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EUROPEAN COMMISSIONOFFICE FOR ADMINISTRATION AND PAYMENT OF INDIVIDUAL ENTITLEMENTS
Pensions
DOCUMENTS TO BE COMPLETED
SO THAT YOUR RIGHTS CAN
BE ESTABLISHED
Brussels, 2003
ANNEX 1 Declaration with a view to the establishment of pension rightswith form “Personal codes and bank details”
ANNEX 2 Declaration with a view to membership of the Joint SicknessInsurance Scheme
ANNEX 3 Declaration with a view to the regularisation of days' leave nottaken or taken in excess
ANNEX 4 Application for access to the Intranet of the Commission
ANNEX 5 Application for a pensioner's pass
ANNEX 6 Application for the "Commission en direct"
ANNEX 7 A.F.P.E. Subscription form
ANNEX 8 A.I.A.CE. Membership Application
ANNEX 9 Activity statement after departure from the CommissionArticle 16 of the Staff Regulations
ANNEX 1, p.1
Please return this form - duly completed, signed and dated - to Unit“Pensions”, PMO/4 - B28 5/72as soon as possible
Please fill in this document in block capitals and with a black pen.
Your pension cannot be calculated or paid out without this declaration. You will receivea notice of assessment of your entitlement in due course.
In the case of an under-age orphan, the forms must be completed by the legalrepresentative or guardian. A separate form must be completed by or on behalf of eachentitled person (Annex 1).
Type of pension: retirement/invalidity/survivor's
Pension No:
DECLARATION
I, THE UNDERSIGNEDSURNAME, FORENAME: .................................................................................................
(NAME AT BIRTH): .........................................................................................................
MARITAL STATUS : single – married – divorced – widow(er) – legally separated(delete whichever does not apply)
SURNAME (MAIDEN NAME if applicable), FORENAME, NATIONALITY ANDDATE OF BIRTH OF SPOUSE: .......................................................................................................................................................................................................................................
DATE OF MARRIAGE OR LEGAL SEPARATION OR DIVORCE: ..............................
hereby DECLARE that
(a) I currently reside at:
Street and number: .....................................................................................................
Place and postcode: ....................................................................................................
Country: ......................................................................................................................
Telephone number: .....................................................................................................
ANNEX 1, p.2
My residence from: ............................................................................................. will be:
Street and number: .....................................................................................................
Place and postcode: ....................................................................................................
Country: ......................................................................................................................
Telephone number: .....................................................................................................
I enclose the required documents for the determination of the weighting allowance(see Vademecum). For the survivor’s pensions, please enclose as well a copy of youridentity card or passport.
Person to be contacted in the event of an emergency:
Name: ........................................................................................................................
Address: .....................................................................................................................
Telephone number: ....................................................................................................
(b) Bank account (Please give personal and Bank details on attached form whichshould be returned to us with the Bank’s stamp and representative’s signature)
Bank: ..........................................................................................................................
Address of branch: .....................................................................................................
Other references:.........................................................................................................
Account number: | | | | | | | | | | | | | |
(maximum 13 figures)
(c) I currently maintain the following children:
Surname Forename Date of birth
........................... .......................... .................
........................... .......................... .................
........................... .......................... .................
ANNEX 1, p.3
........................... .......................... .................
........................... .......................... .................
Children in the care of another person:
Surname Forename Date of birth
........................... .......................... .................
........................... .......................... .................
........................... .......................... .................
........................... .......................... .................
Name, address, telephone and bank account number of person with custody: (theattached optical reader form should be also completed)
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
The children listed above have a personal income: YES/NO**
earned or grants
If the answer is yes, please indicate the net amount and the period(s) covered
and enclose supporting documents.
They are in full–time education or vocational training: YES/NO**
If the answer is yes, please enclose a certificate for each child from the institutionthey are attending.
** Delete whichever does not apply.
ANNEX 1, p.4
(d) I have a personal income:* YES/NO**
If the answer is yes, please state
- the net amount:
- the period to which it relates:
and attach a certificate from your employer.
(e) My spouse is gainfully employed: YES/NO**
If the answer is yes, please state:
- whether in a Community institution/elsewhere**
- the amount of income before tax and enclose a supporting document:
...............................................................................................................................
If the answer is no, please state :
- whether unemployed,
- whether pensioner of a EC Institution: n° …………………..
- whether pensioner of a non-European Institution (please enclose a supportingdocument)
(The purpose of this question is to establish whether you are entitled to receive orcontinue to receive allowances).
(f) I receive (or my spouse, the person who has custody, the person whom I maintain,receives) family allowances from other sources similar to those paid by theCommission of the European Communities: YES/NO**
If the answer is yes, please state the nature and amount of the allowances and thename of the organization responsible, and enclose a certificate confirming theseparticulars:
.....................................................................................................................................
