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DECISION No 201
of 15 December 2004
on model forms necessary for the application of Council Regulations (EEC) No 1408/71 and (EEC) No 574/72 (E 400 series)
(Text with EEA relevance and for the EU/Switzerland Agreement)
(2005/376/EG)
THE ADMINISTRATIVE COMMISSION OF THE EUROPEAN COMMUNITIES 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 ( 1 ) , under which it is the duty of the Administrative Commission to deal with all administrative matters arising from Regulation (EEC) No 1408/71 and subsequent regulations,
Having regard to Article 2(1) of Council Regulation (EEC) No 574/72 of 21 March 1972 fixing the procedure for implementing Regulation (EEC) No 1408/71 on the application of social security schemes to employed persons and their families moving within the Community ( 2 ) , under which it is the duty of the Administrative Commission to draw up models of documents necessary for the application of Regulations (EEC) No 1408/71 and (EEC) No 574/72,
Having regard to Decision No 146 of 10 October 1990 concerning the interpretation of Article 94(9) of Regulation (EEC) No 1408/71 ( 3 ) ,
Having regard to Decision No 155 of 6 July 1994 on the model forms necessary for the application of Council Regulations (EEC) No 1408/71 and (EEC) No 574/72 (E 401 to 411) ( 4 ) ,
Having regard to Decision No 157 of 1 July 1995 on the model forms necessary for the application of Council Regulations (EEC) No 1408/71 and (EEC) No 574/72(E 401 to 411) ( 5 ) ,
Whereas:
(1)
The enlargement of the European Union on 1 May 2004 requires the forms in the E 400 series to be adapted.
(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 shall be identical,
HAS DECIDED AS FOLLOWS:
1.
Decision No 155 is deleted and the model forms E 401, E 402, E 403, E 404, E 405, E 406, E 407 and E 411 reproduced in that Decision are replaced by the model forms appended hereto.
2.
The model form E 413F reproduced in Decision No 146 is deleted.
3.
Decision No 157 is deleted.
4.
The competent authorities of the Member States shall make available to the parties concerned the forms according to the models appended hereto. These forms shall be available in the official languages of the Community and laid out in such manner that the different versions are perfectly superposable, thereby making it possible for all addressees to receive the form printed in their own language.
5.
The present decision shall apply from the first day of the month following its publication in the Official Journal of the European Union .
The Chairman of the Administrative Commission
C. J. VAN DEN BERG
( 1 )
OJ L 149, 5.7.1971, p. 2 .
( 2 )
OJ L 74, 27.3.1972, p. 1 . Regulation as last amended by Commission Regulation (EC) No 77/2005 ( OJ L 16, 20.1.2005, p. 3 ).
( 3 )
OJ L 235, 23.8.1991, p. 9 . Decision as last amended by Decision No 167 ( OJ L 195, 11.7.1998, p. 35 ).
( 4 )
OJ L 209, 5.9.1995, p. 1 .
( 5 ) Not published Decision extending Decision No 155 to Austria, Finland and Sweden.
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THE ADMINISTRATIVE COMMISSION ON SOCIAL SECURITY FOR MIGRANT WORKERS
See ‘instructions’ on page 4
E 401
( 1 )
CERTIFICATE CONCERNING THE COMPOSITION OF THE FAMILY FOR THE PURPOSE OF GRANTING FAMILY BENEFITS
Reg. 1408/71: Art. 73; Art. 74; Art. 77; Art. 78
Reg. 574/72: Art. 86.2; Art. 88; Art. 90; Art. 91; Art. 92
A. Request for certificate
1.
Employed person
Person supporting the orphan
Pensioner (scheme for employed persons) ( 4 )
Self-employed person
Orphan
Pensioner (scheme for self-employed persons) ( 4 )
1.1.
Surname ( 1a )
…
1.2.
Forenames
Previous names ( 1b )
Place of birth ( 2 )
… … …
1.3.
Date of birth
Sex
Nationality
… … …
1.4.
Identification/insurance number ( 3 ) …
1.5.
Civil status
single
married
widow/widower
divorced
separated ( 5 )
cohabiting ( 6 ) ( 7 )
1.6.
Address in the country of residence of the members of the family:
Street
…
No
…
Post code
…
Town
…
Country
…
2.
Spouse
Spouse divorced or separated from the worker or pensioner
Surviving parent ( 8 )
Cohabiting partner ( 6 ) ( 7 )
2.1.
Surname ( 1a )
…
2.2.
Forenames
Previous names ( 1b )
Place of birth ( 2 )
… … …
2.3.
Date of birth
Sex
Nationality
Identification/insurance number ( 3 )
… … … …
2.4.
Address:
Street
…
No
…
Post code
…
Town
…
Country
…
2.5.
Pursuit of gainful employment:
Yes
No
3.
Person or persons, other than the spouse, in whose household the members of the family are living
3.1.
Surname ( 1a )
…
3.2.
Forenames
Previous names ( 1b )
Place of birth ( 2 )
… … …
3.3.
Date of birth
Sex
Nationality
Identification/insurance number ( 3 )
… … … …
3.4.
Family relationship with child or children …
3.5.
Address:
Street
…
No
…
Post code
…
Town
…
Country
…
3.6.
Pursuit of gainful employment:
Yes
No
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E 401
4.
Family members for whom the family benefits are claimed, living with the person named either in box 2 or box 3
Surname
Forenames
Date of birth ( 9 )
Relationship ( 10 )
Place of residence
Insurance ( 3 )
………………………………
5.
Name and address of the institution competent as regards the granting of family benefits
5.1.
Name …
5.2.
Address ( 11 ) … …
5.3.
File reference number …
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E 401
B. Certificate
Part B of this form should be completed by the population registration office or the authority or administration competent in matters of civil status in the country of residence of the members of the family ( 13 ).
6.
Composition of the family in which the members named in box 4 live
6.1.
Surname ( 1a )
Forenames
Date of birth ( 9 )
Relationship ( 10 )
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
6.2.
Remarks ( 13 ) ……
7.
Information to be supplied if the form is to be sent to a Danish, Icelandic or Norwegian institution ( 14 )
7.1.
Person exercising the parental authority …
7.2.
The maintenance of the children
is
is not paid
from public funds
7.3.
The mother and/or father of the children
are/is
are/is not dead ( 15 )
If he/she is, please indicate the date of the death …
7.4.
The mother and/or father of the children
do/does
do/does not ( 15 )
receive an old-age invalidity pension
8.
Population registration office or authority or administration competent in matters of civil status ( 12 )
The accuracy of the information given above has been verified from the official documents in our possession by:
8.1.
Name and address of the registration office, authority or administration ( 11 ) ……
8.2.
Stamp
8.3.
Date …
8.4.
Signature …
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E 401
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. It should be completed in the language of the authority designated in box 8.
NOTES
( 1 ) Symbol of the country to which the institution completing the form belongs: BE = Belgium; CZ = Czech Republic; DK = Denmark; DE = Germany; EE = Estonia; GR = Greece; ES = Spain; FR = France; IE = Ireland; IT = Italy; CY = Cyprus; LV = Latvia; LT = Lithuania; LU = Luxembourg; HU = Hungary; MT = Malta; NL = The Netherlands; AT = Austria; PL = Poland; PT = Portugal; SI = Slovenia; SK = Slovakia; FI=Finland; SE=Sweden; UK=United Kingdom; IS = Iceland; LI = Liechtenstein; NO = Norway; CH = Switzerland.
( 1a ) In the case of Spanish nationals state both names. In the case of Portuguese nationals state all names (forenames, surname, maiden name) in the order of civil status in which they appear on the identity card or passport.
( 1b ) Previous names include surname at birth.
( 2 ) In the case of Portuguese districts, state also the parish and the local authority.
( 3 ) Where the form is being sent to a Czech institution, state the birth number; to a Cypriot institution, if a Cypriot national state the Cypriot identification number, if not a Cypriot national state the Alien Registration Certificate (ARC) number; to a Danish institution, indicate the CPR number; to a Finnish institution, indicate the population register number; to a Swedish institution, indicate the personal number (personnummer); to an Icelandic institution, indicate the personal identification number (kennitala); to a Liechtenstein institution, indicate the AHV insurance number; to a Lithuanian institution state the personal identification number; to a Latvian institution state the identity number state; to a Hungarian institution, state the TAJ (social insurance identification) number; to a Maltese institution, in the case of Maltese nationals, state the identity card number, or, if not a Maltese national, state the Maltese social security number; to a Norwegian institution, indicate the personal 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); to a Spanish institution, state the number appearing on the national identity card (DNI) or N.I.E. in the case of foreign people, even if the card is out of date; to a Polish institution, state the PESEL and NIP numbers; to a Portuguese institution, indicate also the registration number with the general pensions scheme, if the person concerned has been insured under the social security scheme for civil servants in Portugal; to a Slovak institution, state the birth number; to a Slovene institution, state the personal identification number (EMŠO) and tax number; to a Swiss institution, state the AVS/AI (AHV/IV) insurance number.
