-
The Pension Service
Tyneview Park
Newcast[e. u pon Tyne
ENGLAND NE98 lBA
Department
for Work &
Pensions
If yo u get in touch with us, please tell us this reference number
Ifyou are outside the Únited Kingdom the dialling code is +44191
Ifyou are in the United Kingdom the dialling code is 0191
Ou r phone number is -----------~
or (dialling code) 21
( (dialling code) 21
Our fax number is '
( (dialling code) 21 •
Date
(
1
1
Textphone users wit h
speech or hearing
difficulties call
(dialling code) 21 87280
We need more information
• Part 1 About your late spoÚse or civil partner
Please read and answer all the question. We use spouse to inean your husband or wife.
Did your late spouse or civil partner contribute
to a social security scheme of one of the
countries listed at Part 2, question 3, other
than the United Klngdom (UK)?
Did your late spouse or civil partner complete
military service in the torces of a country listed
at Part 2, question 3, other than the UK?
Did your late spouse or civil partner pay taxes
while living in Denmark, Finland, Iceland,
Liechtenstein, the Netherlands, Norway or
Sweden?
No
O
YesO Answer the questions in Parts 2, 3 and 4
that apply to you . Then sign and date Part S
Declaration and send the form back to us.
If we hove sent yo u form CF-N-484 you
must also fill it in and send it back to us.
No
O
YesO Answer the questions in Parts 2, 3 and 4
that apply to you . Then sign and date Part S
Declaration and send the form back to us.
If we hove sent you form CF-N-484 you
must also fill it in and send it back to us.
No
O
YesO Answer the questions in Parts 2, 3 and 4
that apply to you . Then sign and date Part S
Declaration and send the form back to us.
If we hove sent yo u form CF-N-484 yo u
must also fill it in and send it back to us.
Please note - If you hove answered Noto all the questions in Part 1 you need only
sign and date Part S Declaration. Then send the form back to us.
·
"
• Part 2 About your late spouse or civil partner
l. Tell us, in capitalletters,
1
their full name
Doy
1
their date of birth
their place of birth
town
country
Month
1
l
1
their place of death
town
country
If they were bórn in ltaly, France
or Spain tell us the Province,
Department and County
)
1
1
Doy
their date of death
Year
Month
1
Year
1
1
1
1
-·1
Province
Department .
_
County ---- - - -- - - - - - - - -- - - ----1
-------------------------------~
If they were born in Portugal
tell us the District, Parish and
Local Authority
District
Parish
~-==================================~
Losa! Aut.hority . •..
2. Was their death caused by a third party?
No
Ves
o
o
' 3. Were they a national of a country where
European Union Regulations apply?
No
Ves
o
o
Austria
Belgium
Bulgaria
Croatia
Cyprus
Czech
Republic
Denmark
Estonia
Finland
France
Germany
tell us the country
o
o
o
o
o
o
o
o
o
o
o
Netherlands
Latvia
o
o
o
o
o
o
o
Liechtenstein
O
Spain
Lithuania
o
o
o
Sweden
Gibraltar
Greece
Hungary
Iceland
lreland
Italy
Luxembourg
Malta
Norway
Poland
Portugal
Romanía
Slovakia
Slovenia
Switzerland
United
Kinadom
o
o
o
o
o
o
o
o
o
o
o
If they were not-a national of one of the
countries listed tell us
their nationality
Had they ever been a national of one of
the countries listed?
·-~----------------'------'
O
O
No
Ves
If Ves what was their nationality and the
period covered
nationality
I_.._________. . ;. _________,:___
--J
Doy
period
4.
Did they have a Belgian identity card?
Month
.•____
! _ _! _
No
Ves
O
O
Year
__,] to
Doy
Month
Year
l____l _ _! _
__,
If Ves send it with this form
Belgian identity card is
O
O
5.
Did th~y ever live in Finland, lceland or
Norway?
No
O
Ves
O
.sent with this form
not sent with this form
If Ves tell us the last address they had
there
address
1
6.
Did they ever live in Denmark?
No
Ves
O
O
If Ves tell us the last address they had
there and their Danish CentraiPensions
Register number (if you know Ít)
address
Central Pensions Register number
7.
Did they ever live in lreland?
1
1
No
O
Ves
O
If Ves tell us their lrish DSFA and PRSI
numbers. If yo u do not know either you
must fill in form CF-N-484 which we hove
sent you.
DSFA number
1_.._______________,;. . ____
PRSinumber
•----------------------------------~
--J
8.
Were they a Spañish national?
DNinumber
9.
Were they a French national who had been
insured in France, or a Spanish national
who had been insured in Spain?
No
O
Ves
O
If Ves tell us their identity card nurnber
(DNI number). If they did not hove an
identity card write "NONE".
