IV-Rundschreiben Nr. 292 / Anwendung der neuen Gemeinschaftsverordnungen Nr. 883/2004 und 987/2009 in der EU ab dem 1. Mai 2010 - Auswirkungen für die Schweiz. Infocharakter.

Département fédéral de l'intérieur (DFI) Office fédéral des assurances sociales (OFAS) Domaine Assurance-invalidité

10 mai 2010

Circulaire AI n° 292

Application des nouveaux règlements communautaires n° 883/2004 et 987/2009 au sein de l’UE à partir du 1er mai 2010 – Conséquences pour la Suisse A partir du 1er mai 2010, les règlements 1408/71 et 574/72 seront remplacés par le règlement (CE) n° 883/2004 (JO L 200 du 7.6.2004) et son règlement d’application 987/2009 (JO L 284 du 30.10.2009) dans les 27 Etats membres de l’UE.

Les nouveaux règlements 883/2004 et 987/2009 ne sont pour l’instant pas applicables dans les relations entre la Suisse et les Etats membres de l’UE. La date d’entrée en vigueur pour la Suisse de ces règlements est encore inconnue. Une information à ce sujet sera diffusée en temps opportun.

Comme les précédentes actualisations du droit communautaire, les experts suisses et de la Commission européenne examinent la reprise des nouveaux règlements dans le cadre d’une actualisation de l’annexe II de l’Accord sur la libre circulation des personnes. L’accent est mis sur une mise en œuvre rapide des nouvelles dispositions par la Suisse. La coordination multilatérale des systèmes nationaux de sécurité sociale ne peut réellement fonctionner que si toutes les Parties appliquent les mêmes règles.

A partir du 1er mai 2010, de nouveaux formulaires seront mis en circulation dans les Etats membres de l’UE.

A l’issue d’une période transitoire d’au moins deux ans, l’échange des formulaires E papier actuellement utilisés sera remplacé par des échanges de formulaires électroniques, appelés SEDs (Structured Electronic Document). Les SEDs ont un contenu similaire aux formulaires E papier actuels.

Durant la période transitoire, les formulaires E papier seront progressivement remplacés par les SEDs provisoirement utilisés en format papier et ayant en principe le même aspect que les formulaires E. Ils seront ensuite convertis en échanges électroniques. En outre, de nouveaux documents portables (Portable Document ; PD) seront introduits.

La Suisse étudie l’opportunité de participer à cet échange électronique.

Aussi longtemps que la Suisse ne reprend pas formellement les nouveaux règlements, les nouveaux formulaires communautaires ne sont pas utilisables dans les relations entre la Suisse et les Etats membres de l’UE.

Service juridique Office fédéral des assurances sociales OFAS Effingerstrasse 20, CH-3003 Berne http://www.ofas.admin.ch

Toutefois, il n’est pas exclu qu’une institution ou un organisme d’un Etat membre de l’UE émette erronément un nouveau formulaire (PD ou SED papier) à l’attention d’une institution suisse. Dans un tel cas, nous vous saurions gré de bien vouloir observer une grande souplesse lors de l’examen de la validité d’un tel document. Seule une application pragmatique et flexible des règles de coordination évitera de compromettre les droits des assurés mobiles.

A titre d’information, nous joignons aux présentes des versions provisoires des documents portables. Les versions anglaises définitives de ces documents seront disponibles sur le site de la Commission européenne (DG EMPL), dans le courant du mois de mai ; ils seront traduits dans toutes les langues officielles d’ici la fin de l’année 2010.

Annexes : - Documents portables provisoires en anglais o S3 Nouveau formulaire. La Suisse ne devrait jamais l’accepter, compte tenu d’une réserve à ce sujet

Service juridique Office fédéral des assurances sociales OFAS Effingerstrasse 20, CH-3003 Berne http://www.ofas.admin.ch

Certificate concerning the Social Security legislation which applies to the holder EU Regulations 883/04 and 987/09 (*) INFORMATION FOR THE holder

This certificate concerns the social security legislation which applies to you and confirms that you have no obligations to pay contributions in another State. Before you leave the State where you are insured to go to another State to work, make sure you have the documents which entitle you to receive the necessary benefits in kind (e.g. medical care, treatment in hospital, and other) in the State where you are working.

