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ANNEX

1.2.3 // // // // EUROPEAN COMMUNITIES // // FORM // // // EC - FTS (1) // // //

CERTIFICATE CONCERNING THE REGISTRATION AS A PERSON SEEKING EMPLOYMENT AND CONCERNING THE RIGHT TO UNEMPLOYMENT BENEFITS OF A FORMER MEMBER OF THE TEMPORARY STAFF OF THE EUROPEAN COMMUNITIES

(Council Regulation (ECSC, EEC, Euratom) No 2799/85, Article 33)

1.2 // // // 1 // Institution of the European Communities to which the form is addressed // // // 1.1 // Name: // 1.2 // Address: // // // // 1.2 // // // 2 // Information concerning the former member of the temporary staff // // // 2.1 // Surname: // 2.2 // Maiden name: // 2.3 // Fornames: // 2.4 // Date of birth: // 2.5 // Residence: // // // 2.6 // Personnel number or file reference number: // //

Section A - Registration and checks

3 This is to certify that the above named person:

3.1 registered as a person seeking employment on

with the employment services of

3.2 was registered as seeking employment from to

3.3 did not subject himself/herself to the obligations under national legislation from

to because

1.2 // // // 4 // National institution issuing this certificate (Section A) // // // 4.1 // Name: // 4.2 // Address: // 4.3 // Stamp // // 4.4 Date: // temporary staff.

Section B - Claim for unemployment benefit

5 This is to certify that:

5.1 the person referred to in Box 2 submitted a claim for unemployment benefit on

5.2 the claim is currently being examined

5.3 no claim has been made

6 The person referred to in Box 2:

6.1 is not entitled to unemployment benefit because

6.2 has not registered as a person seeking employment

6.3 has not subjected himself/ herself to the obligations under national legislation

6.4 does not satisfy the conditions for payment of unemployment benefit

6.5 (other reasons; please specify)

7 is entitled to unemployment benefit

7.1 from (date)

7.2 gross daily amount

7.3 gross weekly amount

7.4 gross monthly amount

7.5 for days

7.6 until

7.7 amount of benefit paid for the month in question

8 Payment of unemployment benefit was

8.1 suspended from to

8.2 withdrawn

8.3 because

1.2 // // // 9 // National institution issuing this certificate (Section B) // // // 9.1 // Name // 9.2 // Address: // 9.3 // Stamp // // 9.4 Date: // // 9.5 Signature: // // // // // 4.5 Signature: // // // //

(1) EC = European Communities. FTS = Former member of the

INSTRUCTIONS

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

A. Instructions for the administrative services of the European Communities

1. The appropriate department of the institution of the European Communities for which the former member of the temporary staff worked should complete Boxes 1 and 2.

2. It should give five copies of the completed form to the former member of the temporary staff.

B. Instructions for the national administrative services

1. When the person concerned is registered as a person seeking employment, the competent national institution should at least complete Section 3.1, Box 4 and Section 5 of this form, which the former member of the temporary staff should present to it. He should then send it thus completed to the European Communities institution shown in Box 1.

2. Next, the national institution should at monthly intervals fill in the other appropriate sections, in addition to Section 3.1, Box 4 and Section 5 referred to above.

C. Instructions for the former member of the temporary staff

In order to receive the unemployment benefits provided for in Article 33 of Council Regulation (ECSC, EEC, Euratom) No 2799/85.

you should,

1. before the 31st day following the end of your employment as a member of the temporary staff, register as a person looking for work with the employment office of the Member State where you take up residence (or domicile).

Note: These offices are shown in a list prepared and updated by the Commission which will be provided by the institution to which you belonged.

2. comply with the obligations regarding unemployment laid down by the legislation of the Member State in which you register as a person looking for work;

3. present a copy of this form to the national employment office when you register as a person looking for work and subsequently once a month in order to have it filled in (see B above);

4. send the completed form to the institution shown in Box 1.