of insured person/reference number of file: … 8.4 Stamp 8.5 Date: … 8.6 Signature:

THE ADMINISTRATIVE COMMISSION ON SOCIAL SECURITY FOR MIGRANT WORKERS See ‘ Instruction ’ page 3 E 211 (1) SUMMARY OF DECISIONS Regulation (EEC) No 574/72, Article 48 The investigating institution should complete this form and send a copy to the claimant in his own language attaching a copy of each of the formal decisions. The investigating institution should also send a copy of an E 211 form to each of the institutions concerned, attaching a copy of its own decision and of the decisions of the other institutions concerned. 1. Claimant 1.1 Surname (2): … 1.2 Forenames: … Previous names (2): … Place of birth (3): … 1.3 Date of birth: … Sex: … Nationality: … 1.4 Address (5): … … 1.5 Identification No at the investigating institution (4): … 1.6 Identification No at the institution concerned (4): … 2.

Your claim for a pension for 2.1 old age invalidity survivor 2.2 has been examined by the following institutions: 3. Institutions concerned: Country Institution File reference 3.1 3.2 3.3 3.4 3.5 4. These institutions have taken the following decisions (see original decisions attached) 5. Your claim has been rejected 5.1. Concerning (6): … Reason: … … … … 5.2. Concerning (6): … Reason: … … … … E 211 6. A pension (7) has been awarded to you Concerning (6): Annual amount in currency of country responsible for payment (8) (9): Payable from (date): 6.1 6.2 6.3 6.4 6.5 7. If you do not agree with the decision or decisions taken, you may appeal.

For this purpose you should, for each contested decision: 1. clearly state the grounds for your appeal in a letter, which you must sign, 2. if you cannot sign, you may make a cross and have the letter signed by two persons of full age, who must give their surnames, forenames and full addresses, 3. in this letter you must give the references of the notification relating to the contested decision and attach a copy of the decision, 4. the letter must be sent to the authority mentioned in the decision within the period indicated in the decision, 5. in accordance with Article 48(1) of Regulation (EEC) No 574/72, this period commences on the date of receipt of the summarised statement, IT IS ESSENTIAL TO COMPLY WITH THE TIME PERIODS INDICATED IN EACH DECISION, 6. in accordance with Article 86 of Regulation (EEC) No 1408/71, appeals which would have been submitted within the period stipulated by the legislation of one State are admissible if they are submitted within the same period to the corresponding authority of another State.

8. Appeals and periods allowed for appeals 8.1 Concerning (6): … Procedure to be followed: … Time limit: … 8.2 Concerning (6): … Procedure to be followed: … Time limit: … 8.3 Concerning (6): … Procedure to be followed: … Time limit: … 9. Investigating institution 9.2 Address (5): … 9.3 Stamp 9.1 Name: … 9.4 Date: … 9.5 Signature: E 211 INSTRUCTIONS Please complete this form in block letters, writing on the dotted lines only 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. (2) 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. For the purposes of Czech institutions, always state the surname at birth and all further surnames in the item ‘ Previous names ’ .

(3) In the case of Portuguese districts state also the parish and the local authority. (4) Where the form is being sent to a Czech institution, state the Czech 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 Liechtenstein institution, indicate the AHV insurance number; to a Lithuanian institution state the personal identification number; to a Latvian institution, state the identity 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 identification number (fødselsnummer); 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); for the purpose of Spanish institutions in the case of Spanish nationals state the number appearing on the national identity card (DNI) or NIE in the case of foreign people, for both cases if it exists, even if the identity card is out of date, failing this, state ‘ None ’ ; to an Austrian institution, state the Austrian insurance number (VSNR); to a Polish institution, state the reference number of the pension file for the person who applied for or had established the right to a pension from the Polish social security system, for persons applying for Polish pension for the first time, state PESEL and NIP or NKP number (NKP number – if the person concerned is subject to social insurance for farmers), if there is no such number state the series and number of identity card or passport; 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.