If you are staying temporarily in the State where you are working, ask your health care institution for the European Health Insurance Card (EHIC). You must show this card to your health care provider if you need benefits in kind during your stay.
If you are going to be living in the State where you are working, ask your health care institution for the S1 document and submit it as soon as possible to the competent health care institution of the place you are going to work (**). Provisionally the insurance institution in the State of stay will also provide special benefits in the event of an accident at work or an occupational disease.

1. personal details of the holder

1.1 Personal Identification Number  Female  Male

1.2 Surname

1.3 Forenames

1.4 Surname at birth (***)

1.5 Date of birth 1.6 Nationality

1.7 Place of birth

1.8 Address in the State of residence

1.8.1 Street, N° 1.8.3 Post code

1.8.2 Town 1.8.4 Country code

1.9 Address in the State of stay

1.9.1 Street, N° 1.9.3 Post code

1.9.2 Town 1.9.4 Country code

2. Member state legislation which applies

2.1 Member State

2.2 Starting date 2.3 Ending date

 2.4 The certificate applies for the duration of the activity  2.5 The determination is provisional  2.6 Regulation 1408/71 remains applicable on the basis of Article 87 (8) of Regulation 883/2004

(*) Regulations (EC) No 883/2004, articles 11 through 16, and 987/2009, article 19. (**) For Spain, Sweden and Portugal , the certificate must be handed over to, respectively, the head provincial offices of social security National Institute (INSS), the social insurance institution and the social security institution of the place of residence. (***) Information given to the institution by the holder when this is not known by the institution.

©European Commission

Certificate concerning the Social Security legislation which applies to the holder

3. STATUS confirmation of your position

 3.1 Posted employed person  3.2 Employed, working in two or more States  3.3 Posted self-employed person  3.4 Self-employed, in two or more States  3.5 Civil servant  3.6 Contract staff  3.7 Mariner  3.8 Working as an employed person and as a self-employed person in different countries

 3.9 Working as a civil servant in one country  3.10 Exception and as an employed/self-employed person in one or more other countries

4. Employer / Self-Employment Details in the State whose legislation applies

 4.1.1 Employee  4.1.2 Self-employed activity

4.2 Employer/self-employed activity code

4.3 Name or business name

4.4 Registered address

4.4.1 Street, N° 4.4.2 Country code

4.4.3 Town 4.4.4 Post code

5. Employer / Self-Employment Details IN the other Member State(s)

5.1 Name(s) or business name(s) and code(s) of the firm(s) or ship(s) where you will be employed

5.2 Address(es) or name(s) of ship(s) where you will be (self) employed in the ‘host’ State(s)

 5.3 Or no fixed address in State(s) of (self)employment

Certificate concerning the Social Security legislation which applies to the holder

6. Institution completing THE form

6.1 Name

6.2 Street, N°

6.3 Town

6.4 Post code 6.5 Country code

6.6 Institution ID

6.7 Office fax N°

6.8 Office phone N°

6.9 E-mail

6.10 Date

6.11 Signature

stamp

DA1 Entitlement to Health care cover under insurance against Accidents at work and Occupational Diseases EU Regulations 883/04 and 987/09 (*) information for the holder

This document is for insured persons who move to, reside or stay in a EU State other than the State of insurance against Accidents at Work and Occupational Diseases (AWOD). You must present this document to the healthcare/AWOD institution in the State of residence or stay to gain entitlement to health care benefits. You may be entitled to a supplementary reimbursement according to national reimbursement rates of the place of stay. Your health care institution will advise you on this. For a list of health care institutions, see http://ec.europa.eu/social-security-directory/

1. personal details of the holder

1.1 Personal Identification Number in the competent Member State

1.2 Surname

1.3 Forenames

1.4 Surname at birth (**)

1.5 Date of birth

1.6 Status

 1.6.1 Employee  1.6.2 Self-employed person  1.6.3 Unemployed

1.7 Address in the State of residence/stay

1.7.1 Street, N° 1.7.3 Post code

1.7.2 Town 1.7.4 Country code

2. The holder may receive benefits in kind

 2.1.1 for accident at work  2.1.2 for occupational disease

2.2 Expected period of treatment

 2.2.1 for a period laid down in the provisions of the legislation of his State of residence  2.2.2 start date end date

 2.2.3 for a maximum of three months  2.2.4 for an unlimited period

(*) Regulations (EC) No 883/2004, article 36, and 987/2009, article 33. (**) Information given to the institution by the holder when this is not known by the institution.