..................................................................................................................................... * Only to be completed by orphans and persons in receipt of a special termination of service
allowance.
** Delete whichever does not apply.
ANNEX 1, p.5
(g) I am eligible for cover under another public sickness insurancescheme: YES/NO**
(h) I am aware that, under Article 43 of Annex VIII to the Staff Regulations, I amrequired (or those entitled under me are required) to supply any written proofthat may be requested and to notify the Administration of any circumstanceslikely to affect my entitlement to benefit.
I am also aware that, under Article 85 of the Staff Regulations, theAdministration is entitled to recover any undue payment resulting from falsedeclarations or incorrect or incomplete information.
(i) Before establishment, I was employed as a member ofthe auxiliary staff: YES/NO**
If the answer is yes, please state the Community Institution and the period:
From ............... to .................. Institution .....................
I have transferred my pension rights: YES/NO**
(Article 11 § 2 of Annex VIII to the Staff Regulations)
(j) I am an official or temporary staff member in aCommunity institution: YES/NO**
(k) I already receive a survivor's pension / invalidity pension / retirement
pension from a Community institution: YES/NO**
(l) I have a contract with the BHW: YES/NO**
(If so, please attach a copy of the latest contract. This type of contract is nowmentioned on your remuneration bulletin under codes 696 or 697, 850, 896 or 897)
(m) I have a BHW insurance contract: YES/NO**
(If so, please attach a copy of the latest contract. This contract is mentioned on yourremuneration bulletin under code 855)
______________________________
** Delete whichever does not apply.
ANNEX 1, p.6
(n) I have a building loan contract with the European Commission: YES/NO**
(If so, please attach a copy of the latest contract. This contract is mentioned on yourremuneration bulletin under code 842)
(o) I have a UGPFE/VITA insurance contract: YES/NO**
(If so, please attach a copy of the latest contract. This contract is mentioned on yourremuneration bulletin under code 854)
I hereby confirm that the information given above is true and complete and certify that Ihave duly noted how the pension scheme works.
I hereby commit to informing the Commission, as soon as possible, of any changesrelative to my declaration.
....................... .......................... ..........................
(Place) (Date) (Signature)
Annexes: .......................................................
.......................................................
.......................................................
** Delete whichever does not apply.
PERSONAL AND BANK DETAILS (EN)- one document per person -
ACCOUNT HOLDER(S)
NAME(S)
FIRST NAME(S)
STAFF/PENSION No
STREET AND No
FULL ADDRESS
COUNTRY
TELEPHONE FAX
E - MAIL
BANK
NAME OF BANK
STREET AND No
FULL ADDRESS
NATIONAL CODES (1)
CHECK DIGIT (DC) (SPAIN)
CHECK DIGIT (CD/RIB)
IBAN
National codes (1):Belgique/België: none Italia : Codice ABI (5 cifre) - CAB (5 cifre)Danmark : Register (4 tal) Luxembourg/Luxemburg : noneDeutschland : Bankleitzahl (8 Stellen) Österreich: Bankleitzahl (5 Stellen)España : Entidad (4 cifras) - Oficina (4 cifras) Nederland: noneFrance : Etablissement (5 chiffres) - Guichet (5 chiffres) Portugal : Entidade (4 digitos) - Agencia (4 digitos)Hellas: none Sverige: Register (4 siffror) Ireland: Sort Code (6 figures) Suomi: Konttorinumero (6 numeroa)
United Kingdom: Sort Code (6 figures)
BANK STAMP + DATE + SIGNATURE OF BANK REPRESENTATIVE SIGNATURE OF ACCOUNT HOLDER(Both are required) (Required)
POST CODE + TOWN/CITY
ACCOUNT No
POST CODE + TOWN/CITY
B-1049 Bruxelles/B-1049 Brussel - Belgium - Office: B-28 3/150.Telephone: direct line (+32-2)295.80.37, switchboard 299.11.11. Fax: 295.20.39.
EUROPEAN COMMISSION ANNEX 2OFFICE FOR ADMINISTRATION AND PAYMENT OF INDIVIDUAL ENTITLEMENTS
Sickness and accident insurance
Brussels,PMO/3/HJ
NOTE TO ALL NEW PENSIONERS
Subject: Sickness Insurance
Once you become a pensioner, the Settlements Office to which you are attached dependson your official country of residence, as communicated to the Pensions Unit.
Please find attached (Annex 2.1) the distribution of the different Offices. If you find thatyou will be changing your Settlements Office on taking up your pension, your file will beautomatically transferred to the new office.
The addresses and phone numbers of the Offices can be found at Annex 2.2.
We would please ask you to fill in the questionnaire at Annex 2.3 and return it to us atyour earliest convenience, together with proof of your spouse’s income/pension if youwish to claim complementary cover for him/her.