( 4 ) Denmark, Poland, Slovakia, Liechtenstein, Norway and Switzerland do not differentiate between Pensioner (scheme for employed persons) and Pensioners (scheme for self-employed persons).
( 5 ) For the purpose of Norwegian institutions state date of separation …
( 6 ) For the purpose of Czech, Danish, Icelandic and Norwegian institutions.
( 7 ) This information is based on a statement from the person concerned.
( 8 ) Except if already mentioned in box 1.
( 9 ) For the purpose of Danish and Norwegian institutions indicate only children under the age of 18. For the purpose of Latvian institutions indicate only children under the age of 15, and, if they are attending general or vocational educational establishments and not receiving scholarships and are not married, children under the age of 20.
( 10 ) Show the relationship of each member of the family to the worker, using the following symbols: A = legitimate child. In Spain and Poland child born in wedlock (matrimonial) and child born out of wedlock (non-matrimonial).
B = legitimised child.
C = adopted child.
D = natural child (if the form is completed for a male worker, the natural children must be mentioned only if the paternity or the worker’s obligation to maintain them has been officially recognised).
E = child of a spouse belonging to the worker’s household.
F = grandchildren, brothers and sisters whom the person concerned has taken into his household. Also nephews and nieces to the third degree where the competent institution is a Greek institution. Where the competent institution is a Polish institution, only grandchildren and siblings, whose legal guardian is an entitled person or his/her spouse.
G = other children belonging permanently to the household on the same footing as the worker’s children (foster children). Where the competent institution is a Polish institution, only other children, whose legal guardian is an entitled person or his/her spouse.
H = for the purposes of the Czech institutions describe further forms of custody (custody awarded following the court decision to other persons than parents, guardian, curator, etc.).
Other relationships (e.g. grandfather) must be written in full. If a child is married, divorced, a widow or a widower, mention this in item 4 and 6.1. Also, if a child has no father or no mother, for the purposes of Greek institutions.
( 11 ) Street, number, post code, town, country.
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( 12 ) In Spain, the ‛Dirección Provincial del Instituto Nacional de Seguridad Social’ (Provincial Directorate of the National Social Security Institute) of the place of residence, or the ‛Autoridad Municipal’ (Municipal Authority) where appropriate. In case of seamen ‛Direccion Provincial del Instituto Social de la Marina’ (Provincial Directorate of the Marine’s Social Institute); in France, the ‛mairie’ (registrar’s office) or the ‛caisse d’allocations familiales’ (fund for family allowances);
in Ireland, Child Benefit Section, Department of Social and Family Affairs, St. Oliver Plunkett Road, Letterkenny, County Donegal;
in Cyprus the Ministry of Finance, Grants and Benefits Service, 1489 Nicosia;
in Latvia, the ‛Valsts sociālās apdrošināšanas aģentūra’ (State Social Insurance Agency), Riga;
in Poland, commune or district;
in Portugal, the ‛Junta de Freguesia’ (Parish Council) of the place of residence of the members of the family;
in Slovakia, the ‛úrad práce, sociálnych vecí a rodiny’ (Office of Labour, Social Affairs and Family) in the place of residence of claimant;
in Finland, the Social Insurance Institution, Helsinki;
in Sweden, the ‛forsäkringskassan’ (social insurance office) at the place of residence;
in the United Kingdom, Inland Revenue, Child Benefit Office (GB), PO Box 1, Newcastle-upon-Tyne NE 88 IAA or for Northern Ireland, Child Benefit Office (NI), Windsor House, 9-15 Bedford Street Belfast BT2 7UW, and Inland Revenue, Tax Credits Office (Northern Ireland), 52-58 Great Victoria Street, Belfast BT2 7WF, as appropriate;
in Switzerland, the local administration (registry office) of the place of residence.
( 13 ) If the child resides at an address other than that indicated at point 2.5 or 3.6, please indicate the other address. For the purpose of Norwegian and Polish institutions please state if the child resides in an orphanage, a special school or another residential institution.
( 14 ) This information is supplied only if the civil administrations have the necessary data at their disposal.
( 15 ) Strike out the alternative that is not relevant.
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THE ADMINISTRATIVE COMMISSION ON SOCIAL SECURITY FOR MIGRANT WORKERS
E 401 Annex PL
CERTIFICATE CONCERNING THE AMOUNT OF A FAMILY’S INCOME FOR THE PURPOSE OF GRANTING FAMILY BENEFITS ACCORDING TO POLISH LAW
Reg. 1408/71: Art. 73; Art. 74; Art. 77; Art. 78
Reg. 574/72: Art. 86; Art. 88; Art. 90
To be used for the purpose of the granting of family benefits according to Polish legislation.
This form is to be completed by the institution of a Member State other than the competent Member State ( 1 ).
1.
Gross income received by persons listed in points 1, 2 and 4 of the E 401 form in the period from …
until … in a Member State other than the competent one ( 2 )
Person listed in point 1 of the E 401 form
Person listed in point 2 of the E 401 form)
Child/children (persons listed in point 4 of the E 401 form
1.1.
Salary from gainful employment
…
…
…
1.2.
Other incomes from professional activities (self-employment incomes)
…
…
…
…
…
…
…
…
…
1.3.
Social security benefits:
…
…
…
family benefits
…
…
…
1.4.
Alimony received ( 3 )
…
…
…
…
…
…
…
…
…
1.5.
Incomes in total
…
…
…
1.6.
Alimony paid in favour of other persons ( 4 )
…
…
…
1.7.
Social insurance contributions
…
…
…
…
1.8.
Personal Income Tax (PIT)
…
…
…
…
2.
Institution of a Member State other than the competent Member State ( 1 )
2.1.
Name …
2.2.
Address ( 5 ) …
…
2.3.
File reference number …
2.4.
Stamp
2.5.
Date
…
2.6.
Signature
…
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E 401 Annex PL
NOTES
( 1 ) To be completed by the institution mentioned in the Annex to Decision No 151 or new Decision No 201 (approving that form). If either all or part of the information requested cannot be confirmed by the institution, this form should be returned even though it has been left blank or only partially completed; where possible, it should be sent together with a certified statement containing the necessary information from the person or persons concerned.
( 2 ) Period the form refers to is to be completed by the institution listed in point 5 of the E 401 form.
( 3 ) If they were not included in incomes listed in point 1.3.
( 4 ) Persons other than listed in points 1, 2 and 4 of the E 401 form.
( 5 ) Street, number, post code, town, country.
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THE ADMINISTRATIVE COMMISSION ON SOCIAL SECURITY FOR MIGRANT WORKERS
See ‘instructions’ on page 3
E 402
( 1 )
CERTIFICATE OF CONTINUATION OF STUDIES FOR THE PURPOSE OF THE GRANTING OF FAMILY BENEFITS
Reg. 1408/71: Art. 73; Art. 74; Art. 77; Art. 78
Reg. 574/72: Art. 86; Art. 88; Art. 90; Art. 91; Art. 92
A. Request for certificate
To be completed by the institution competent as regards the granting of family benefits. If the form is addressed to a Belgian or Czech institution, an ‘E 402 Annex’ form should be attached.
1.
Applicant for family benefits
Employed person
Pensioner (scheme for employed persons)
Self-employed person
Pensioner (scheme for self-employed persons)
Persons other than the aforementioned
Orphan
1.1.
Surname ( 1a )
…
1.2.
Forenames
Previous names ( 1a )
Place of birth ( 2 )
… … …
1.3.
Date of birth
Sex
Nationality
Identification/insurance number ( 3 )
… … … …
1.4.
Address ( 5 ) …
…
2.
Pupil or student
2.1.
Surname ( 1a )
…
2.2.
Forenames
Previous names ( 1a )
… …
2.3.
Place of birth ( 2 ) ( 4 )
Date of birth
Identification/insurance number ( 3 )
… … …
2.4.
Address ( 5 )
……
2.5.
has completed higher education
has not completed higher education ( 11 )
3.
Institution competent as regards granting family benefits
3.1.
Name
…
3.2.
Address ( 5 ) …
…
3.3.
File reference number
…
3.4.
Stamp
3.5.
Date
…
3.6.
Signature
…
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E 402
B. Certificate
To be completed by the establishment (school, university or establishment of higher education) and sent to the institution named in box 3.
4.
4.1.
The person named in box 2 has been attending the establishment shown in box 7
since
…
4.2.
The school year started
…
(date) and finished
…
(date)
4.3.
Type of school ( 6 )
…
The form of study ( 6a )
…
4.4.
His/her education in this establishment will probably last until
…
4.5.
The number of hours of the course is
…
a week ( 7 ).
These hours are spread over
…
half days ( 8 ).
4.6.
Estimate number of hours required to do homework
…
a week ( 9 ).
5.