©European Commission

DA1 Entitlement to Health care cover under insurance against Accidents at work and Occupational Diseases

3. THE HOLDER has a right to health care on grounds of

 3.1 The accident at work sustained 3.1.1 on (date)

3.1.2 which had the following consequences

 3.2 The occupational disease diagnosed 3.2.1 on (date)

3.2.2 which had the following consequences

 3.3 The authorisation which we have granted to the person concerned to retain the rights to benefits in kind in (State) where he is going

 3.3.1 to take up residence  3.3.2 to receive medical treatment

4. The report of our examining doctor

 4.1 is attached in a sealed envelope  4.2 may be obtained on request  4.3 was sent 4.3.1 on 4.3.2 to

 4.4 has not been drawn up

5. Institution completing THE form

5.1 Name

5.2 Street, N°

5.3 Town

5.4 Post code 5.5 Country code

5.6 Institution ID

5.7 Office fax N°

5.8 Office phone N°

5.9 E-mail

5.10 Date

5.11 Signature

stamp

Summary of pension entitlements

EU Regulations 883/04 and 987/09 (*)

1. PERSONAL DETAILS OF THE HOLDER (CLAIMANT)

1.1 Personal Identification Number  Female  Male

1.2 Surname

1.3 Forenames

1.3 Surname at birth (**)

1.4 Date of birth

1.4 Place of birth

1.5 Current address

1.5.1 Street, N° 1.5.3 Post code

1.5.2 Town 1.5.4 Country code

INFORMATION FOR THE HOLDER

Your claim for an invalidity/survivors/old age pension with [name of the institute] led, on the basis of European legislation, also to appraisal of a claim in the other countries of the European Union where you have worked or have been insured. In this document we give you a summary of how the institutions concerned have assessed these claims. The purpose of this overview is to allow you to assess whether or not your right to a pension in one or more Member States has been adversely affected by the interaction of decisions taken by two or more institutions. For instance, your pension could be reduced in view of other income or benefit; it could also be affected by rules regarding the overlapping of periods. For details please check the relevant national pension decision or contact the pension institution which issued the pension decision. Under Article 48 of Regulation 987/09, your request for review has to be submitted to the institution concerned within the time limits laid down in the national legislation of the Member State concerned. These time limits shall commence on the date of receipt of this summary. You will find the relevant time limit and the address of the institution below. This right to a review should be distinguished from the right to an appeal under national law against a decision by a pension institution on a claim for a pension. A request for a review can only be granted in case your rights to a pension are adversely affected by the interaction of national pension decisions. This document states the pension decision from each institution that has investigated your claim. The amount of the pension may depend on the length and the character of the insurance periods. We are not supplying you here with an exhaustive overview of the way in which each separate member state has taken into account insured periods since the appraisal of these periods can differ as a result of different national provisions.

(*) Regulations (EC) No 883/2004, articles 44 through 60, and 987/2009, article 48. (**) Information given to the institution by the holder when this is not known by the institution. 1/4 . ©European Commission

Summary of pension entitlements

2. PERSONAL DETAILS OF THE INSURED PERSON (IF DIFFERENT FROM THE HOLDER)

2.1 Personal Identification Number  Female  Male

2.2 Surname

2.3 Forenames

2.3 Surname at birth (**)

2.4 Date of birth

2.4 Place of birth

2.5 Current address

2.5.1 Street, N° 2.5.3 Post code

2.5.2 Town 2.5.4 Country code

3. TYPE OF PENSION CLAIM

 3.1 Old-age  3.2 Invalidity  3.3 Survivor

Summary of pension entitlements

4. PENSION(S) AWARDED

4.4 Review

p e r i o d (s t a r t s o n

4.3 Gross

4.1 Institution awarding the 4 . 2 S t a r t date of

amount (1) 4.5 Where to address the review pension payment receipt of the summary)

Centro Nacional de Pensoes E U R 2 11 Tribunal administrativo, Magallaes 425, 30/04/2012  1 month week Lisboa Deutsche Rentenversicherung EUR 678 01/02/2012  3 months DRB, Konstanzerstrasse, 451, Koeln Bund month      (1) If checked, the pension amount was reduced in view of national/EU rules, for instance on the taking into account of other income or benefit. For details please check the relevant national pension decision or contact the pension institution which issued the pension decision.