·-----------------------------------~
No
Ves
O
O
If Ves tell us the na mes of both their
parents
Mother
surname or family name
firstnames
·-~--------------------J
·-~---------------------J
Father
surname or family name
··~-----------------___,)
firstnames
·-~-----------------___,)
10. Were they getting a pension or benefit
from any of the count~ies listed at Part 2,
question 3 when:
. they married or formed a civil partnership?
they died?
No
No
o
o
o
o
Ves
Ves
If the answer to either question is Ves tell us:
the country paying the pension or benefit
the na me of the pension or benefit
the pension or benefit reference number
the na me and address of the institution
that paid them
na me
address
11. Had they been married or formed a civil
1
1
1
1
l
1
No
o
o
partnership before, if so did they live in
the Netherlands at any lime during the
marriage or civil partnership?
Ves
t he dqte the marriage or civil partnership
ended
1
1
how the marriage or civil partnership ended
O
death
If Ves tell us
Doy
Month
Year
1
O
divorce or dissolution
O
annulment
the na me of this previous spouse or
civil partner and their SOFI number
surname or family name (,..___ __ _ _~_ _ _ _ __ _ _ _____;__ ___,J)
first names
~--------------------------------~)
12. If your late spouse or dvil partner had
been insured or ever lived in one of the
countries listed below tell us the
information that applies to them.
Finnish population register number
Swedish personal number
Icelandic personal identification number
(kennitala)
Liechtenstein AHV - insurance number
Norwegian personal identification number
(f0dselsummer)
Czech Republic birth number
Estonian personal identification number in
population register
Hungarian tax payer's number
Latvian identification number
1
1
1
1
1
1
1
1
1
Lithuanian personal identification number
and state social insurance certificate serial
number
1
Maltese identity card number - for Maltese
nationals (6 or 7 digit number + letter M, G,
P, A, or L) or social security number (6 or 8
digit number preceded by A, B, C, or D)
1
Slovene personal identificat ion number EMSO - for Slovene nationals
Croatian personal identification number (Osobni identifikacijski broj (OIB))
)
).
1
1
• Part 3 About you
l.
Tell us, in capitalletters, your
name before marriage or civil partnership,
if it was different to your current na me
1
Doy
Month
Year
date of birth
place of birth
date of marriage or civil partnership
town ~~--------------~--------------~~~
country -
1
Doy
Month
1
Year
1
place of marriage or civil partnership town ~~------------------------~-------~
count ry _
nationality
1
2.
Are you a Spanish national?
O.
O If Ves tell us your identity card number
No
Ves
(DNI number). If yo u do not hove an
identity card write "NONE").
DNI number • - - - - - - - - - - - - ' - - - - - - - - ' )
3.
Hove you lived in Denmark?
O
O
No
Ves
1------- ------ll
address
CPRnumber
3.
Hove you lived in Portugal?
•---------------------~----------~
O
O
No
Ves
Tax number
4.
Hove you been resident in the
Netherlands?
If Ves tell us your last address there
and your Central Persons Register
(CPR) number
·-~------------------J
' No
Ves
address
If Ves tell us your tax number
O
O
If Ves tell us your last address there and
your SOFI number
1•-----------------l
SOFinumber •------------------------------------'
S.
6.
If you hove been insured, or lived, in
Finland what language do you want the
decision on your Finnish pension to be
sent to you in.
O
O
O
Hove you lived in Finland, lceland or
Norway?
No
Finnish
Swedish
English
Ves
O
O
If Ves tell us your last address there
------~----------1
addressl•-:-.
7.
Hove you claimed, or are you getting,
benefit from any of the countries listed at
Part 2, question 3, other than the UK?
No
o
Ves O ~ If Ves tell us
1
1
the na me of the pension or benefit
the pension or benefit number
the na me and address of the institution
paying the pension or benefit
na me
address
1
)
1
Month
Doy
8.
the date payment started (if this applies)
1
If you are awarded a foreign pension, do
you want to hove it paid to your UK bank
account or a bank account in another
country?
No
O
Ves
O
Na me of bank
1
Year
1
If Ves give bank account details
1
.)
~==========~========~
Addressl
- -- - - - - ' ------,--'------]
Bank Identification code number
Name of account
International Bank Account Number (IBAN)
9.
If you hove been insured in Greece
or ltaly, do you want your foreign
pension paid to someone else
there?
1
)
~====================~)·
1
~====================~)
1
No
Ves
na me
address
O
O
1
1
If Ves tell us their
e-
l
No
10. Do you have any other income?
Ves
o
o
This information is needed by the
foreign authorities
so urce
amount
11. Were you completely dependent on your
late spouse or civil partner?
11
No
Ves
12. If you have been insured in. Austria,
Germany or Liechtenstein do you have
a legal representative in the UK?