Information to be provided only for the institutions in the Czech Republic, France, Latvia, Luxembourg and the Netherlands
5.1.
The person named in box 2 has been attending the establishment shown in box 7 where s/he has been following education of the following nature:
general education
higher or university education
technical or vocational training
other (please specify)
5.2.
Special cases (please specify):
Correspondence course
evening courses
Courses involving less than 20 hours a week
Education of less than one school year, from
…
to
…
Other
…
5.3.
Amount of college fee ( 9 )
…
5.4.
Does the person named in box 2 receive a study grant ( 6 )
Yes
No
5.4.1.
Amount of the study grant
…
5.5.
Form of remuneration or allowance ( 10 )
…
5.6.
Marital status
…
6.
Information to be provided only for the institutions in Germany, if the course involves less than 10 hours a week
6.1.
The course is prescribed or recommended by a State approved curriculum.
Yes
No
If no,
6.2.
The course ends with a prescribed or generally recognised exam.
Yes
No
If no,
6.3.
There are regular proficiency tests during the course.
Yes
No
If no,
6.4.
The lessons in the course require extensive preparation or follow-up.
Yes
No
If no,
6.5.
Additional knowledge or skills are acquired which are necessary or useful for the course.
Yes
No
7.
School, university or establishment of higher education
7.1.
Name
…
7.2.
Address ( 5 )
……
7.3.
Stamp
7.4.
Date
…
7.5.
Signature
…
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E 402
INSTRUCTIONS
Please complete this form in block letters, writing on the dotted lines only. It should be completed in the language of the establishment named in box 7.
NOTES
( 1 ) Symbol of the country to which the institution completing the form belongs: BE = Belgium; CZ = Czech Republic; DK = Denmark; DE = Germany; EE = Estonia; GR = Greece; ES = Spain; FR = France; IE = Ireland; IT = Italy; CY = Cyprus, LV = Latvia; LT = Lithuania; LU = Luxembourg; HU = Hungary; MT = Malta; NL = The Netherlands; AT = Austria; PL = Poland; PT = Portugal; SI = Slovenia; SK = Slovakia; FI = Finland; SE = Sweden; UK = United Kingdom; IS = Iceland; LI = Liechtenstein; NO = Norway; CH = Switzerland.
( 1a ) In the case of Spanish nationals state both names. In the case of Portuguese nationals state all names (forenames, surname, maiden name) in the order of civil status in which they appear on the identity card or passport. In the case of the Czech republic, when family benefits are claimed by a student, persons specified under points 1 and 2 are identical.
( 2 ) In the case of Portuguese districts, state also the parish and the local authority.
( 3 ) Where the form is being sent to a Czech institution, state the birth number; to a Cypriot institution, if a Cypriot national state the Cypriot identification number, if not a Cypriot national state the Alien Registration Certificate (ARC) number; to a Danish institution, indicate the CPR number; to a Finnish institution, indicate the population register number; to a Swedish institution, indicate the personal number (personnummer); to an Icelandic institution, indicate the personal identification number (kennitala); to a Latvian institution, state the identity number; to a Liechtenstein institution, indicate the AHV insurance number; to a Lithuanian institution, state the personal identification number; to a Hungarian institution, state the TAJ (social insurance identification) number; to a Maltese institution, in the case of Maltese nationals, state the identity card number, or, if not a Maltese national, state the Maltese social security number; to a Norwegian institution, indicate the personal 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); to a Spanish institution, state the number appearing on the national identity card (DNI), or N.I.E in the case of foreign people, even if the card is out of date; to a Polish institution, state the PESEL and NIP numbers; to a Portuguese institution, indicate also the registration number with the general pensions scheme, if the person concerned has been insured under the social security scheme for civil servants in Portugal; to a Slovak institution, state the birth number; to a Slovene institution, state the personal identification number (EMŠO); to a Swiss institution, state the AVS/AI (AHV/IV) insurance number.
( 4 ) In the case of Swedish nationals information cannot be provided unless stated necessary.
( 5 ) Street, number, post code, town, country.
( 6 ) Please indicate whether it is a publicly maintained school, ‘public school’, or State-controlled school. To be completed only if the institution shown in box 3 is an institution in the United Kingdom.
( 6a ) For the purposes of Slovak institutions, please indicate if the study is full-time or part-time.
( 7 ) For the purposes of German institutions, please fill in point 6 if the course involves less than 10 hours a week.
( 8 ) To be completed if the form is to be sent to a Belgian or Finnish institution; the number of half-days is to be indicated in the case of primary and secondary schools.
( 9 ) For the purposes of Netherlands institutions.
( 10 ) For the purposes of Maltese institutions, state whether the child receives some form of remuneration for his or her studies, and state weekly amount.
( 11 ) For the purpose of Slovak institutions please state if the education of second grade has been completed.
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THE ADMINISTRATIVE COMMISSION ON SOCIAL SECURITY FOR MIGRANT WORKERS
For instructions and notes see page 3 of an E 402 form
E 402 Annex
( 1 )
To be completed by the school or the establishment of higher or university education named in box 2 if the claim for family benefits must be submitted to a Belgian or Czech institution.
1.
1.1.
Over how many half-days and how many hours a week are the lessons spread?
half-days
…
hours
…
1.2.
The lessons
are
are not given before 7 p.m.
1.3.
The pupil
does
does not attend lessons regularly.
If he/she does not, show the number of days of absence and the reason
…
1.4.
The lessons mentioned in 1.1 above
(a)
include
do not include
hours of practical training outside the establishment, required for obtaining an official diploma.
If they do, show the gross wage or salary paid or gross allowances granted:
…
for the period: from
…
to
…
(b)
include
do not include
hours of practical lessons which take place in the establishment.
If they do, show the number of hours a week
…
(c)
include
do not include
hours devoted to study in the establishment.
If they do, show the number of hours a week
…
1.5.
Type of education provided
general education
technical or vocational training
art education
higher non-university education
university education
1.6.
The student
has been preparing
has not been preparing
a thesis.
If he/she has, indicate
since when? …
when must he/she submit the thesis? …
1.7.
The study programme
is
is not recognized by the State
corresponds to
does not correspond to a study programme recognized by the State
1.8.
Show the periods of holidays
Christmas holidays:
from …
to …
Easter holidays:
from …
to …
Summer holidays:
from …
to …
2.
School, university or establishment of higher education
2.1.
Name …
2.2.
Address ( 5 ) …
…
2.3.
Stamp
2.4.
Date
…
2.5.
Signature
…
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THE ADMINISTRATIVE COMMISSION ON SOCIAL SECURITY FOR MIGRANT WORKERS
See ‘instructions’ on page 3
E 403
( 1 )
CERTIFICATE OF APPRENTICESHIP AND/OR VOCATIONAL TRAINING FOR THE PURPOSE OF THE GRANTING OF FAMILY BENEFITS
Reg. 1408/71: Art. 73; Art. 74; Art. 77; Art. 78
Reg. 574/72: Art. 86; Art. 88; Art. 90; Art. 91; Art. 92
A. Request for certificate
To be completed by the institution competent as regards the granting of family benefits. If the form is addressed to a French institution, please enclose a form ‘ E 403 Annex’ if the person concerned attends vocational training.
1.
Applicant for family benefits
Employed person
Pensioner (scheme for employed persons)
Self-employed person
Pensioner (scheme for self-employed persons)
Persons other than the aforementioned
Orphan
1.1.
Surname ( 1a )
…
1.2.
Forenames
Previous names ( 1a )
Place of birth ( 2 )
… … …
1.3.
Date of birth
Sex
Nationality
Identification/insurance number ( 3 )
… … … …
1.4.
Address in the apprentice’s country of residence ( 4 ) …
…
2.
Apprentice
Vocational trainee ( 5 )
2.1.
Surname ( 1a )
…
2.2.
Forenames
Previous names ( 1a )
… … …
2.3.
Place of birth ( 2 )
Date of birth
Sex
Identification/insurance number ( 3 )
… … … …
2.4.
Address ( 4 )
…
…
3.
Institution competent as regards the granting of family benefits
3.1.
Name …
3.2.
Address ( 4 ) …
…
3.3.
File reference number …
3.4.
Stamp
3.5. Date
…
3.6. Signature
…
Text of image
E 403
B. Certificate
To be completed by the person, undertaking or institution responsible for the apprenticeship and sent to the body responsible for supervision of the apprenticeship, which must forward the completed form to the institution mentioned in box 3.
4.
Information concerning the apprenticeship
4.1.
The person named in box 2 has been apprenticed to us from …
to receive training in the following trade: …
4.2.
The apprenticeship is provided
… days per week
… hours per week
and will last until …
4.3.
The apprentice
is receiving
an apprenticeship allowance or wage
net ( 6 )
gross amounting to
weekly
monthly
…
other benefits ( 7 ) namely
accommodation
full board
part board
tips
meals a day
other ( 8 )
from … to …amounting to …
is not receiving
an apprenticeship allowance or wage
other benefits
4.4.