Summary of pension entitlements

5. PENSION(S) REJECTED

5.3 Review

p e r i o d

5.2 Reasons for the rejection (*)

(s t a r t s o n

5.1 Institution rejec ting the date of

5.4 Where to address the review

pension receipt of the 1 2 3 summary)

The UK pensions service    1 month Manor house, Newcastle 4B7 H2K, UK

               (*) 1. No insurance periods; 2. Insurance periods less than one year ; 3. Other. For details please check the relevant national pension decision or contact the pension institution which issued the pension decision.

6. INSTITUTION COMPLETING THE FORM (CONTACT INSTITUTION)

6.1 Name

6.2 Street, N°

6.3 Town

6.4 Post code 6.5 Country code

6.6 Institution ID

6.7 Office fax N°

6.8 Office phone N°

6.9 E-mail

6.10 Date

6.11 Signature

DATE AND STAMP

Registering for health care cover EU Regulations 883/04 and 987/09 (*) INFORMATION FOR THE holder

This is your and your family members’ certificate of entitlement to sickness, maternity, and equivalent paternity benefits in kind (i.e. health care, medical treatment etc.) in your State of residence. Family members are only covered if they fulfil the conditions laid down in the legislation of the State of residence. The certificate must be handed over as soon as possible to the health care institution in the place of residence (**). For a list of health care institutions, see http://ec.europa.eu/social-security-directory/

1. personal details of the holder

1.1 Personal Identification Number in the competent Member State

1.2 Surname

1.3 Forename

1.4 Surname at birth (***)

1.5 Date of birth

1.6 Address in the State of residence

1.6.1 Street, N° 1.6.3 Post code

1.6.2 Town 1.6.4 Country code

1.7 Status

 1.7.1 Insured person  1.7.2 Family member of insured person  1.7.3 Pensioner  1.7.4 Family member of pensioner  1.7.5 Pension claimant

2. long-term care benefits in cash

 2.1 The holder receives long-term care benefits in cash

(*) Regulations (EC) No 883/2004, articles 17, 22, 24, 25, 26 and 34, and 987/2009 articles 24 and 28. (**) For Spain, Sweden and Portugal , the certificate must be handed over to, respectively, the head provincial offices of social security National Institute (INSS), the social insurance institution and the social security institution of the place of residence. (***) Information given to the institution by the holder when this is not known by the institution.

©European Commission

Registering for health care cover

3. Personal details of the insured person

(to be filled if the holder has a right to health care because of another person’s insurance)

3.1 Personal Identification Number in the competent Member State

3.2 Surname

3.3 Forenames

3.4 Surname at birth (*)

3.5 Date of birth

3.6 Address of the insured person if different from that in 1.6

3.6.1 Street, N° 3.6.3 Post code

3.6.2 Town 3.6.4 Country code

4. Insurance coverage from/to:

4.1 Starting date 4.2 Ending date

5. Institution completing THE form

5.1 Name

5.2 Street, N°

5.3 Town

5.4 Post code 5.5 Country code

5.6 Institution ID

5.7 Office fax N°

5.8 Office phone N°

5.9 E-mail

5.10 Date

5.11 Signature

stamp

(*) Information given to the institution by the holder when this is not known by the institution.

Entitlement to scheduled treatment EU Regulations 883/04 and 987/09 (*) INFORMATION FOR THE HOLDER

This is your certificate of entitlement to certain medical treatment abroad. If you present it to the health care institution in the State where the treatment will be provided, you will receive medical treatment under the same conditions as persons insured in that State. You may be entitled to a supplementary reimbursement according to national reimbursement rates. Your health care institution will advise you on this. For a list of health care institutions, see http://ec.europa.eu/social-security-directory/

1. personal details of the holder

1.1 Personal Identification Number in the competent Member State

1.2 Surname

1.3 Forenames

1.4 Surname at birth (**)

1.5 Date of birth

1.6 Current address

1.6.1 Street, N° 1.6.3 Post code

1.6.2 Town 1.6.4 Country code

2. Kind and location of treatment

2.1 Treatment

2.2 Location of the treatment

2.3 Expected period of treatment

2.3.1 Start date 2.3.2 End date

(*) Regulations (EC) No 883/2004, articles 20, 27 and 36, and 987/2009, article 26 and 33. (**) Information given to the institution by the holder when this is not known by the institution.