The TAJ number or personal identification number is required when the form is being sent to Hungarian institutions. (5) Street, number, post code, town, country, telephone number. (6) Indicate country and where necessary the scheme concerned. (7) Or cash compensation in Liechtenstein. (8) Where rates of pensions are upgraded by virtue of national legislation, the amount indicated above will be changed. The new amount will not be communicated to any other institution. (9) It is possible that this amount is reduced by taxes and contributions payable by the pensioner. THE ADMINISTRATIVE COMMISSION ON SOCIAL SECURITY FOR MIGRANT WORKERS See ‘ Instructions ’ on page 7 E 213 (1) DETAILED MEDICAL REPORT Regulation (EEC) No 1408/71:

Articles 39 to 41; Article 43a; Article 87 1.1 Institution to which the report is addressed 1.1.1 Name: … … 1.1.2 Address (2): … … 1.1.3 Reference: … 1.2. Person examined 1.2.1 Surname (3): … 1.2.2 Forenames: … Previous names (3): … Place of birth (4): … 1.2.3 Date of birth: … Sex: … Nationality: … Identification No (5): … 1.2.4 Address (2): … … 1.2.5 Last occupation (6): … 1.2.6 Insurance No: … 1.2.7 Pension No: … 1.2.8 File No: … 1.2.9 Date of submission of pension claim: … 1.2.10 Date of submission of request on grounds of aggravation: … 1.3 Doctor who drew up the report 1.3.1 Surname: … Forenames: … 1.3.2 Address (2): … … 1.3.3 Examining doctor of (7): … 1.4 Institution which requested the examination 1.4.1 Name: … … 1.4.2 Address (2): … … 1.4.3 Reference No of file: … 1.4.4 Stamp 1.4.5 Date: … 1.4.6 Signature:

E 213 Surname, Forenames … Date: … 2.1 Opinion based on the own examination of (date): … 2.2 Opinion based on medical report of (date): … 3. Patient’s history 3.1 Medical history: … … 3.2 Current chief complaints: … … 3.2.1 Doctor currently treating the patient: … 3.3 Current treatment: … … 3.4 Social and employment history (6): … 3.4.1 Is the insured person currently gainfully employed? Yes No Number of working hours: … Type of actual employment: … 3.4.2 Accidents at work/occupational diseases: … 3.4.3 Type of last employment: … 3.4.4 Unfit for work Since … Cessation of work on … 4.

Findings 4.1 General conditions Height: … cm Weight: … kg Nutrition condition: good overweight underweight Mucous membranes: … Skin: … Mental status, mood: … Remarks: … 4.2 Head: … 4.2.1 Vision: … 4.2.2 Hearing: … 4.2.3 Other sensory organs: … 4.3 Neck (external findings): … 4.3.1 Review of thyroid gland: … 4.3.2 Lymphatic nodes: … 4.3.3 Others: … 4.4 Respiratory organs: … 4.5 Circulatory system: … 4.5.1 Heart: … 4.5.2 Pulse: … 4.5.3 Blood pressure (at rest): … 4.5.4 Blood pressure (second measurement): … 4.5.5 Peripheral blood vessels: … 4.5.6 Oedema: … 4.5.7 ECG (at rest): … E 213 Surname, forenames: … Date: … 4.6 Abdomen: … 4.6.1 Digestive system and linked intra-abdominal organs: … 4.6.2 Liver: … 4.6.3 Spleen: … 4.6.4 Endocrine system: … 4.7 Genito-urinary system: … [See page 4 - Diagrams] 4.8 Locomotor system (if necessary use Neutral-0 method, page 4): … 4.8.1 Spine: … 4.8.2 Upper limbs: … 4.8.3 Lower limbs: … 4.9 Presence of lymphatic nodes: … 4.10 Neurologic findings Movement (power and tone) (8): unremarkable stiff slowed weak Gait: unremarkable ponderous impaired on right impaired on left Reflexes: … 4.11 Psychoautonomic symptoms or psychologically determined physical symptoms: … 4.12 Other (Allergies, etc.): … 5.

