- 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 ., rci...óU-ci rci...ciU-ci rci...ciU-ci rci...ciU-ci rci...ciU-ci ró..óU-ci ró...ciU-ci
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