If you wish to obtain a Sickness Insurance Carnet, please fill in the application form atAnnex 3 and send it, along with a photograph, to the address indicated. You may alsoapply for a Carnet for each member of your family who is fully covered by the Scheme.Please complete a form for each person and send a photograph of each person concerned.
If you have any queries on these points, please do not hesitate to contact us onBrussels : tel. : 02-295.80.37 - fax : 02-295.20.39) or send an email to the followingaddress:
Internally: PMO-BXL AFFIL CAISSE MALADIE
Externally: [email protected]
Helen James
Enclosures: 3
BILAGANLAGE
ANNEX
ANEXO 2.1ANNEXE
ALLEGATOBIJLAGE
ANEXO
BopælslandWohnsitz
Country of ResidencePais de ResidenciaPays de résidencePaese di residenzaLand van verblijfPaís de residencia
AfregningskontorZuständige Abrechnungsstelle
Settlements Office to which you are attachedDespacho de liquidacion del que depende Vd.
Bureau liquidateur dont vous dépendezUfficio di liquidazione competente
Afwikkelingsbureau waarbij U bent aangeslotenServiço de Liquidação de que depende
Luxembourg, France, Switzerland Luxembourg
Deutschland, Denmark,Österreich
Finland, Sweden,United Kingdom
Karlsruhe
Italia, España, Greece, Portugal Ispra
Øvrige landeAndere Mitgliedstaaten
All other countriesTodos los demás países
Autres paysTutti gli altri paesiAlle andere landenRestantes paíseis
Brussels
BILAGANLAGE
ANNEX
ANEXO 2.2ANNEXE
ALLEGATOBIJLAGE
ANEXO
Bruxelles COMMISSION EUROPEENNECaisse Maladie (B-28 2/180)B - 1049 BRUXELLESTél : (32) 2 295.14.15 / 32 2 295 30 26Fax : (32) 2 295.97.01Répondeur automatique pour les pensionnés : (32) 2 295.37.97Lettre de prise en charge : tél. 32 2 295.98.56
Luxembourg COMMISSION EUROPEENNECaisse Maladie (WAGNER C1/34)Plateau du KirchbergL - 2920 LUXEMBOURG
Tél. : (352) 4301 36100 / 36101Fax : (352) 4301 36353Lettre de prise en charge : tél. (352) 4301 36100
Ispra CENTRO COMUNE DI RICERCAStabilimento di IspraUfficio di Liquidazione (TP 640)I - 21020 ISPRA (VA)
Tel. : (39) 332 785757 / 785687Fax : (39) 332 789423Segreteria telefonica 24/24 ore : (39) 332 785844Per ottenere un’impegnativa : tél. (39) 332 785757 / 785687
Karlsruhe GEMEINSAME FORSCHUNGSSTELLEEuropäisches Institut für TransuraneAbrechnungsstelle KrankenkassePostfach 2340D - 76125 KARLSRUHETel. : (49) 7247 951.534Fax : (49) 7247 22696Anträge auf Kostenübernahme : Tel : (49) 7247 951.534
ANNEX 3
REGULARIZATION OF DAYS' LEAVE NOT TAKEN OR TAKEN IN EXCESSON TERMINATION OF SERVICE
This form must be filled in and returned to:
For Brussels : PMO/2“Salaries, mission expenses, experts' expenses”
SC11 4/28
For Luxembourg : Mrs Garavelli – JMO A1/108
For Ispra : CCR Ispra
Pension No ...................................................
would like to be issued with a pensioner's pass.
He/she encloses with this request :
- a recent photograph AND
- a photocopy of his/her identity card or passport.
.........................................
Date
.........................................
Signature
Personnel Number: .................
Date of termination of service: ......../......../........
Surname: ................................. Forename: ……………………………
Home address:………………………………………..
………………………………………..
Bank: ………………………………………………..
Bank Address: ………………………………………..…………………………………………
Other references: BLZ (D), bank code (F), sort code (UK), register number (DK),ABI+CAB (I)
Account number : | | | | | | | | | | | | | |
Signature: ………………………..
ANNEX 4
EUROPEAN COMMISSIONDIRECTORATE-GENERALPERSONNEL AND ADMINISTRATION
Brussels, 2002
Dear Retired,
Subject: Request to access the Commission's Intranet
Upon receipt of this form, duly completed and signed by you, the Administration of theCommission will introduce a request for access to the institution's Intranet, IntraComm.
As soon as your request has been processed, you will be sent a user identifier, together withinstructions on how to initiate the connection to the Commission's Intranet. Please, readthese instructions carefully before attempting to connect to IntraComm. A “Help Desk” hasbeen created by the Informatics Directorate in order to facilitate the configuration of yourPC. Once you are connected, navigation through the server is not very complicated.
