DECISION No 168 of 11 June 1998 on the amending of forms E 121 and E 127 and the discontinuance of form E 122 (Text with EEA relevance) (98/443/EC)

THE ADMINISTRATIVE COMMISSION OF THE EUROPEAN COMMUNITIES ON SOCIAL SECURITY FOR MIGRANT WORKERS,

Having regard to Article 81(a) of Council Regulation No 1408/71 of 14 June 1971 on the application of social security schemes to employed persons, to self-employed persons and to members of their family moving within the Community, under which it is the duty of the Administrative Commission to deal with all administrative matters arising from Regulation (EEC) No 1408/71 and subsequent Regulations,

Having regard to Article 2(1) of Council Regulation (EEC) No 574/72 of 21 March 1972, under which it is the duty of the Administrative Commission to draw up models of certificates, certified statements, declarations, applications and other documents necessary for the application of the Regulations,

Having regard to Decision No 153 of 7 October 1993 on the model forms necessary for the application of Council Regulations (EEC) No 1408/71 and (EEC) No 574/72 (E 001, E 103 to E 127),

Having regard to Decision No 170 of 11 June 1998 amending Decision No 141 of 17 October 1989 amending Decision No 127 of 17 October 1985 concerning the compilation of the lists provided for in Article 94(4) and Article 95(4) of Council Regulation (EEC) No 574/72 of 21 March 1972,

Whereas Council Regulation (EC) No 3095/95 of 22 December 1995 amended Regulation (EEC) No 574/72, firstly Article 17(2) and Article 30(1), by limiting to one year the period of validity of form E 122 issued by German, Italian or Portuguese institutions, and secondly Article 95, by replacing the average cost per family by the average cost per person;

Whereas this amendment to Article 95 of Regulation (EEC) No 574/72 will not, however, take effect until 1 January 2002 in the French Republic;

Whereas Council Regulation (EC) No 1223/98 of 4 June 1998 amended Articles 29 and 31 of Regulation (EEC) No 1408/71 and Articles 29, 30, 31, 93 and 95 of Regulation (EEC) No 574/72;

Whereas forms E 121 and E 127 must therefore be adapted and form E 122 discontinued;

Whereas the Agreement on the European Economic Area of 2 May 1992, as amended 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;

Whereas by Decision of the EEA Joint Committee the model forms necessary for the application of Regulations (EEC) No 1408/71 and (EEC) No 574/72 will be adapted and implemented within the European Economic Area;

Whereas for practical reasons identical forms should be used within the Community and within the European Economic Area;

Whereas the language in which forms should be issued is the subject of Recommendation No 15 of the Administrative Commission,

HAS DECIDED AS FOLLOWS:

1. The model forms E 121 and E 127 reproduced in Decision No 153 of 7 October 1993 shall be replaced by the models appended hereto, and the model form E 122 reproduced in the same Decision shall be discontinued.

2. Separate forms E 121 and E 127 shall be filled in for each recipient of a pension or allowance, and for each member of the family of a recipient of a pension or allowance.

3. The competent authorities of the Member States shall make the appended forms available to the persons concerned (rightful claimants, institutions, employers, etc.). However, E 121 forms valid on the date this Decision enters into force shall remain valid until they are invalidated and/or replaced by the new model form E 121 covering only the recipient of a pension or allowance and thus not the members of their families.

4. Each form shall be available in the official languages of the Commuity and laid out in such manner that the different versions are perfectly superposable, thereby making it possible for all persons or bodies to whom a form is addressed (rightful claimants, institutions, employers, etc.) to receive the form printed in their own language.

5. This Decision shall be published in the Official Journal of the European Communities and shall be applicable as from 1 January 1998. In France, however, it shall not take effect until 1 January 2002.

Peter CLEASBY

The Chairman of the Administrative Commission

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EUROPEAN COMMUNITIES

Social Security Regulations

EEA (*)

See Instructions on page 4

E 121

(1)

CERTIFICATE FOR THE REGISTRATION OF PENSIONERS OR MEMBERS OF THEIR FAMILIES AND THE

UPDATING OF LISTS

Regulation (EEC) No 1408/71: Article 28.1.a; Article 29.1.a

Regulation (EEC) No 574/72: Article 29.1, 2 and 3; Article 30.1; Article 95.4

The institution which has to to draw up this certificate in accordance with Article 29.2 or Article 30.1 of Regulation (EEC) No 574/72 should complete Part A of the form and issue two copies to the pensioner or the member of his family, or send them to the institution in the place of residence if the form was requested by the latter institution. If the pensioner or the member of his family resides in the United Kingdom, the two copies of the form should be sent direct to the Department of Social Security, Benefits Agency, Overseas Benefits Directorate, Newcastle-upon-Type. Where appropriate, the two copies shall first be sent to the institution which has to complete boxes 6 and 7. The institution in the place of residence should, on receiving the two copies, complete Part B and send one copy to the institution shown in box 7.