Place of work …
4.5.
Name of the person, undertaking or institution responsible for the apprenticeship
…
4.6.
Address ( 4 ) …
…
4.7.
Stamp
4.8. Date
…
4.9. Signature
…
5.
Endorsement of the body responsible for supervision of the apprenticeship ( 9 )
5.1.
Name …
5.2.
Address ( 4 ) …
…
5.3.
Stamp
5.4. Date
…
5.5. Signature
…
Text of image
E 403
INSTRUCTIONS
Please complete this form in block letters, writing on the dotted lines only. It consists of three pages, none of which may be left out even if it does not contain any relevant information. It should be completed in the language of the institution indicated in box 5.
NOTES
( 1 ) Symbol of the country to which the institution completing the form belongs: BE = Belgium; CZ = Czech Republic; DK = Denmark; DE = Germany; EE = Estonia; GR = Greece; ES = Spain; FR = France; IE = Ireland; IT = Italy; CY = Cyprus; LV = Latvia; LT = Lithuania; LU = Luxembourg; HU = Hungary; MT = Malta; NL = The Netherlands; AT = Austria; PL = Poland; PT = Portugal; SI = Slovenia; SK = Slovakia; FI = Finland; SE = Sweden; UK = United Kingdom; IS = Iceland; LI = Liechtenstein; NO = Norway; CH = Switzerland.
( 1a ) In the case of Spanish nationals state both names. In the case of Portuguese nationals state all names (forenames, surname, maiden name) in the order of civil status in which they appear on the identity card or passport. In the case of the Czech republic, when family benefits are claimed by a student, persons specified under points 1 and 2 are identical.
( 2 ) In the case of Portuguese districts, state also the parish and the local authority.
( 3 ) Where the form is being sent to a Czech institution, state the birth number; to a Cypriot institution, if a Cypriot national state the Cypriot identification number, if not a Cypriot national state the Alien Registration Certificate (ARC) number; to a Danish institution, indicate the CPR number; to a Finnish institution, indicate the population register number; to a Swedish institution, indicate the personal number (personnummer); to an Icelandic institution, indicate the personal identification number (kennitala); to a Latvian institution, state the identity number; to a Liechtenstein institution, indicate the AHV insurance number; to a Lithuanian institution, state the personal identification number; to a Hungarian institution, state the TAJ (social insurance identification) number; to a Maltese institution, in the case of Maltese nationals, state the identity card number, or, if not a Maltese national, state the Maltese social security number; to a Norwegian institution, indicate the personal 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); to a Spanish institution, state the number appearing on the national identity card (DNI), or N.I.E in the case of foreign people, even if the card is out of date; to a Polish institution, state the PESEL and NIP numbers; to a Portuguese institution, indicate also the registration number with the general pensions scheme, if the person concerned has been insured under the social security scheme for civil servants in Portugal; to a Slovak institution, state the birth number; to a Slovene institution, state the personal identification number (EMŠO); to a Swiss institution, state the AVS/AI (AHV/IV) insurance number.
( 4 ) Street, number, post code, town, country.
( 5 ) For the French institutions form ‘E 403 Annex’ should be completed if the person concerned follows practical vocational training.
( 6 ) For German institutions only indicate the gross amount of the education allowance.
( 7 ) If applicable, give details of these other benefits in the box below.
( 8 ) This box should be completed by the following institutions: in Ireland: Child Benefit Section, Department of Social and Family Affairs, St. Oliver Plunkett Road, Letterkenny, County Donegal, in the case of apprenticeships that are not supervised by the industrial training authority (FAS); in Italy: by the ‘Ufficio provinciale del lavoro e della massima occupazione’ (Provincial Office of Labour and Employment); in Slovenia, the Chamber of Crafts of Slovenia.
( 9 ) In relation to French legislation, in the preliminary training and training for a professional career, aimed at allowing those without professional qualifications and without a work contract to reach a level necessary to follow a formal professional training course or to enter professional employment directly.
( 10 ) Indicate the amount received in the currency of the State in the territory in which the professional training is followed.
( 11 ) Complete if such an organisation exists in the territory in which the professional training is followed.
Text of image
THE ADMINISTRATIVE COMMISSION ON SOCIAL SECURITY FOR MIGRANT WORKERS
For instructions and notes see page 3 of an E 403 form
E 403 Annex
To be completed if the claim for family benefits must be submitted to a French institution and if it concerns a person undergoing practical vocational training.
1.
Information concerning the vocational training ( 9 )
1.1.
The person named in box 2 of form E 403
has been attending vocational training since …
attended vocational training from … to
…
1.2.
Does the person concerned have an employment contract for this training?
yes
no
1.3.
Nature of the training provided …
…
1.4.
Total duration of training … (months, weeks)
1.5.
Number of hours of training:
theoretical part
… per week
… per month
practical training
… per week
… per month
1.6.
Does the person concerned receive pay during training?
yes
no
If yes, please specify nature
…
Net amount per month ( 10 )
…
1.7.
Place of training …
1.8.
Name of the person, undertaking or institution responsible for providing training
…
1.9.
Address ( 4 ) …
…
1.10.
Stamp
1.11. Date
…
1.12. Signature
…
2.
Endorsement of the body responsible for supervision of training ( 11 )
2.1.
Name …
2.2.
Address ( 4 ) …
…
2.3.
Stamp
2.4. Date
…
2.5. Signature
…
Text of image
THE ADMINISTRATIVE COMMISSION ON SOCIAL SECURITY FOR MIGRANT WORKERS
See ‘instructions’ on page 3
E 404
( 1 )
MEDICAL CERTIFICATE FOR THE PURPOSE OF THE GRANTING OF FAMILY BENEFITS
Reg. 1408/71: Art. 73; Art. 74; Art. 77; Art. 78
Reg. 574/72: Art. 86; Art. 88; Art. 90; Art. 91; Art. 92
A. Request for certificate
To be completed by the institution competent as regards the granting of family benefits.
1.
Applicant for family benefits
Employed person
Pensioner (scheme for employed persons)
Self-employed person
Pensioner (scheme for self-employed persons)
Persons other than the aforementioned
Orphan
1.1.
Surname ( 1a )
…
1.2.
Forenames
Previous names ( 1a )
Place of birth ( 2 )
… … …
1.3.
Date of birth
Sex
Nationality
Identification/insurance number ( 3 )
… … … …
1.4.
Address ( 4 ) …
…
2.
Person to whom the medical certificate relates
2.1.
Surname ( 1a )
…
2.2.
Forenames
Previous names ( 1a )
… …
2.3.
Place of birth ( 2 )
Date of birth
Sex
Identification/insurance number ( 3 )
… … … …
2.4.
Address ( 4 )
… …
3.
Institution competent as regards the granting of family benefits
3.1.
Name …
3.2.
Address ( 4 ) …
…
3.3.
File reference number …
3.4.
Stamp
3.5. Date
…
3.6. Signature
…
Text of image
E 404
B. Certificate
To be completed by the doctor designated by the liaison body ( 5 ) ( 6 ) in the country of residence of the person examined and to be sent to the institution mentioned in box 3.
4.
4.1.
(a) The physical or mental faculties of the person examined
have diminished
have not diminished
If they have, indicate percentage of diminution
…
%
(b) The person examined
is capable of earning his/her living
is incapable or earning his/her living and continue in the occupational training by studying owing to physical or mental deficiency
(c) The person examined
is
is not a housewife
If she is, indicate whether
she is
she is not in a fit condition to look after her home
(d) Observations
………
(e) Description of the condition of the person examined
………
4.2.
Date of commencement of disability or illness (as precise as possible)
…
4.3.
Probable duration …
4.4.
(a) A further examination
is necessary
is not necessary
(b) If it is, indicate date of the examination …
5.
5.1.
Surname and forenames of the doctor …
5.2.
Address ( 4 ) …
…
5.3. Date
…
5.4. Signature
…
Text of image
E 404
INSTRUCTIONS
Please complete this form in block letters, writing on the dotted lines only. It consists of three pages, none of which may be left out even if it does not contain any relevant information. It should be completed in the language of the doctor issuing the certificate.
NOTES
( 1 ) Symbol of the country to which the institution completing the form belongs: BE = Belgium; CZ = Czech Republic; DK = Denmark; DE = Germany; EE = Estonia; GR = Greece; ES = Spain; FR = France; IE = Ireland; IT = Italy; CY = Cyprus; LV = Latvia; LT = Lithuania; LU = Luxembourg; HU = Hungary; MT = Malta; NL = The Netherlands; AT = Austria; PL = Poland; PT = Portugal; SL = Slovenia; SK = Slovakia; FI = Finland; SE = Sweden; UK = United Kingdom; IS = Iceland; LI = Liechtenstein; NO = Norway; CH = Switzerland.