Function and other tests (when necessary) 5.1 Lung function: … 5.2 Cardiac function/exercise ECG: … 5.3 Doppler ultransonography (Heart and vessels): … 5.4 Imaging studies (please specify date): … 5.4.1 Findings in today’s X-rays examination: … 5.4.2 Earlier findings/X-ray examinations done elsewhere: … 5.4.3 Ultrasonography (abdomen et al): … 5.4.4 MRI and special investigations: … 5.5 Laboratory results: … 5.6 Other tests: … 6. Additional sheet for further specialists’ findings (shall be completed only if relevant). 7. Diagnosis: (ICD code recommended) E 213 DIAGRAMS E 213 Surname, forenames: … Date: … 8.

Summary: Course of disease: … Damage to health: … Functional deficits: … Compared with previous report (dated ) worsening no change improvement 9. The insured person is still capable of regularly performing the following types of work: heavy average light 10. The following restrictions should be taken into account 10.1 Work can only be performed without Damp Cold Heat Noise Smoke, gases, vapours Shifts Nightshifts Frequent bending, lifting, carrying objects Climbing ramps, ladders or stairs Danger of falling 10.2 Work can only be performed under the following conditions Only in seated positions Only with additional breaks Only indoors (in addition to the usual breaks) number and length of breaks … Work with varying body posture 10.3 The work performance is reduced because the insured person is restricted in using his/her sensory organs, hands etc. … is allergic to … Work varying between walking, standing, sitting Work only without particular time pressure 11.

Additional questions 11.1 Can the insured person do video-screen work? Yes No If ‘ No ’ please specify the reason: … 11.2 Can the insured person work without the support of another person at the working place? Yes No 11.3 Can the insured person work without the support of another person at home? Yes No If ‘ No ’ please specify the reason: … E 213 Surname, forenames … Date: … 11.4 Can the insured person work full time in his/her last occupation as Yes No If ‘ No ’ please specify maximum working time (in hours or percentages of a working day): … 11.5 Can adapted work be performed? Yes No If ‘ Yes ’ please indicate some examples of adapted work 11.6 Can adapted work be performed full time? Yes No If ‘ No ’ specify maximum working time (in hours or percentages of a working day): … 11.7 The invalidity for the last occupation is, under the legislation of the country of residence, total partial If partial, indicate the degree: … (Does not concern Germany, the Netherlands and Poland) 11.8 Degree of invalidity for any other work with reference to the aptitudes of the person concerned under the legislation of the country of residence: … (Does not concern Germany, Ireland, Luxembourg and the Netherlands) 11.9 Category of invalidity under the legislation of the country of residence: … (Complete only if the medical examination was carried out with a view to the decision to be taken on a disability or invalidity pension claim).

(Does not concern Germany and the Netherlands). 11.10 The established restrictions: have been permanent since … are temporary, from … to … 11.11 Would it be possible to improve the present state of health? Yes No No answer possible If ‘ Yes ’ indicate the measures: … 11.12 Are there possibilities to ameliorate the work capacity through medical training? vocational training? Yes No No answer possible 12. Is re-examination necessary in the future? Yes No If ‘ Yes ’ please state when: … Stamp Date: … Doctor’s signature: E 213 INSTRUCTIONS Please complete this form in block letters or typewriting It consists of seven pages, none of which may be left out even if it does not contain any relevant information.

NOTES (1) 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. (2) Street, number, post code, town, country, telephone number. (3) In the case of Spanish nationals state both names. In the case of Portugese nationals state all names (forenames, surname, maiden name) in the order of civil status in which they appear on the identity card or passport.

(4) In the case of Portugese districts state also the parish and the local authority. (5) 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 Liechtenstein institution, indicate the AHV insurance number, to a Lithuanian institution state the personal identification number, to a Latvian institution, state the identity number; to a Hungarian institution state the TAJ 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 identification number (fødselsnummer); 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) and to an institution of the social security scheme for civil servants, indicate the personal identification number (PRS-Kenn-Nr; for the purpose of Spanish institutions in the case of Spanish nationals state the number appearing on the national identity card (DNI) or N.I.E in the case of foreign people, for both cases if it exists, even if the identity card is out of date, failing this, state ‘ None ’ ; to an Austrian institution, state the Austrian insurance number (VSNR); to a Polish institution, state the reference number of the pension file for the person who applied for or had established the right to a pension from the Polish social security system, for persons applying for a Polish pension for the first time, state PESEL and NIP or NKP number (NKP number — if the person concerned is subject to social insurance for farmers), if there is no such number state the series and number of identity card or passport; 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.