No
Ves
na me
address
13. Are you employed?
If Ves, and your late spouse or civil
partner was either insured in France,
Italy or lived in Denmark, tell us the
source of your income and yearly amount
o
o
O
O
If Ves tell us their
1
1
l
No
O ·
Ves
O
If Ve.s tell us if yo u work for an employer
or are you self-employed
O
Employed
Ves
O
O
If Ves tell us
will you be unfit for work for at least 3
months?
No
O
Ves
O
are you permanently unfit for work?
No
O
Ves
O
do you need someone to look after you all
of the time?
No
O
O
14. Are you unfit for vvork?
No
na me
address
Ves
1
1
O
Self-employed
If Ves and you r late spouse or civil
partner wa s insured in Portugal tell us
t he na me and address of t he person who
looks after you
• Part 4 About your children
l.
Have you any children under age 28
or an invalid child of any age? If you
are claiming a French benefit list all
, children, regardless of their age.
No
Ves
surname or family name
first
name~
nationality
date of birth
surname or family name
first names
nationality
date of birth
surname or family name
first names
nationality
1
1
1
1
1
1
1
o
o
If Ves tell us their
.
Doy
Month
1
1
Month
1
2.
Tell us the address of any child
named above who·does not live
with you
na me
address
na me
address
3.
Are any of your children getting an
orphan's pension from a country listed
at Part 2 question 3, except the UK?
their full na me
the na me of the country
t he institution paying the pension
the pension number
Year
1
1
1
Doy
date-of birth
1
1
Doy
Year
1
Month
1
Year
1
1
1
1
1
No
Ves
1
1
1
1
o
o
If Ves tell us
4.
ls any country listed at Part 2, question 3,
other than the UK, paying a Family
Allowance for any of your children?
S.
Ves
their full name
1
the na me of the country
1
1
the institution paying the allowance
o
o
No
the reference number
1
the amount being paid
1
If Ves tell us
Tell us the full name of any child who
is married or has formed a civil partnership
is a student
is an apprentice
is not a national of a country listed at Part 2,
question 3
is getting an lncapacity Benefit or
Employment and Support Allowance
1
1
1
1
1
If an lncapacity Benefit or Employment and
Support Allowance is being paid, tell us which
office is paying the benefit
na me
1
)
1
l
address
reference number
1
• Part 5 Declaration
1 understand that if 1 give information that is incorrect or
incomplete action may be token against me.
1 declare
Signature
that the information 1 hove given on this form is
correct and complete.
Date
Doy
1
1
Month
1
Year
1
The Pension Service
Tyneview Park
Newcast[e upon Tyne
ENGLAND NE98 1 BA
Schedule of employments and insurance outside the United Kingdom
---~-------==------ -
Name
Notes:
1.
2:
3.
(1)
- -
IPC Reference No.¡
4.
Fill in this form to show each stage of the insured person's career in all countries outside
the United Kingdom (UK) iricluding the lsle of Mah, whether or not they are countries
where the Europeán Community regulations apply. Please send documentary evidence of
insurance/employment, if yo u have it.
Show the type of work done (salaried worker or self-employed), For example engineer,
salesman, self-employed farmer. Where applicable also military service (country),
professional training. periods without·paid employment (For example housewife,
unemployed, sickness, etc).
Where the' period of employment is in Denmark, Finland, lceland, Liechtenstein,
the Netherlands, Norway or Sweden, column (6) must be filled in to show all periods of
residence.
·
-
Periods
From
-
-
To
(2)
S.
6.
¡
P ·e_ /
~
•
·
(3)
Name and address
of employer
'
1
a. Place and country ofefféctive employment
b. lnsurance lnstitution
c. Registration number (where registration is iil
Denmark, CPR number - see note 3)
d. Type of .insurance (see note 4)
(S)
(4)
J
Show whether compulsory insur~nce, voluntary insurance, optional continued
insurance (applies to certain foreign schemes only) or period uninsured.
Column (7) must only be filled in to show periods of education or training in
Germany. Show the dates in columns (1) and (2) and enter in column (7) the type
of educational or training course and the name and address of the school~ college,
university etc.
lf employed in the mining industry, state the type of mine in which employed and
the substance extracted or produced. Also give a description of the different
activities, showing the periods involved aríd whether they were done on the
surface or underground.
Employment and insurance periods
Type of work (see
notes 2 and 6}
Par! of the Department
for Work and Pensions
Periods of education
and training in
.
Germany (see note S)
a. Type of course
b. Name and address
of educational
institution
Place of residence
during period of work
(see note 3}
(6)
(7)
•
a.
a.
b.
b.
i
c.
d.
-
a.
a.
b.
b.
c.
d.
a.
a.
b.
b.
c.
d.
CF-N-484 08/05
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