( 1a ) In the case of Spanish nationals state both names at birth. In the case of Portuguese nationals state all names (forenames, surname, maiden name) in the order of civil status in which they appear on the identity card or passport.
( 2 ) In the case of Portuguese districts, state also the parish and the local authority.
( 3 ) Where the form is being sent to a Czech institution, state the birth number; to a Cypriot institution, if a Cypriot national state the Cypriot identification number, if not a Cypriot national state the Alien Registration Certificate (ARC) number; to a Danish institution, indicate the CPR number; to a Finnish institution, indicate the population register number; to a Swedish institution, indicate the personal number (personnummer); to an Icelandic institution, indicate the personal identification number (kennitala); to a Latvian institution, state the identity number; to a Liechtenstein institution, indicate the AHV insurance number; to a Lithuanian institution, state the personal identification number; to a Hungarian institution, state the TAJ (social insurance identification) number; to a Maltese institution, in the case of Maltese nationals, state the identity card number, or, if not a Maltese national, state the Maltese social security number; to a Norwegian institution, indicate the personal 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); to a Spanish institution, state the number appearing on the national identity card (DNI), or N.I.E in the case of foreign people, even if the card is out of date; to a Polish institution, state the PESEL and NIP numbers; to a Portuguese institution, indicate also the registration number with the general pensions scheme, if the person concerned has been insured under the social security scheme for civil servants in Portugal; to a Slovak institution, state the birth number; to a Slovene institution, state the personal identification number (EMŠO); to a Swiss institution, state the AVS/AI (AHV/IV) insurance number.
( 4 ) Street, number, post code, town, country.
( 5 ) Or the doctor of the fund designated by the liaison body.
( 6 ) In Slovenia, this is the chosen physician.
Text of image
THE ADMINISTRATIVE COMMISSION ON SOCIAL SECURITY FOR MIGRANT WORKERS
See ‘instructions’ on page 3
E 404 Annex PL
MEDICAL CERTIFICATE FOR THE PURPOSE OF THE GRANTING OF FAMILY BENEFITS ACCORDING TO POLISH LEGISLATION
Reg. 1408/71: Art. 73; Art. 74; Art. 77; Art. 78
Reg. 574/72: Art. 86; Art. 88; Art. 90; Art. 91; Art. 92
To be used for the purpose of granting family benefits depending on the health of family members, according to Polish legislation.
A. Application for certificate
To be completed by the Polish institution competent to grant family benefits.
1.
Person applying for family benefits
Employed person
Self-employed person
Other than the above mentioned
Pensioner (Employed person scheme)
Pensioner (Self-employed person scheme)
Orphan
1.1.
Surname ( 1 )
…
1.2.
Forenames
Previous names ( 1 )
Place of birth ( 2 )
… … …
1.3.
Date of birth
Sex
Nationality
PESEL and NIP numbers
… … … …
1.4.
Address ( 3 ) …
…
2.
Person to whom the medical certificate applies
2.1.
Surname ( 1 )
…
2.2.
Forenames
Previous names and surnames ( 1 )
… …
2.3.
Place of birth ( 2 )
Date of birth
Sex
… … …
2.4.
Address ( 3 ) …
…
3.
Institution competent to grant family benefits
3.1.
Name …
3.2.
Address ( 3 ) …
…
3.3.
Reference number of files …
3.4.
Stamp
3.5. Date …
3.6. Signature …
Text of image
E 404 Annex PL
B. Certificate
To be completed by a doctor appointed by liaison institution ( 4 ) in the country of residence of examined person and to be sent to the institution stated in box 3. Depending on the age of the person to whom the certificate applies, part I or part II is to be completed. Depending of the state of health of persons aged over 16, part IIa or part IIb is to be completed.
I. It applies to persons under 16
4.
Disability
4.1.
Age of child on the day of examination:
…
years
…
months
Weight of child
…
Height
…
4.2.
Expected period of physical or mental impairment due to congenital malformation, long-term illness or body injury is over 12 months
Yes
No
4.3.
Requires permanent care of assistance to fulfil basic living needs in a manner that is appropriate for a person of this age
Yes
No
II. It applies to persons over 16
a. Advanced level of disability (due to physical impairment)
4.4.
Limited employment:
(a) incapable of work
Yes
No
(b) capable of working under condition of protected labour only
Yes
No
4.5.
He/she requires one of the following in order to fulfil social roles:
(a) permanent care and assistance of others
Yes
No
(b) long-term care and assistance of others
Yes
No
4.6.
He/She is incapable of living independently
Yes
No
b. Intermediate level of disability (due to physical impairment)
4.7.
Limited employment:
(a) incapable of work
Yes
No
(b) capable of working under condition of protected labour only
Yes
No
4.8.
He/she requires one of the following in order to fulfil social roles:
(a) temporary care and assistance of others
Yes
No
(b) partial care and assistance of others
Yes
No
4.9.
Period when disability occurred: before the ages of 16
Yes
No
5.
5.1.
Surname and forenames of the doctor …
5.2.
Address ( 3 ) …
…
5.3.
Stamp
5.4. Date …
5.5. Signature …
Text of image
E 404 Annex PL
INSTRUCTIONS
Please complete the form in block capitals and write text over dotted lines only. In other places please mark the answer YES or NO. To be completed in the language of the doctor issuing the certificate.
NOTES
( 1 ) In the case of Spanish nationals state both names at birth. In the case of Portuguese nationals state all names (forenames, surname, maiden name) in the order of civil status in which they appear on the identity card or passport.
( 2 ) In the case of Portuguese districts, state also the parish and the local authority.
( 3 ) Street, number, post code, town, country.
( 4 ) Or the doctor of the fund designated by the liaison body.
INFORMATION
According to Polish law, persons who are under 16 are treated as disabled if they have physical or mental impairment during an expected period exceeding 12 months, due to congenital malformation, long-term illness or bodily injury and they require permanent care or support to fulfil basic living needs, in a manner that is appropriate for a person of their age.
A marked ‘YES’ in points 4.2 and 4.3 means that a person is disabled according to Polish law.
According to Polish law, persons may belong to one of three groups of disability due to physical or mental impairment: advanced, intermediate and light.
A person with advanced disability is a person who has physical impairment, who is incapable of work or capable of work under the conditions of protected labour, who is not able to live independently and requires permanent or long-term care and support from others in order to fulfil their social roles.
A person with intermediate disability is a person who has physical impairment, who is incapable of work or capable of work under the conditions of protected labour, or who requires temporary or partial care and assistance from others in order to fulfil their social roles.
A marked ‘YES’ in points 4.4a, 4.5a, 4.6 or 4.4a, 4.5b, 4.6 or 4.4b, 4.5a, 4.6 or 4.4b, 4.5b, 4.6 means that a person is disabled at the advanced level; 4.7a or 4.7b or 4.8a or 4.8b means that a person is disabled at the intermediate level.
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THE ADMINISTRATIVE COMMISSION ON SOCIAL SECURITY FOR MIGRANT WORKERS
See ‘instructions’ on page 3
E 405
( 1 )
CERTIFICATE CONCERNING THE AGGREGATION OF PERIODS OF INSURANCE, EMPLOYMENT OR SELF-EMPLOYMENT OR CONCERNING SUCCESSIVE EMPLOYMENT IN SEVERAL MEMBER STATES, BETWEEN THE DATES ON WHICH PAYMENT IS DUE ACCORDING TO THE LEGISLATION OF THESE STATES
Reg. 1408/71: Art. 12; Art. 72
Reg. 574/72: Art. 10a; Art. 85.2 and 3
This certificate should be issued to the insured person at his/her request. Where necessary, the competent institution should request it from the institution with which the insured person was last registered.
A. To be completed by the institution competent as regards the granting of family benefits with which the insured person is registered.
1.
Employed person
Self-employed person
Unemployed person
1.1.
Surname ( 1a )
…
1.2.
Forenames
Previous names ( 1a )
Place of birth ( 2 )
… … …
1.3.
Date of birth
Sex
Nationality
Identification/insurance number ( 3 )
… … … …
1.4.
Civil status
single
married
widow/widower
divorced
separated
cohabiting ( 4 ) ( 5 )
1.5.
Address ( 6 )
… …
2.
Person who should receive the family benefits
2.1.
Surname ( 1a )
…
2.2.
Forenames
Previous names ( 1a )
Place of birth ( 2 )
… … …
2.3.
Date of birth
Sex
Nationality
Identification/insurance number ( 3 )
… … … …
2.4.
Address ( 6 )
… … …
3.
Period for which the information is requested
3.1.
From …
to …
3.2.
Name and address of employer ( 7 )
…
3.3.
Nature of self-employment ( 7 )
…
4.
Institution with which the insured person was last registered as an employed or self-employed person
4.1.
Name
…
4.2.
Address ( 6 )
…
5.
Institution of the place of residence of the members of the family
5.1.
Name
…
5.2.
Address ( 6 )
…
Text of image
E 405
6.