(6) Please list as far as possible all the occupations in which the insured person has worked. This information is given after the statement of the person concerned. Where necessary, insert extra pages. (7) Not relevant for Norway. (8) For the purposes of Polish institutions please complete point 1 on the ‘ Additional page No 4 ’ . E 213 additional page 1 NL ADDITIONAL INFORMATION FOR THE PURPOSES OF INSTITUTIONS IN THE NETHERLANDS Questions Answers Can the person insured No Incidentally Sometimes Regularly No limit 1. sit? 2. stand? 3. walk? 4. kneel/crawl/squat? 5. work with bent back? 6. bow or twist back often? 7. use the nape? 8. hold the arms extended? 9. hold the arms raised? 10. use his/her hands/fingers? 11. lift and carry … kg max? 12. work under the following conditions: be exposed to sudden changes of temperatures? stand high humidity ( > 90 %)? stand low humidity ( < 35 %)? stand strong changes of climate? 13. stand intensive (skin) contacts with solid and liquid substances? 14. stand vibrations? 15. wear protective gear? 16. maintain a demanding rhythm of work? 17. abide doing nothing? 18. handle conflicting demands arising from his/her functions? 19. handle conflicts? 20. perform monotonous work? 21. perform cyclical repeated work? 22. bear responsibility? 23. work alone? 24. work with others? E 213 additional page 2 UK ADDITIONAL PAGE FOR THE PURPOSES OF THE UNITED KINGDOM INSTITUTIONS A.

Complete in all cases 1. Name and address of the doctor of the person named in item 1.2 … … B. Complete in cases where the person suffers from a mental health problem 2. Tick one of the boxes below if the person has any of the following illnesses or disabling conditions: a psychiatric illness (if yes, please specify) … a significant degree of personality disorder a severe learning disability alcohol or substance abuse impairment of brain function consequent to organic disease or traumatic brain injury If any box in item 2 above is ticked, complete boxes 3 to 7. 3. Has the person exhibited paranoid features, delusions, hallucinations, or other frankly psychotic symptoms/behaviour at any time during the past six months? Yes No 4.

Is the person receiving neuroleptic drug and/or mood altering drugs which could be given orally or as depot (long term injected treatment)? Yes No 5. Does the person need continual care or supervision because of the effects of the condition(s) ticked at item 2 above? Yes No If ‘ Yes ’ is the person being looked after in home surroundings or in sheltered care? Home Sheltered care 6. Is the person attending a day care centre (where constant qualified nursing care is available) for at least one day a week? Yes No 7. Name and address of consultant psychiatrist: … 8. Add any comments which may assist in determining the severity of the person’s mental health problem even if none of the boxes in item 2 have been ticked: … … … E 213 additional page 3 NO ADDITIONAL PAGE FOR THE PURPOSES OF NORWEGIAN INSTITUTIONS 1.

If there are causes of incapacity for work other than illness, please give a brief description and the degree of contribution: … 2. During the period immediately preceding the present disability has the patient been partly occupied by domestic work and partly been employed/self-employed? Yes No 3. Due to the illness and on a permanent basis does the patient have extra expenses for transport needs, dietary needs, etc, which are not covered in full or in part by any social security scheme? Yes No If ‘ Yes ’ state types and costs of extra expenses: … E 213 additional page 4 PL ADDITIONAL INFORMATION FOR THE PURPOSES OF POLISH INSTITUTIONS 1.

Information pertaining to position 4.10 ‘ Neurological examination ’ : Muscular tone normal increased decreased Muscle power normal decreased (adynamia) Range of movements: … 2. Was impairment of organ function caused by: accident at work? accident on the way to or from work? accident which occurred in the particular circumstances? accident at service? date of accident: … occupational disease? date of onset of the occupational disease: … other circumstances (please, give details)? 3.1 Does the examined person require permanent or long-term assistance of others? No Yes, in the scope of: mobility at home feeding themselves maintenance of personal hygiene performing bodily functions managing every-day activities outside home 3.2 Is the mental condition of the examined person a reason for permanent or long-term assistance by others? No Yes, because:

4. Complete in cases where the person suffers from mental health problem 4.1 Tick one of the boxes below if the person has any of the following illnesses or disabling conditions: a psychiatric illness (if yes, please specify): … a significant degree of personality disorder a severe learning disability alcohol or substance abuse impairment of brain function consequent to organic disease or traumatic brain injury If any box in item 4.1 above is ticked, complete boxes 4.2 to 4.6 E 213 additional page 4 PL (continued) 4.2 Has the person exhibited paranoid features, delusions, hallucinations, or other frankly psychotic symptoms/behaviour at any time during the past six months? Yes No 4.3 Is the person receiving neuroleptic drug and/or mood altering drugs which could be given orally or as depot (long term injected treatment)? Yes No 4.4 Does the person need continual care or supervision because of the effects of the condition(s) ticked at item 4.1 above? Yes No If `Yes’ is the person being looked after in home surroundings or in sheltered care? Home Sheltered care 4.5 Is the person attending a day care centre (where constant qualified nursing care is available) for at least one day a week? Yes No 4.6 Name and address of consultant psychiatrist:

4.7 Add any comments which may assist in determining the severity of the person’s mental health problem even if none of the boxes in item 4.1 have been ticked: E 213 additional page 5 HU ADDITIONAL PAGE FOR THE PURPOSES OF THE HUNGARIAN INSTITUTIONS 1. Does the person need continual care or supervision? Yes No If ‘ Yes ’ is the person being looked after in home surroundings or in sheltered care? Home Sheltered care 2. Which activities does the person need help with? 3. Does the person need use of any therapeutic equipment? Yes No If ‘ Yes ’ which ones? THE ADMINISTRATIVE COMMISSION ON SOCIAL SECURITY FOR MIGRANT WORKERS See ‘ Instructions ’ on pages 6 and 7 E 215 (1) ADMINISTRATIVE REPORT ON THE POSITION OF A PENSIONER Regulation (EEC) No 574/72:

Articles 40 and 51 1. Institution to which the form is addressed 1.1 Name: … … 1.2 Address (2): … … 2. Pensioner 2.1 Surname (3): … 2.2 Surname at birth (3): … 2.3 Forenames (4): … 2.4 Previous names (5): … 2.5 Sex (6): … 2.6 Father’s surname and forenames (7): … 2.7 Mother’s surname and forenames at birth (7): … 2.8 Civil status: single divorced separated from spouse since … since … married remarried (8) widower/widow since … since … since … cohabiting since … (9) (10) 2.9 Identification No at investigating institution (11): … 2.10 Identification No at other institution concerned (11): … 2.11 Type of pension: … 3.

Nationality (12): … 4. Details of birth 4.1 Date of birth (14) (15): … 4.2 Place of birth (16): … 4.3 Province, department, county (17): … 4.4 Country (18): … 5. Address (2) (19) … … E 215 6. Spouse/cohabiting partner (9) 6.1 Surname (3): … 6.4 Address (2) (20): … … 6.5 Date of marriage/cohabiting: … 6.6 The spouse/partner 6.2 Forenames (4): … Previous names (5): … 6.3 Date of birth (15): … Place of birth (16): … is is not pursuing a professional activity or trade 6.7 If in the affirmative, state amount of weekly earnings (21): monthly (22): annual earnings (23): 6.8 The spouse/partner receives does not receive a pension from a scheme for employed persons self-employed persons civil servants If in the affirmative, indicate:

6.9 Type of pension: … 6.10 Pension No: … 6.11 Institution responsible for pension payment: … 6.12 Amount monthly quarterly annually 6.13 The spouse/partner (24) receives other does not receive other benefitsbenefits namely for unemployment sickness invalidity other 6.14 Date of: … 6.15 Amount monthly quarterly annually 6.16 Other known resources: Type: … Amount (25): … E 215 7. Children (26) 7.1 Surname (3): Forenames: Date of birth (15): Relationship: 1. 2. 3. 4. 7.2 Address (2) (27): … … 7.3 Remarks (28) (29): … … 8. Ascendants and other members of the household (30) 8.1 Surnamne (3):

