Support for the determination of the social security legislation applicable in the case of pursuit of activity in two or more States according to Reg. (EC) No. 883/2004 and No. 987/2009 (English version)

Das Logo steht in ve Federal Department of Home Affairs FDHA Je nach Verwendung Federal Social Insurance Office FSIO dies gilt für die farb International Affairs Die Skalierung nach hingegen ist frei.

Support for the determination of the social security legislation applicable in the caseEmpfehlungen of zu de pursuit of activity in two or more States according to Reg. nos. 883/2004 and 987/2009 Kapitel 7.1 definiert

This form must be completed if a person holds Swiss citizenship or citizenship of an EU/EFTA State AND

1. is resident in Switzerland AND

2. pursues an activity in at least two States (CH, EU or EFTA) OR

3. pursues an activity in one State (CH, EU or EFTA) and receives social security benefits from another State (CH, EU or EFTA) OR 4. is carrying out a specific professional activity (civil servant, contract staff of the EU, flight crew or cabin crew, seaman). We recommend transmitting the form to the competent AVS Compensation fund office to determine the applicable legislation.

Interested party

Swiss social security number (OASI no.) (if known) Last name First name(s) as officially registered Originalgrösse (100%) Minimalgrösse Minimalgrösse Date of birth (dd.mm.yyyy) für Bürodrucker (65,4%) für professionelle All citizenships Diese heldgilt als Originalgrösse. Anwendungsgrösse Drucksysteme (58,2%)

P.O. Sie Boxbei den meisten Anwendungsgebieten kommt Diese Anwendungsgrösse ist die zum Einsatz. Sämtliche Schriftdefinitionen und kleinstmögliche für Drucksachen, Diese Anwendungsgrösse Street and no. Vermassungen in diesem Handbuch beziehen sich die auf einem Desktop-Printer ist die kleinstmögliche für Postcode auf dieses Format. Town/municipality ausgedruckt werden. Bis zu die- Drucksachen, die auf einem

Country sem Format ist die Druckqualität professionellen Drucksys- Anwendungsgrösse z. B. für Printprodukte A4 auf Desktop-Printern gewähr- tem (Druckerei) verarbeitet Tel. E-mail und A5, Visitenkarten und Kuverts. leistet. werden. Mandatory health insurance (KVG) Residence permit in Switzerland for EU/EFTA citizens L B G C

17 CD Bund Handbuch 7.0

Activity as an employed person or as a self-employed person (complete one section for each activity)

Employee Contract staff of the EU Occupation Self-employed Flight or cabin crew member Civil servant or considered to be such Seaman Employer / firm Name of employer Contact person P.O. Box Street and no. Postcode Town/municipality Country Level of employment less than 5% 5% - 24% 25% or more Start of (self-)employment (dd.mm.yyyy) End of contract, if fixed-term (dd.mm.yyyy)

Support for the determination of the social security legislation applicable in the case of pursuit of activity in two or more States according to Regulation nos. 883/2004 and 987/2009 1/3

Activity as an employed person or as a self-employed person (complete one section for each activity)

Employee Flight or cabin crew member Occupation Self-employed Flight or cabin crew member Civil servant or considered to be such Seaman Employer / firm Name of employer Contact person P.O. Box Street and no. Postcode Town/municipality Country Level of employment less than 5% 5% - 24% 25% or more Start of (self-)employment (dd.mm.yyyy) End of contract, if fixed-term (dd.mm.yyyy)

Support for the determination of the social security legislation applicable in the case of pursuit of activity in two or more States according to Regulation nos. 883/2004 and 987/2009 2/3

Social security benefits

Type and duration of benefit. State and institution paying the benefit none Disability benefit Country Institution Start date (dd.mm.yyyy) End date (dd.mm.yyyy) Accident benefit Country Institution Start date (dd.mm.yyyy) End date (dd.mm.yyyy) Sickness benefit Country Institution Start date (dd.mm.yyyy) End date (dd.mm.yyyy) Unemployment benefit Country Institution Start date (dd.mm.yyyy) End date (dd.mm.yyyy) Maternity benefit Country Institution Start date (dd.mm.yyyy) End date (dd.mm.yyyy) Other (please give details) Country Institution Start date (dd.mm.yyyy) End date (dd.mm.yyyy)

The undersigned hereby declare that all the information given is true and accurate. They are aware that the competent bodies may carry out checks both in Switzerland and in EU or EFTA States and that, if the information given in this application is not correct, the person might be subjected to a foreign social security system.

The employer or self-employed worker undertakes to inform the AVS Compensation fund office immediately of any changes in the informa- tion given in this application. They will ensure that social security contributions are collected in Switzerland on the whole of their salary, whether received in Switzerland or in the foreign country.

Information regarding data protection:

The information given on this form will be used by the AVS Compensation fund office in the course of its mandatory duties. It may be entered and recorded electronically and used in compliance with the rules governing data protection. The co-signatories consent to these data being made available to other Swiss social insurance bodies or to any other legally approved institution to ensure that the statutory regulations are duly implemented.

The employee

Date:

Signature:

The employer(s) or the self-employed person

Date:

Company stamp and signature:

Support for the determination of the social security legislation applicable in the case of pursuit of activity in two or more States according to Regulation nos. 883/2004 and 987/2009 3/3