©European Commission

Entitlement to scheduled treatment

3. Institution completing THE form

3.1 Name

3.2 Street, N°

3.3 Town

3.4 Post code 3.5 Country code

3.6 Institution ID

3.7 Office fax N°

3.8 Office phone N°

3.9 E-mail

3.10 Date

3.11 Signature

stamp

Medical treatment for former cross-border worker in former country of work EU Regulations 883/04 and 987/09 (*) INFORMATION FOR THE HOLDER

This is your certificate of entitlement to certain medical treatment in your former State of work. If you present it to the health care institution at the place of stay, you will receive medical treatment under the same conditions as persons insured in that State. For a list of health care institutions, see http://ec.europa.eu/social-security-directory/

1. personal details of the holder

1.1 Personal Identification Number in the competent Member State

1.2 Surname

1.3 Forenames

1.4 Surname at birth (**)

1.5 Date of birth

1.6 Current address

1.6.1 Street, N° 1.6.3 Post code

1.6.2 Town 1.6.4 Country code

1.7 Personal Identification Number in the former Member State of work

1.8 Status

 1.8.1 Former cross-border worker  1.8.2 Family member of former cross-border worker

2. Treatment details

The person referred to above is entitled to

 2.1 continuation of treatment that began in former State of work, i.e. (***)

2.1.1 nature of treatment / illness

 2.2 treatment in the former State of work (***)

(*) Regulations (EC) No 883/2004, article 28, and 987/2009, article 29. (**) Information given to the institution by the holder when this is not known by the institution. (***) Please indicate the former Member State of work.

©European Commission

Medical treatment for former cross-border worker in former country of work

3. Institution completing THE form

3.1 Name

3.2 Street, N°

3.3 Town

3.4 Post code 3.5 Country code

3.6 Institution ID

3.7 Office fax N°

3.8 Office phone N°

3.9 E-mail

3.10 Date

3.11 Signature

stamp

Periods to be taken into account for granting unemployment benefits EU Regulations 883/04 and 987/09 (*) INFORMATION FOR THE HOLDER

This document is for an unemployed person who claims unemployment benefits in a Member State and who was previously insured or worked in another Member State. Where appropriate, it is issued by the latter Member State. You should submit it to the employment service or the insurance fund in the country where you claim. The Member State where the claim is made will decide to what extent the period(s) of insurance and other certified period(s) can be used.

1. PERSONAL DETAILS OF THE HOLDER

1.1 Personal Identification Number  Female  Male

1.2 Surname

1.3 Forenames

1.4 Surname at birth (**)

1.5 Date of birth 1.6 Nationality

1.7 Place of birth

1.8 Current address

1.8.1 Street, N° 1.8.3 Post code

1.8.2 Town 1.8.4 Country code

2. THE HOLDER HAS COMPLETED THE FOLLOWING PERIODS(1) :

2.1 PERIODS OF INSURANCE AND PERIODS TREATED AS SUCH

2.1.1 Insured employment From to

From to From to From to From to From to From to

2.1.2 Insured self employment From to

From to From to From to From to From to From to

(*) Regulations (EC) No 883/2004, articles 61 and 62, and 987/2009 article 54 (1 and 2). (**) Information given to the institution by the holder when this is not known by the institution.

Periods to be taken into account for granting unemployment benefits

2. THE HOLDER HAS COMPLETED THE FOLLOWING PERIODS (CONTINUED):

2.1 PERIODS OF INSURANCE AND PERIODS TREATED AS SUCH (CONTINUED)

2.1.3 Other periods of insurance From to

From to Type 2  2.1.3.1 Sickness  2.1.3.2 Maternity or child-rearing  2.1.3.3 Deprivation of liberty  2.1.3.4 Education  2.1.3.5 Military or alternative civil service  2.1.3.6 Unemployment benefits before commencing last employment  2.1.3.7 Other (please indicate)

2.1.4 Periods treated as periods of insurance From to

From to Reason for treating as such 3

2.2 PERIODS OF EMPLOYMENT AND SELF EMPLOYMENT, WHICH ARE NOT INSURANCE PERIODS

2.2.1 Employment From to

From to From to From to

2.2.2 Self employment From to

From to From to

2.2.3 These are not insurance periods because

2.3 INCOME DETAILS 4,5 If the income details are not immediately available at the time of the request, the institution completing this document shall leave this part blank and submit the income details later, if required.