Forenames: Date of birth (15): Relationship: 8.2 Address (27): … … 8.3 Remarks: … … E 215 9 Benefits 9.1 The pensioner has applied for the following benefits: and/or receives the following benefits: 9.2 Continued wage or salary payments in case of illness 9.3 Sickness insurance cash benefits for incapacity for work 9.4 Rehabilitation allowance 9.5 Invalidity pension (31) 9.6 Old-age pension (31) 9.7 Survivor’s pension (31) 9.8 Pension for accident at work or occupational disease 9.9 Unemployment benefits 9.10 Occupational pension (from a former employer) (31a) 9.11 Institutions responsible for paying the benefits listed in 9.3 to 9.10 [name, address (2)] :

9 … 9 … 9 … 9 … 9.12 Additional information on the benefits in 9.3 to 9.10 Reference No: Period of date: Amount: weekly 9 … monthly annual weekly 9 … annual monthly weekly 9 … monthly annual weekly 9 … monthly annual E 215 10. Activity pursued, if any 10.1 The pensioner is unemployed is engaged in paid employment intends to pursue paid employment (32) is engaged in self-employment intends to pursue self- employment (32) Type of work: … 10.2 Date of commencement of present work: … 10.3 No of hours worked: … per week 10.4 Amount of daily weekly monthly 10.5 Earnings daily weekly monthly of a healthy person employed in the same activity with a normal working period of … hours per: day week month 10.6 Period in which the income mentioned in 10.4 was earned: … … 11.

The pensioner died on … 12. Remarks , if any: … … … 13. Institution which drafted the report 13.1 Name: … 13.2 Address (2): … 13.3 Stamp 13.4 Date: … 13.5 Signature: E 215 INSTRUCTIONS Please complete this form in block letters, writing on the dotted lines only. It consists of seven 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. (2) Street, number, post code, town, country, telephone number. (3) For surname please state usual surname or surname acquired by marriage. The ‘ surname at birth ’ must always be given; if same as current surname, put ‘ IDEM ’ . Expressions such as ‘ called … ’ or ‘ alias … ’ and prefixes to surnames must be written in full in the order in which they appear on the birth certificate.

If the form is being completed by a Netherlands institution, in cases where the insured person or the rightful claimant is a married woman or a woman who was married before, put the present or last husband’s surname for current surname and the maiden name for surname at birth. In the case of Spanish nationals state both names at birth. In the case of Portuguese nationals state all names (forenames, surname, maiden name) in the order of civil status in which they appear on the identity card or passport. (4) Give all forenames in the order in which they appear on birth certificate. (5) Previous names should be stated particularly in the case of adoption or in the case of other names in current use.

Expressions such as ‘ called … ’ or ‘ alias … ’ must be written in full in the order in which they appear on the birth certificate. (6) Put M for male and F for female. (7) This information is required for a Spanish national, or a French national born outside metropolitan France, or when the form is to be sent to Hungarian institutions. (8) Complete where possible, for Belgian, German, French, Hungarian, Italian, Luxembourgish, Netherlands, Maltese, Polish, Slovak, Austrian and Portuguese institutions. If this information is not available from the investigating institution, the competent institution should contact the person concerned.

(9) For the purposes of Belgian, Danish, Hungarian, Netherlands, Finnish, Icelandic and Norwegian institutions. (10) This information is based on a statement from the person concerned. (11) 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 Liechtenstein institution, indicate the AHV insurance number; to a Lithuanian institution state the personal identification number; to a Latvian institution state the identity 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 identification number (fødselsnummer); 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) and to an institution of the social security scheme for civil servants, indicate the personal identification number (PRS-Kenn-Nr); to an Austrian institution, state the Austrian insurance number (VSNR); to a Polish institution, state the reference number of the pension file for the person who applied for or had established the right to a pension from the Polish social security system, for a person applying for a Polish pension for the first time, state PESEL and NIP or NKP number (NKP number — if the person concerned is subject to social insurance for farmers), if there is no such number state the series and number of identity card or passport ; 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 reference number of the file if known; to a Swiss institution, state the AVS/AI (AHV/IV) insurance number.