A. Notification of entitlement

1.

Institution of the place of residence (2)

1.1.Name: ...................

1.2.Address (3): ....................................

1.3.Reference: your E 107 form of ...................

2.

Pensioner (scheme for employed persons)

Pensioner (scheme for self-employed persons)

2.1.Surname (4)

2.2.ForenamesPrevious names (4)Date of birth2.3.Address in the country of residence (3):

2.4.Date of transfer of residence, if applicable:2.5.Identification number (5):3.

To be completed by the institution responsible for payment of the pension

3.1.The person concerned indicated above has been entitled to a pension for

old ageinvaliditysurvivalaccident at workoccupational disease3.2.since3.3.Pension No:4.

Institution which completed box 3 (6)

4.1.Name: ................... 4.2.Address (3):4.3.Stamp

4.4.Date 4.5.Signature ....................

E 1215.

Member of the family of the pensioner

5.1.Surname (4) ....................

5.2.Forenames / Previous names (4) / Date of birth

............../ .................../ .............

5.3.Address in the country of residence (3): ...................

5.4.Date of transfer of residence, if applicable: ..............

5.5.Identification No (5): .....................................

6.

To be completed by the institution responsible for payment of the pension or by the sickness or maternity insurance institutionin the country responsible for payment of the pension (7)

6.1.Code number of the investigation institution (8):6.2.The person concerned indicated in box 2

The person concerned indicated in box 5

is entitled to sickness and maternity benefits in kind from6.3.The cost of the benefits to be provided in their country of residence - unless they reside in the competent country -

will be borne by us6.4.fromuntil this certificate is cancelled

6.5.for one year from (9)6.6.The issue of this certificate renders the E form of null and void7.

Institution which completed box 6 (7)

7.1.Name: ...................

7.2.Address (3):..............

7.3.Stamp

7.4.Date: .....................

7.5.Signature: ................

B. Notification of registration or non-registration8.

(10)

8.1.The person concerned indicated in box 2

The person concerned indicated in box 5

could not be registered

8.2.because the person concerned is already entitled to benefits in kind under the legislation of our country

8.3. other reasons: ........................

E 121

9.

(10)

9.1.The person concerned indicated in box 2

The person concerned indicated in box 5

has been registered.

9.2.The costs of these benefits should be borne by you; the date from which the lump sum provided for in Article 95 of Regulation (EEC) No 574/72 should be calculated is9.3.Code number of the institution of the place of residence (8):10.

Institution of the place of residence of the pensioner or member of his family

10.1.Name: ....................

10.2.Address (3): .........................................

Téléphone ..................... Télécopieur ...............

10.3.Stamp

10.4.Date: ......................

10.5.Signature: .................

E 121

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. A separate form must be completed for each person to be registered.

Information for the pensioner or member of his family

(a)You should, as soon as possible, send the two copies of this form to one of the following insurance institutions:

in Belgium, the 'mutualité' (local sickness insurance fund) of your choice

in Denmark, the local government office at the place of residence

in Germany, the 'Krankenkasse' (sickness fund) in the place of residence chosen by the person concerned

in Greece, normally the regional or local branch of the Social Insurance Institute (IKA). The branch office should issue the person concerned with a 'health book', without which no benefits in kind can be provided

in Spain, the 'Direcci贸n Provincial del Instituto Nacional de la Seguridad Social' (Provincial Directorate of the National Social Security Institution) of the place of residence

in France, the 'Caisse primaire d'assurance-maladie' (local sickness insurance fund)

in Ireland, the Health Board in whose area the benefit is claimed

in Italy, the 'Unit脿 sanitaria locale' (USL, the local health administration unit) responsible for the area concerned

in Luxembourg, the 'Caisse de maladie des ouvriers' (sickness fund for manual workers)

in the Netherlands, any sickness fund competent for the place of residence

in Austria, the 'Gebietskrankenkasse' (Regional Fund for Sickness Insurance) competent for your place of residence

in Portugal for mainland Portugal: the 'Centro Regional de Segurança Social' (Regional Social Security Centre) of the place of residence; for Madeira, the 'Direcç茫o Regional de Segurança Social' (Regional Social Security Directorate) in Funchal; for the Azores: 'Direcç茫o Regional de Segurança Social' (Regional Social Security Directorate) in Angra do Hero铆smo

in Finland, the local office of the 'Kansanel盲kelaitos' (Social Insurance Institution)

in Sweden, 'f枚rs盲kringskassan' (Social Insurance Office) at the place of residence

in Iceland, the 'Tryggingastofnun Rikisins' (State Social Security Institution), Reykjavik

in Liechtenstein, the 'Amt f眉r Volkswirtschaft' (Office of National Economy), Vaduz

in Norway, the 'lokale Trygdekontor' (local Insurance Office) at the place of residence.