2.3.1 Income from employment From to

Wage for reference period

2.3.2 Income from self-employment From to

Earnings for reference period

3. REASON FOR END OF EMPLOYMENT

 3.1 termination by employer  3.4 resignation by the employee  3.2 contract terminated by mutual consent  3.5 contract expired  3.3 dismissal for disciplinary reasons  3.6 redundancy  3.7 other (employment)  3.8 other (self-employment)

Periods to be taken into account for granting unemployment benefits

4. OTHER RECEIVED PAYMENTS

The holder  4.1 has received or has still to receive wages for the period after end of emploment, up to  4.2 has received or has still to receive compensation for ending of employment or other similar payment, amounting to  4.3 has received or has still to receive payment in lieu of annual leave, amounting to for days  4.4 has waived the above rights under their employment contract

4.4.1 Reason

 4.5 is currently receiving other benefits

5. SINCE THE BEGINNING OF THE FIRST PERIOD COVERED IN BOX 2 THE HOLDER HAS RECEIVED UNEMPLOYMENT BENEFIT

5.1 Period 5.1.1 from 5.1.2 to

5.2 Local employment or benefit agency 5.3 Identification N°

5.4 Name

5.5 Address

5.5.1 Street, N° 5.5.3 Post code

5.5.2 Town 5.5.4 Country code

6. UNEMPLOYMENT BENEFIT ENTITLEMENT

6.1  The holder is entitled to unemployment benefits from the office issuing this document Under Article  64  65 (5) (b) of Regulation 883/2004 For the period From to

6.2  The holder is not entitled to unemployment benefits from the office issuing this document because  No entitlement exists under the State’s laws  The holder did not apply to have their unemployment benefits exported

Periods to be taken into account for granting unemployment benefits NOTES [1] The period(s) recorded in box 2 of this document are provided in accordance with the reference periods shown in this Note for the Member State concerned. The reference periods are: One year - if the document is to be presented to Luxembourg institution. Two Years - if it is to be presented to an Italian, Icelandic, Liechtenstein or Swiss institution. Italy may also request information on the complete insurance history abroad of the named person. For the purposes of Swiss institutions, four years in the case of child education or self-employment of short duration. Three years - if it is to be presented to a Belgian, Czech, Danish, French, Greek, Irish, Portuguese or United Kingdom institution. More than three years - if the document is to be presented to a Finnish (20 years), Spanish (6 years), German (5 years), Austrian (10, 15 or 25 years), Hungarian and Slovak (4 years), Swedish (8 years), Polish (20 years), Estonian, Cypriote, Latvian, Netherlands, Slovenian or Maltese institution (total insurance history). In some cases the Belgian institution requests information on the complete insurance periods. If necessary, as regards workers aged 52 or over, the Spanish institution may require information on supplementary periods preceding the last six years. The last ended calendar year or the three last calendar years - if the form is to be presented to a Norwegian institution. [2] Please complete as appropriate [3] Indicate whether the periods treated as such refer to, for example, i Periods of sickness – indicate the name and address of the health insurance fund/company ii Periods of maternity or child-rearing – indicate the name and address of the health insurance fund/company iii Period of deprivation of liberty iv Period of education v Period of Military or alternative civilian service vi Period of granting unemployment benefits before commencement of the last employment [4] Income time reference periods, counted from the end of last employment/insurance, backwards. Austria: last six month; Czech Republic: last employment; Germany, last 24 months; Slovakia, whole employment duration ; Poland: incomes from employment and self-employment that are not insurance periods; UK: no need to fill.

[5] Type of income. Austria, Belgium, Poland, Slovakia: gross income; Germany, gross income for each month (or monthly average) and the average weekly hours; Czech Republic, Hungary, Poland: net income. UK: no need to fill.