Institution with which the insured person is currently registered
6.1.
Name …
6.2.
Address ( 6 ) …
…
6.3.
File reference number …
…
6.4.
Stamp
6.5.
Date
…
6.6.
Signature
…
B. To be completed by the institution competent as regards the granting of family benefits with which the person was previously registered
7.
7.1.
We certify that the insured person named in box 1
was insured from … to … ( 8 ) …
7.2.
In ( 9 ) …
7.3.
He/she is entitled
He/she is not entitled to family benefits
7.4.
Family benefits were paid to him/her from
…
to
…
7.5.
Family members for whom the family benefits were paid:
7.5.1.
Surname
Forenames
Date of birth
Monthly amount
…………………………………………
7.5.2.
Are the amounts adjusted? …
…
8.
Institution with which the insured person was last registered either as an employed or self-employed person
8.1.
Name …
8.2.
Address ( 6 ) …
…
8.3.
Stamp
8.4.
Date
…
8.5.
Signature
…
9.
Remarks
……
Text of image
E 405
INSTRUCTIONS
Please complete this form in block letters, writing on the dotted lines only. It consists of three pages, none of which may be left out even if it does not contain any relevant information.
NOTES
( 1 ) Symbol of the country to which the institution completing the form belongs: BE=Belgium; CZ=Czech Republic; DK=Denmark; DE=Germany; EE=Estonia; GR=Greece; ES=Spain; FR=France; IE=Ireland; IT=Italy; CY=Cyprus; LV=Latvia; LT=Lithuania; LU=Luxembourg; HU=Hungary; MT=Malta; NL=The Netherlands; AT=Austria; PL=Poland; PT=Portugal; SI=Slovenia; SK=Slovakia; FI=Finland; SE=Sweden; UK=United Kingdom; IS=Iceland; LI=Liechtenstein; NO=Norway; CH=Switzerland.
( 1a ) In the case of Spanish nationals, state both names 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.
( 2 ) In the case of Portuguese districts, state also the parish and the local authority.
( 3 ) Where the form is being sent to a Czech institution, state the birth number; to a Cypriot institution, if a Cypriot national state the Cypriot identification number, if not a Cypriot national state the Alien Registration Certificate (ARC) number; to a Danish institution, indicate the CPR number; to a Finnish institution, indicate the population register number; to a Swedish institution, indicate the personal number (personnummer); to an Icelandic institution, indicate the personal identification number (kennitala); to a Latvian institution, state the identity number; to a Liechtenstein institution, indicate the AHV insurance number; to a Lithuanian institution, state the personal identification number; to a Hungarian institution, state the TAJ (social insurance identification) number; to a Maltese institution, in the case of Maltese nationals, state the identity card number, or, if not a Maltese national, state the Maltese social security number; to a Norwegian institution, indicate the personal 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); to a Spanish institution, state the number appearing on the national identity card (DNI) or N.I.E, in the case of foreign people, even if the card is out of date; to a Polish institution, state the PESEL and NIP numbers; to a Portuguese institution, indicate also the registration number with the general pensions scheme, if the person concerned has been insured under the social security scheme for civil servants in Portugal; to a Slovak institution, state the birth number; to a Slovene institution, state the personal identification number (EMŠO); to a Swiss institution, state the AVS/AI (AHV/IV) insurance number.
( 4 ) For the purpose of Czech, Danish, Icelandic and Norwegian institutions.
( 5 ) This information is based on a statement from the person concerned.
( 6 ) Street, number, post code, town, country.
( 7 ) For the period preceding the worker’s transfer to the Member State to whose legislation he/she is currently subject.
( 8 ) (a) For Greek institutions, state the number of days completed in the calendar year preceding the year in which the family benefits or family allowances are applied for.
(b) For Belgian institutions, state below the number of days as an employed or self-employed person: number of days as an employed person …
number of days as a self-employed person …
(c) For French institutions, state below the number of days and hours of employment and the gross wage/salary received: Number of days in employment
Number of hours in employment
Gross wage/salary received
During the last month
During the last three months
During the last six months
( 9 ) Country in which the employment in question was pursued.
Text of image
THE ADMINISTRATIVE COMMISSION ON SOCIAL SECURITY FOR MIGRANT WORKERS
See ‘instructions’ on page 2
E 405 Annex PL
CERTIFICATE CONCERNING THE PERSON ON PARENTAL LEAVE FOR THE PURPOSE OF THE GRANTING OF FAMILY BENEFITS
Reg. 1408/71: Art. 12; Art. 72; Art. 73
Reg. 574/72: Art. 10a; Art. 85; Art. 86
To be used for the purpose of the granting of family benefits according to Polish legislation.
A. Application for certificate
1.
Person applying for family benefits
Employed person
1.1.
Surname ( 1 )
…
1.2.
Forenames
Previous names and surnames ( 1 )
Place of birth ( 2 )
… … …
1.3.
Date of birth
Sex
Nationality
PESEL and NIP number
… … … …
1.4.
Civil status
unmarried
married
widow/widower
divorced
in separation
common-law husband/wife ( 3 ) ( 4 )
1.5.
Address ( 5 ) …
…
2.
Person concerned by the certificate
2.1.
Surname ( 1 )
…
2.2.
Forenames
Previous names and surnames ( 1 )
Place of birth ( 2 )
… … …
2.3.
Date of birth
Sex
Nationality
PESEL and NIP number
… … … …
2.4.
Address ( 5 )
…
…
2.5.
Period to which application applies
from …
until …
3.
Institution competent for granting family benefits
3.1.
Name …
3.2.
Address ( 5 ) …
…
3.3.
File reference number …
3.4.
Stamp
3.5. Date
…
3.6. Signature
…
Text of image
E 405 Annex PL
B. Certificate
To be completed by the competent institution for granting family benefits where the person was previously registered.
4.
This is to certify that the person named in box 2
4.1.
was a wage worker in the period from … until … ( 6 )
in … ( 7 )
5.
The person named in box 2
5.1.
is currently employed or works in another paid work
Yes
No
5.2.
is currently on parental leave ( 8 )
Yes
No
6.
The name of the institution where the person named in box 2 was recently registered as an employed person
6.1.
Name …
6.2.
Address ( 5 ) …
…
6.3.
Stamp
6.4. Date
…
6.5. Signature
…
INSTRUCTIONS
Please complete the form in block capitals and write the text over dotted lines only. The form consists of two pages of which none should be omitted, even if they do not contain relevant information.
NOTES
( 1 ) In the case of Spanish nationals state both names at birth. In the case of Portuguese nationals state all names (forenames, surname, maiden name) in the order of civil status in which they appear on the identity card or passport.
( 2 ) In the case of Portuguese districts, state also the parish and the local authority.
( 3 ) For the purposes of Dutch, Icelandic, Norwegian and Polish institutions.
( 4 ) Information is based on the declaration of the interested person.
( 5 ) Street, number, post code, town, country.
( 6 ) Please, indicate the exact dates (day/month/year).
( 7 ) Country where the given work is being performed.
( 8 ) It refers to benefits granted for a child when one of parents is on parental leave.
Text of image
THE ADMINISTRATIVE COMMISSION ON SOCIAL SECURITY FOR MIGRANT WORKERS
See ‘instructions’ page 2
E 406
( 1 )
CERTIFICATE OF POST-NATAL MEDICAL EXAMINATIONS
Reg. 1408/71: Art. 73; Art. 74
Reg. 574/72: Art. 86; Art. 88
Information for the insured person
In order to qualify for French family benefits in accordance with Article 73 or 74, the child must undergo post-natal medical examinations, one examination during the 9th or 10th month from birth and the other during the 24th or 25th month. Failure to comply with this obligation and these deadlines will lead to loss of part of the entitlement. In order to qualify for Slovak parental allowance in line with the Slovak legislation, the child has to be officially registered as the patient of a practitioner and has to regularly undergo preventive medical examinations including inoculation as per the obligatory vaccination regime.
A. Request for certificate
1.
Employed person
Self-employed person
1.1.
Name ( 1a )
…
1.2.
Forenames
Previous name ( 1a )
Place of birth ( 1b )
… … …
1.3.
Date of birth
Sex
Nationality
Identification/insurance number ( 1c )
… … … …
1.4.
Address ( 2 )
…
…
2.
Child for whom the certificate is requested
2.1.
Surname ( 1a )
…
2.2.
Forenames
…
2.3.
Place of birth ( 1b )
Date of birth
Sex
Identification/insurance number ( 1c )
… … … …
2.4.
Address ( 2 )
…
…
3.
Institution responsible for the granting of family benefits
3.1.
Name
…
3.2.
Address ( 2 ) …
…
3.3.
File reference number
…
3.4.
Stamp
3.5.
Date
…
3.6.
Signature
…
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E 406
B. Certificate
To be completed by the doctor treating the child or by the doctor chosen by the person looking after the child.
4.
4.1.