An “Individual Statement of Acceptance of the access rules” will be sent with the accesscode. Please note that, in signing the present form, you also acknowledge that you have readand undertaken to comply with this statement. The main purpose of these rules is to makeyou aware of the need to treat the user identification you will receive from the Commissionwith appropriate care, so as to protect the Commission against unauthorised access.
Several services are concerned with the attribution of the access codes so that the delay canlast, in several cases, a few weeks. Thanks for your comprehension.
Best wishes from the Administration of the Commission.
Please fill in the data in the slip below and return to:
European Commission
A.I.A.C.E. – “Access Codes”
SC-29 02/04
B – 1049 BRUSSELS
�……………………………………………………………………………………………………………………………………………………
Retired official number
First Name, Initial, Second Name, Third Name
Commission's Administration Visa Retired Official Signature
ANNEX 5
Please return to
European Commission
“Pensioner’s pass”
SC 29 02/04 (Tel.: 02/295.29.60)
B-1049 Brussels
APPLICATION FOR A PENSIONER'S PASS
Mr, Mrs, Ms .........................................................................................................................
(name, forename)
Address: ...............................................................................................................................
(place) (country)
Street ........................................................... No .................................
ANNEX 6
Please return this form, duly completed, signed and dated to :
UNIT PMO/4European Commission
B-28 5/72B - 1049 Brussels
Mr., Mrs,Miss..................................................................................................................................
(name and forename)
Pension N° .................................................
Type of Pension : (*) Institution : (*)
� Retirement � Commission
� Invalidity � Council
� Widow/widower � European Parliament
� Orphan � Court of Justice
� Other � Court of Auditors
(early retirement, Art. 50, etc.) � Economic and Social Committee
� Other (please specify)
wishes to receive regularly the "Commission en direct" (1).
Observations :
Date .............................................
Signature ......................................
_______________________________________________________________________* Please put a cross in the corresponding boxes.(1) If you would like access to Intranet, you should know that the content of the newsletteris accessible on-line so you would not therefore need to return your subscription form.
ANNEX 8
A RENVOYER A : TO SEND TO :Secrétariat de l’A.I.A.C.E. A.I.A.C.E. SecretariatCommission européenne European CommissionSC-29 02/04 SC-29 02/04B – 1049 BRUXELLES B – 1049 BRUSSELS
ASSOCIATION INTERNATIONALE DES ANCIENS DESCOMMUNAUTES EUROPEENNES
INTERNATIONAL ASSOCIATION OF FORMER OFFICIALSOF THE EUROPEAN COMMUNITIES
DEMANDE D’ADHESION / MEMBERSHIP APPLICATION
Nom et Prénom (+ Nom de jeune fille pour les femmes mariées) :Name and Forename (+ maiden name where applicable) :
…………………………………………………………………………………………..
N° de pension/Pension Nr :..…………………………………………………………….
Nationalité/Nationality :………………………………………………………………….
Date de naissance/Date of birth : ………………………………………………………..
Sexe/Sex : M � F �
Domicile (adresse complète)/Full home address :
Rue/Street……………………………………………………………n°/nr…………….
Code postal/Post code : ………………………………… Localité/Town :……………..
Téléphone/Telephone :…………………………………………………………………..
Dernière fonction occupée aux Communautés/Last post held with the Communities :
…………………………………………………………………………………………..
Période de service/Period of service :
Du/From ……………………………………… au/to…………………………………..
Institution : ……………………………………………………………………………..
Demande à adhérer à l’A.I.A.C.E. Section : ……………………………………………I hereby apply for membership of the A.I.A.C.E. Branch : …………………………….
Fait à/Place …………………………………………. Date ………..………………….
SIGNATURE :
ANNEX 9
The EUROPEAN COMMISSIONDIRECTORATE-GENERALPERSONNEL AND ADMINISTRATION
PLEASE PRINT
Please send back to [email protected] Belliard 28 - B28 1/126B - 1049 Brussels
TO FILL IN AND MAIL ONLY IF YOU DECIDE TO WORK AFTERDEPARTURE FROM THE COMMISSION
Activity statement after departure from the CommissionArticle 16 of the Staff Regulations
The former official or servantName:
First name:
Personal No.: Category/grade/step:
Date of departure from the Commission:
Address:
Telephone: Fax:
E-mail:
Do you - or will you - receive a pecuniary benefit from the Commission since - orafter - your departure? If so, of which type?
In which DGs in the Commission, in the last three years, have you beenemployed?
New activityName of the organisation:
Address:
Telephone: Fax:
E-mail:
Type of activity of the organisation:
Does the organisation receive funds from the European Commission?
Position in the organisation:
Description of your activity:
Foreseen duration of your activity:
Will you receive remuneration?
Links with your former activities in the Commission:
Other useful information:
Done at on the
Signature
You can attach any document that you consider useful to support thecompatibility of your new activities or functions with the activities that you had inthe Commission.