7. INSTITUTION COMPLETING THE FORM

7.1 Name

7.2 Street, N°

7.3 Town

7.4 Post code 7.5 Country code

7.6 Institution ID

7.7 Office fax N°

7.8 Office phone N°

7.9 E-mail

7.10 Date

7.11 Signature

STAMP

Retention of unemployment benefit entitlement EU Regulations 883/04 and 987/09 (*) information for the holder

You may receive unemployment benefit up to the date shown in box 2 from your institution issuing this document, if you:

are moving to another EU State to look for work.
register as a jobseeker with the employment services in that State, submit to their control procedures.
register within 7 days (see box 2) of the date you ceased to be available to the employment service of the State you left. If you register after this date, your benefit will only be paid from the day you register.
continue to meet the conditions of the Member State you left.
meet the conditions of the Member State where you are seeking work.

1. personal details of the holder

1.1 Personal Identification Number  Female  Male

1.2 Surname

1.3 Forenames

1.4 Surname at birth (**)

1.5 Date of birth 1.6 Nationality

1.7 Place of birth

2. periods for which unemployment benefits may be paid by the institution issuing this document

The holder is entitled to unemployment benefit from the office issuing this document

2.1 From and either 2.2.1 to (date)

or 2.2.2 for a maximum of (days) Benefit is payable in principle if the holder registered with the employment service in the State where he/she is seeking work

2.3 at the latest by

and can continue to be paid for the above period if he/she remains registered and subject to controls by the State where he/she is seeking work throughout the period. However benefits can only continue to be paid from the date in 2.1 and for as many days as the entitlement to unemployment benefits under the law of the office issuing this document exists.

(*) Regulations (EC) No 883/2004, article 64, and 987/2009, article 55 (1). (**) Information given to the institution by the holder when this is not known by the institution.

Retention of unemployment benefit entitlement

3. supplementary Information for the HOLDER

3.1 Notification of registration

The employment service in the State where you are seeking work must immediately inform the office that issued this document of the date on which you first registered in its territory and of your address there.

3.2 Monthly reporting

The employment service in the State where you are seeking work

 3.2.1 is required  3.2.2 is not required to send monthly reports to the office that issued this document

3.3 Changes of circumstances

The payment of benefits may be suspended by the State issuing this document if any of the circumstances below occur. The employment service where you are seeking work must immediately notify the issuing State if any of the following applies to you and from which date. You:

take up employment or become self-employed
receive earnings from an activity other than those mentioned above
refuse a job offer or interview request from the employment services
refuse to participate in occupational rehabilitation
are suffering from incapacity for work
do not submit to control procedures
are not available to the employment services
other

4. Institution completing THE form

4.1 Name

4.2 Street, N°

4.3 Town

4.4 Post code 4.5 Country code

4.6 Institution ID

4.7 Office fax N°

4.8 Office phone N°

4.9 E-mail

4.10 Date

4.11 Signature

stamp

Circumstances likely to affect the entitlement to unemployment benefits EU Regulations 883/04 and 987/09 (*) INFORMATION FOR THE holder

This document contains information about your circumstances which have been passed by the institution in the State where you seek a job to the institution paying your unemployment benefit. It may result in your unemployment benefit being stopped. If you disagree with this information please contact the institution paying your benefit without delay.

1. personal details of the holder

1.1 Personal Identification Number  Female  Male

1.2 Surname

1.3 Forenames

1.4 Surname at birth (**)

1.5 Date of birth 1.6 Nationality

1.7 Place of birth

1.8 Current address in the State issuing the certificate

1.8.1 Street, N° 1.8.3 Post code

1.8.2 Town 1.8.4 Country code

1.9 Address in the State paying unemployment benefits

1.9.1 Street, N° 1.9.3 Post code

1.9.2 Town 1.9.4 Country code

2. Applicable circumstances Starting date

The holder

2.1 has taken up employment or has become self-employed 

2.2 is receiving earnings from an activity other than those 

mentioned above (2.1)

2.3 has refused a job offer or interview request from the 

employment services

2.4 has refused to participate in occupational rehabilitation 

2.5 is suffering from incapacity for work 

2.6 did not submit to control procedures 

2.7 is not available to the employment services 

2.8 other: 

(*) Regulations (EC) No 883/2004, article 64, and 987/2009, article 55 (4). (**) Information given to the institution by the holder when this is not known by the institution.