The child named in box 2 above underwent on
…
4.2.
a medical examination during the 9th or 10th month from birth
4.3.
a medical examination during the 24th or 25th month
5.
5.1.
Doctor’s surname and forename
…
5.2.
Address ( 2 ) …
…
5.3.
Date
…
5.4.
Signature
…
INSTRUCTIONS
Please complete this form in block letters, writing on the dotted lines only.
NOTES
( 1 ) Symbol of the country to whose legislation the worker is subject: FR = France; SK = Slovakia.
( 1a ) In the case of Spanish nationals, state both names at birth. In the case of Portuguese nationals, state all names (forenames, surname, maiden name) in the order of civil status in which they appear on the identity card or passport.
( 1b ) In the case of Portuguese districts, state also the parish and the local authority.
( 1c ) Where the form is being sent to a Czech institution, state the birth number; to a Cypriot institution, if a Cypriot national state the Cypriot identification number, if not a Cypriot national state the Alien Registration Certificate (ARC) number; to a Danish institution, indicate the CPR number; to a Finnish institution, indicate the population register number; to a Swedish institution, indicate the personal number (personnummer); to an Icelandic institution, indicate the personal identification number (kennitala); to a Latvian institution, state the identity number; to a Liechtenstein institution, indicate the AHV insurance number; to a Lithuanian institution, state the personal identification number; to a Hungarian institution, state the TAJ (social insurance identification) number; to a Maltese institution, in the case of Maltese nationals, state the identity card number, or, if not a Maltese national, state the Maltese social security number; to a Norwegian institution, indicate the personal 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); to a Spanish institution, state the number appearing on the national identity card (DNI) or N.I.E, in the case of foreign people, even if the card is out of date; to a Polish institution, state the PESEL and NIP numbers; to a Portuguese institution, indicate also the registration number with the general pensions scheme, if the person concerned has been insured under the social security scheme for civil servants in Portugal; to a Slovak institution, state the birth number; to a Slovene institution, state the personal identification number (EMŠO); to a Swiss institution, state the AVS/AI (AHV/IV) insurance number.
( 2 ) Street, number, post code, town, country.
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THE ADMINISTRATIVE COMMISSION ON SOCIAL SECURITY FOR MIGRANT WORKERS
See ‘instructions’ on page 4
E 407
( 1 )
MEDICAL CERTIFICATE FOR THE GRANT OF A SPECIAL FAMILY ALLOWANCE OR OF INCREASED FAMILY ALLOWANCES FOR HANDICAPPED CHILDREN
Reg. 1408/71: Art. 73; Art. 74
Reg. 574/72: Art. 86; Art. 88
A. Request for certificate
To be completed by the institution responsible for the granting of family benefits.
1.
Employed person
Self-employed person
1.1.
Surname ( 1a )
…
1.2.
Forenames
Previous names ( 1a )
Place of birth ( 1b )
… … …
1.3.
Date of birth
Sex
Nationality
Identification/insurance number ( 1c )
… … … …
1.4.
Address ( 2 )
……
2.
Child for whom the certificate is requested
2.1.
Surname ( 1a )
…
2.2.
Forenames
…
2.3.
Place of birth ( 1b )
Date of birth
Sex
Identification/insurance number ( 1c )
… … … …
2.4.
Address ( 2 )
……
3.
Institution responsible for the granting of family benefits
3.1.
Name
…
3.2.
Address ( 2 )
……
3.3.
File reference number
…
3.4.
Stamp
3.5.
Date
…
3.6.
Signature
…
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E 407
B. Certificate
The doctor designated by the institution of the place of residence of the examined child should complete this page and the next page and send it to the institution mentioned in box 3, enclosing all recent supporting medical documents (photographs, X-rays, results of medical examinations, etc.) ( 4 ).
4.
4.1.
Child’s age on date of examination
…
years
…
months
Child’s weight
…
kilograms
…
grams
height:
…
centimetres
4.2.
Psychomotor retardation
Retardation taking account of normal level for the child’s age
Yes
No
If yes, please specifiy
…
4.3.
Independence
Can the child sit up unaided?
Yes
No
Can he/she walk?
Yes
No
Can he/she talk?
Yes
No
Can he/she dress unaided?
Yes
No
Can he/she eat unaided?
Yes
No
Does he/she write?
Yes
No ( 3 )
Is he/she incontinent?
Yes
No ( 3 )
4.4.
Assistance
Does the child’s condition necessitate attendance by another person?
Yes
No
Constant attendance?
Yes
No
Daily attendance though not continuous?
Yes
No
Or other measures (please specify)
…
4.5.
Nature of the principal disability
Is the child’s disability
sensory?
visual?
…
auditory?
…
motor
…
mental
mental level
…
behaviour
…
other
…
4.6.
Origin of disability ( 3 )
congenital anomaly
…
Yes
No
disease
…
Yes
No
date of onset of disability
…
date of diagnosis
month
…
year
…
beginning of treatment
month
…
year
…
accident
…
Yes
No
date of accident
…
4.7.
Associated disabilities
Which ones?
…
Other deficiencies
…
4.8.
Additional observations
Disabilities in the family
…
Supplementary examinations already carried out
…
(Copies of reports of examinations should be enclosed, where appropriate)
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4.9.
Treatment, including rehabilitation and remedial therapy. What forms of treatment are being provided?
…
Since when?
…
What forms of treatment are recommended?
…
Surgery
……
Hospitalisations (the last three years)
…
Treatment at home (medicaments)
…
Since when ……/……/……
…
Since when ……/……/……
…
Since when ……/……/……
Rehabilitation
Beginning
Frequency
Where?
Logopedy
… … …
Physiotherapy
… … …
Occupational therapy
… … …
(Psycho)therapy
… … …
Earliest help at home
… … …
4.10.
Educational and training measures
What forms of education and training are being provided?
……
Since when?
…
What education and training is recommended?
…
4.11.
Prognosis
Please specify:
……
4.12.
ICD (International Classification of Diseases — WHO) code of illness
4.13.
Beginning of illness
4.14.
Date of next control
5.
5.1.
Doctor’s surname and forename
…
5.2.
Address ( 2 )
……
5.3.
Date
…
5.4.
Signature
…
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E 407
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. It should be completed in the language of the doctor issuing the certificate.
NOTES
( 1 ) Symbol of the country to whose legislation the worker is subject: BE = Belgium; CZ = Czech Republic; DK = Denmark; DE = Germany; EE = Estonia; GR = Greece; ES = Spain; FR = France; IE = Ireland; IT = Italy; CY = Cyprus; LV = Latvia; LT = Lithuania; LU = Luxembourg; HU = Hungary; MT = Malta; NL = The Netherlands; AT = Austria; PL = Poland, PT = Portugal; SI = Slovenia, SK = Slovakia, FI = Finland, SE = Sweden, UK = United Kingdom; IS = Iceland; LI = Liechtenstein; NO = Norway; CH = Switzerland.
( 1a ) In the case of Spanish nationals, state both names at birth. In the case of Portuguese nationals, state all names (forenames, surname, maiden name) in the order of civil status in which they appear on the identity card or passport.
( 1b ) In the case of Portuguese districts, state also the parish and the local authority.
( 1c ) Where the form is being sent to a Czech institution, state the birth number; to a Cypriot institution, if a Cypriot national state the Cypriot identification number, if not a Cypriot national state the Alien Registration Certificate (ARC) number; to a Danish institution, indicate the CPR number; to a Finnish institution, indicate the population register number; to a Swedish institution, indicate the personal number (personnummer); to an Icelandic institution, indicate the personal identification number (kennitala); to a Latvian institution, state the identity number; to a Liechtenstein institution, indicate the AHV insurance number; to a Lithuanian institution, state the personal identification number; to a Hungarian institution, state the TAJ (social insurance identification) number; to a Maltese institution, in the case of Maltese nationals, state the identity card number, or, if not a Maltese national, state the Maltese social security number; to a Norwegian institution, indicate the personal 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); to a Spanish institution, state the number appearing on the national identity card (DNI), or N.I.E in the case of foreign people, even if the card is out of date; to a Polish institution, state the PESEL and NIP numbers; to a Portuguese institution, indicate also the registration number with the general pensions scheme, if the person concerned has been insured under the social security scheme for civil servants in Portugal; to a Slovak institution, state the birth number; to a Slovene institution, state the personal identification number (EMŠO); to a Swiss institution, state the AVS/AI (AHV/IV) insurance number. Failing this, indicate ‘None’.
( 2 ) Street, number, post code, town, country.
( 3 ) Need only to be filled in if a Belgian or Slovak institution is responsible for granting family benefits.
( 4 ) In Slovenia it is completed by a medical commission appointed by the Minister of Labour, Family and Social Affairs.