(b) You must inform the insurance institution to which you submit the form of any change of circumstances which might affect the right to benefits in kind, such as suspension or withdrawal of pension, or change of place of residence, etc.

NOTES

(*)EEA Agreement on the European Economic Area, Annex VI, Social Security: for the purposes of this Agreement the present form shall also apply to Iceland, Liechtenstein and Norway.

(1)Symbol of the country to which the institution completing Part A of the form belongs: B = Belgium; DK = Denmark; D = Germany; GR = Greece; E = Spain; F = France; IRL = Ireland; I = Italy; L = Luxembourg; NL = Netherlands; A = Austria; P = Portugal; FIN = Finland; S = Sweden; GB = United Kingdom; IS = Iceland; FL = Liechtenstein; N = Norway.

(2)Complete only if the form is drawn up at the request of the institution in the place of residence.

(3)Street, number, post code, town, country.

(4)In the case of Spanish nationals, state both names at birth.

In the case of Portuguese nationals, state all names (forenames, surname, maiden name) in the order of civil status in which they appear on the identity card or passport.

(5)For the Italian nationals indicate, if possible, the insurance number and/or the 'codice fiscale'.

(6)In France, for self-employed persons, the box must be filled in by the institution for sickness and maternity insurance.

(7)In Italy, boxes 6 and 7 should be completed exclusively by the USL or the Ministry of Health.

(8)To be completed where this exists.

(9)If the form issued by a German, French, Italian or Portuguese institution concerns a family member.

(10)Complete box 8 or 9, where appropriate, and put a cross in the corresponding square.

EUROPEAN COMMUNITIES

Social Security Regulations

EEA (*)

See Instructions on page 3

E 127

(1)

INDIVIDUAL RECORD OF MONTHLY LUMP-SUM PAYMENTS

Regulation (EEC) No 1408/71: Article 36.1 and 2

Regulation (EEC) No 574/72: Article 94; Article 95

1.

Record No ..................... of year 19....... (2)

2.

Competent institution

2.1.Name .............. Code number (4) .............

2.2.Address (3) .....................................

3.

The right to benefits in kind has been acquired for the

employed person

self-employed person

pensioner (scheme for employed persons)

pensioner (scheme for self-employed persons)

3.1.Surname (5) ............................

3.2.Forenames / Previous names (5) / Date of birth

............../ .................../ ..............

3.3.Identification number allocated by the competent institution (6): ..................................

4.

This individual record concerns:

4.1.the family of the worker named in box 3 living at the following address (3):

...................................................

4.2.the pensioner named in box 3 living at the following address (3):

...................................................

4.3.the following member of the family of the pensioner named in box 3

4.3.1.Surname (5): ................................

4.3.2.Forenames: / Previous names (5): / Date of birth:

................ / ..................../ ..............

4.3.3.Address (3): .....................................

4.3.4.Identification number allocated by the competent institution (6):

........................................................

E 127

5.The right to benefits of the person(s) named in 4.1 / 4.2 / 4.3 was certified by your form

E .... of ..............

6.For the period during which this right existed

(from ................. to .....................)

6.1.the number of monthly lump-sum payments

per family (of a worker) / per family member / per individual

is .................

7.

Institution of the place of residence

7.1.Name: ............... Code number (7): .............

7.2.Address (3): .......................................

7.3.Stamp

7.4.Date: ......................

7.5.Signature: .................

8.For official use only

E 127

INSTRUCTIONS

Please complete three copies of this form in block letters, writing on the dotted lines only. A separate form must be completed for each pensioner and each member of the family of a pensioner.

The institution of the place of residence should draw up the form for one calendar year and send it to the competent institution through the body designated for the implementation of Article 102(2) of Regulation (EEC) No 574/72.

NOTES

(*)EEA Agreement on the European Economic Area, Annex VI, Social Security: for the purposes of this Agreement the present form shall also apply to Iceland, Liechtenstein and Norway.

(1)Symbol of the country to which the institution completing Part A of the form belongs: B = Belgium; DK = Denmark; D = Germany;GR = Greece; E = Spain; F = France; IRL = Ireland; I = Italy; L = Luxembourg; NL = Netherlands; A = Austria; P = Portugal;FIN = Finland; S = Sweden; GB = United Kingdom; IS = Iceland; FL = Liechtenstein; N = Norway.

(2)The year to be indicated here is that in which the benefits were provided.

(3)Street, number, post code, town, country.

(4)To be completed if it is known.

(5)In the case of Spanish nationals, state both names at birth.

In the case of Portuguese nationals, state all names (forenames, surname, maiden name) in the order of civil status in which they appear on the identity card or passport.

(6)For Italian nationals indicate, if possible, the insurance number and/or the 'codice fiscale'.

(7)To be completed where this exists.

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