The TAJ number or personal identification number is required when the form is being sent to Hungarian institutions. (12) Where appropriate, indicate the date of naturalisation. For the purpose of Spanish institutions in the case of Spanish nationals state the number appearing on the national identity card DNI (Documento Nacional de IdentidadI) or the NIE (Número de Identificación de Extranjeros) in the case of foreign people, for both cases if it exists, even if the identity card is out of date. Failing this, state ‘ None ’ . In the case of Slovene nationals, state the personal identification number EMŠO.

(13) Deleted. (14) The day and the month should be shown by two digits each and the year by four digits (example: 1 August 1921 = 01.08.1921). (15) Where the form is being sent to a Finnish institution give population register (identity) number where applicable. (16) For French towns comprising several arrondissements, please give the number of the arrondissement (example: Paris 14). In the case ofPortuguese districts state also the parish and the local authority. (17) Must be stated for insured persons of Spanish, French or Italian nationality. Here, the territorial area or district in which the place of birthis located should be stated (example: in the case of France if the place (commune) of birth is Lille, the department of birth should be shownas ‘ Nord ’ followed by the area code if known to the insured person; in this case:

59. The complete entry should therefore read: ‘ Nord 59 ’ ).In the case of persons born in Spain, state only the province. (18) The symbol of the insured person’s country of birth in accordance with ISO code 3166-1. (19) If the form is being sent to a Danish, Finnish, Icelandic or Norwegian institution, give the claimant’s last address in the corresponding country in the box below. Address (2): … … E 215 (20) Complete only if the form is being sent to a Danish, Icelandic or Norwegian institution. (21) Complete only if the form is being sent to an Irish, United Kingdom or Austrian institution.

(22) Complete if the form is being sent to a Belgian or Polish institution. (23) Complete if the form is being sent to a Danish, Spanish, French, Italian, Luxembourgish, Netherlands, Austrian, Portuguese, Icelandic or Norwegian institution. (24) Does not apply to Luxembourgish institutions. (25) Complete for Belgian, German, Italian, Austrian Polish or Portuguese (monthly amount), French (quarterly amount), Danish, Spanish, Netherlands, Icelandic or Norwegian (annual amount) institutions. (26) For the purposes of Norwegian institutions, complete also form E 215/additional page No 1. In the case of Slovene nationals, state the personal identification number EMŠO.

(27) Indicate the common address, if one of the children or ascendants lives at a different address, indicate in the box below. Surname and forenames: … Address (2): … … (28) Indicate if the child is married, an invalid, deceased (date of death), an apprentice or a student. (29) For the purposes of Hungarian, Polish, Slovak, Spanish and Norwegian institutions state whether the invalid child receives an invalidity pension in his or her own right. (30) Complete if the form is being sent to a Belgian, German, French or Austrian institution. (31) For the purposes of Liechtenstein institutions, indicate also if the person applied for or received the pension as cash compensation.

(31 a) Provide details of this in 9.12 for Maltese institutions only. Details of all occupational pensions paid/expected to be paid required. Rate of pension should be that as on original award of pensions/s. (32) For the purposes of Spanish institutions state whether this occupation entails compulsory pension insurance cover. E 215 additional page 1 NO ADDITIONAL INFORMATION FOR THE PURPOSES OF NORWEGIAN INSTITUTIONS 1. Children 1.1 Name: … Forename: … Date of birth: … Income per year (All kinds): … 1.2 Name: … Forename: … Date of birth: … Income per year (All kinds): … 1.3 Name: … Forename: … Date of birth: … Income per year (All kinds): … 1.4 Name: … Forename: … Date of birth: … Income per year (All kinds): … 1.5 Name: … Forename: … Date of birth: … Income per year (All kinds): … 1.6 Name: … Forename: … Date of birth: … Income per year (All kinds): … 2.

Does the child share the household with both parents? Yes No If ‘ No ’ , state which of the children, if not all children are concerned: 3. If the parents are not married and the child (children) shares the household with both parents, give information about the other parent Name: … Date of birth: … Income per year (All kinds. Specify): … Name of the child (children) if not all children are concerned: … 4. Cohabitant 4.1 Has the pensioner previously been married to the cohabitant? Yes No 4.2 Does the pensioner have or has she/he had children by the cohabitant? Yes No