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THE ADMINISTRATIVE COMMISSION ON SOCIAL SECURITY FOR MIGRANT WORKERS
See ‘instructions’ on page 4
E 411
( 1 )
REQUEST FOR INFORMATION ON ENTITLEMENT TO FAMILY BENEFITS IN THE MEMBER STATES OF RESIDENCE OF THE MEMBERS OF THE FAMILY
Reg. 1408/71: Art. 76
Reg. 574/72: Art. 10
A. Request for certificate
The competent institution responsible for the payment of family benefits in the Member State in which the employed or self-employed person works, which wishes to know whether entitlement to family benefits exists in the Member State of residence of the members of the family, should complete two copies of Part A and send them to the institution of the place of residence of the members of the family.
1.
Employed person
Self-employed person
1.1.
Surname ( 1a )
…
1.2.
Forenames
Previous names ( 1a )
Place of birth ( 2 )
… … …
1.3.
Date of birth
Sex
Nationality
Identification/insurance number ( 3 )
… … … …
1.4.
Address ( 4 ) ……
2.
Spouse (former spouse) or other persons whose entitlement to family benefits in the country of residence of the members of the family must be verified
2.1.
Surname ( 1a )
…
2.2.
Forenames
Previous names ( 1a )
Date of birth
Identification/insurance number ( 3 )
… … … …
2.3.
Address ( 4 ) …
……
2.4.
Relationship to the members of the family mentioned in box 3
…
2.5.
Period for which the information is requested …
3.
Members of the family ( 6 )
Surname ( 1a )
Forenames
Date of birth
Relationship ( 5 )
Actual place of residence ( 7 )
Identification/insurance No ( 3 )
3.1.
………………………………………………
3.2.
………………………………………………
3.3.
………………………………………………
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4.
Information concerning the occupation pursued in the country of residence of the members of the family
4.1.
Employer …
4.2.
Address ( 4 ) …
…
4.3.
Self-employment …
4.4.
Activity treated as an occupation as defined by Decision No 119 ( 15 )
…
5.
Competent institution
5.1.
Name …
5.2.
Address ( 4 ) …
…
5.3.
File reference number ( 8 ) …
5.4.
Stamp
5.5.
Date …
5.6.
Signature …
B. Certificate
To be completed by the competent institution in the place of residence of the members of the family or by the employer or the person named in box 2 ( 9 ).
6.
Certificate issued by the competent institution responsible for the payment of family benefits in the place of residence of the members of the family or by the employer
6.1.
During the period from …
to …
the person named in box 2
pursued an occupation (or an activity treated as such as defined in Decision No 119) ( 15 )
from …
to …
did not pursue an occupation (or an activity treated as such as defined in Decision No 119) ( 15 )
from …
to …
6.2.
For the period from …
to …
the person named in box 2
is entitled to family benefits for the members of the family
total amount of family benefits …
is not entitled to family benefits for the following reasons
…
has not submitted a claim ( 10 )
…
6.3.
Income of the persons named in box 2 and 3 ( 4a )
…
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7.
Information concerning the family benefits referred to in box 6 per family members ( 11 )
Surname
Forenames
Date of birth
Relationship
Place of residence
1.
… … … … …
2.
… … … … …
3.
… … … … …
4.
… … … … …
5.
… … … … …
6.
… … … … …
Additional information per family member:
Family member
Kind of benefit ( 14 )
Amount ( 12 )
Periodicity (week/month)
1.
… … … …
2.
… … … …
3.
… … … …
4.
… … … …
5.
… … … …
6.
… … … …
8.
Employer of the person named in box 2 ( 9 )
8.1.
Name of employer (if a company, the corporate name) …
8.2.
Address ( 4 ) …
…
8.3.
Stamp
8.4.
Date …
8.5.
Signature …
9.
Institution of the place of residence of the members of the family ( 13 )
9.1.
Name …
9.2.
Addres ( 4 ) …
…
9.3.
File reference number …
9.4.
Stamp
9.5.
Date …
9.6.
Signature …
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E 411
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: BE = Belgium; CZ = Czech Republic; DK = Denmark; DE = Germany; EE = Estonia; GR = Greece; ES = Spain; FR = France; IE = Ireland; IT = Italy; CY = Cyprus; LV = Latvia; LT = Lithuania; LU = Luxembourg; HU = Hungary; MT = Malta; NL = The Netherlands; AT = Austria; PL = Poland; PT = Portugal; SI = Slovenia; SK = Slovakia; FI = Finland; SE = Sweden; UK = United Kingdom; IS = Iceland; LI = Liechtenstein; NO = Norway; CH = Switzerland.
( 1a ) In the case of Spanish nationals state both names. In the case of Portuguese nationals state all names (forenames, surname, maiden name) in the order of civil status in which they appear on the identity card or passport.
( 2 ) In the case of Portuguese districts, state also the parish and the local authority.
( 3 ) Where the form is being sent to a Czech institution, state the birth number; to a Cypriot institution, if a Cypriot national state the Cypriot identification number, if not a Cypriot national state the Alien Registration Certificate (ARC) number; to a Danish institution, indicate the CPR number; to a Finnish institution, indicate the population register number; to a Swedish institution, indicate the personal number (personnummer); to an Icelandic institution, indicate the personal identification number (kennitala); to a Latvian institution, state the identity number; to a Liechtenstein institution, indicate the AHV insurance number; to a Lithuanian institution, state the personal identification number; to a Hungarian institution, state the TAJ (social insurance identification) number; to a Maltese institution, in the case of Maltese nationals, state the identity card number, or, if not a Maltese national, state the Maltese social security number; to a Norwegian institution, indicate the personal 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); to a Spanish institution, state the number appearing on the national identity card (DNI) or N.I.E,in the case of foreign people, even if the card is out of date; to a Polish institution, state the PESEL and NIP numbers; to a Portuguese institution, indicate also the registration number with the general pensions scheme, if the person concerned has been insured under the social security scheme for civil servants in Portugal; to a Slovak institution, state the birth number; to a Slovene institution, state the personal identification number (EMŠO) and tax number; to a Swiss institution, state the AVS/AI (AHV/IV) insurance number.
( 4 ) Street, number, post code, town, country. If the form is being sent to a Hungarian institution, indicate the last Hungarian address as well.
( 4a ) For the purposes of the Czech institutions, submit the income documentation of persons specified in items 2 and 3. When the benefit is claimed up to 30 September of the current year, the income documentation concerns the calendar year preceding the previous year; when the benefit is claimed after 1 October of the current year, the income documentation concerns the previous calendar year. Please state all kinds of income according to their source (employment, self-employment, rents, stipends, maintenance payments, etc.) including benefits (unemployment benefits, pensions, sickness benefits, family benefits, etc.).
( 5 ) Show the relationship of each member of the family to the worker, using the following symbols: A = legitimate child. In Spain and Poland child born in wedlock (matrimonial) and child born out of wedlock (non-matrimonial).
B = legitimised child.
C = adopted child.
D = natural child (if the form is completed for a male worker, the natural children must be mentioned only if the paternity or the worker’s obligation to maintain them has been officially recognised).
E = child of a spouse belonging to the worker’s household.
F = grandchildren, brothers and sisters whom the person concerned has taken into his household. Also, nephews and nieces to the third degree where the competent institution is a Greek institution. Where the competent institution is a Polish institution, only grandchildren and siblings whose legal guardian is an entitled person or his/her spouse.
G = other children belonging permanently to the household on the same footing as the worker’s children (foster children).
Where the competent institution is a Polish institution, only other children whose legal guardian is an entitled person or his/her spouse.
H = for the purposes of Czech institutions, describe further forms of custody (custody awarded following a court decision to other persons than parents, guardian, curator, etc.). Other relationships (e.g. grandfather) must be written in full.
According to Czech legislation, legitimised and adopted children under B and C have equal status.
( 6 ) For the purposes of Norwegian institutions, state only children under the age of 16. For the purpose of Latvian institutions indicate only children under the age of 15, and, if they are attending general or vocational educational establishments and not receiving scholarship and are not married, children under the age of 20.
( 7 ) If the member of the family resides at an address other than that indicated at 2.3, please indicate here. For the purposes of Latvian and Norwegian institutions, please state if the child resides in an orphanage, a special school or another residential institution.
Surname and forenames
…
…
Address ( 4 )
…
…
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( 8 ) For use by the sending institution.
( 9 ) The certificate should be completed by the employer only if he/she has to pay the family benefits of the country of residence.
( 10 ) In this case the institution of the place of residence should indicate the amount of family benefits that would have been granted if a claim had been submitted. If it does not have sufficient information to do so it should indicate in box 7 the tariffs provided for by its legislation for each member of the family.
( 11 ) For Norwegian family benefits only the total amount will be given.
( 12 ) Where appropriate, indicate the tariffs referred to in footnote 10.
( 13 ) To be completed by the institution of the place of residence of the members of the family or, failing this, by the liaison body.
( 14 ) For Slovak and Czech institutions state the kind of family benefit.
( 15 ) OJ C 295, 2.11.1983, p. 3.