DECISION No 199

of 13 October 2004

on model forms necessary for the application of Council Regulations (EEC) No 1408/71 and (EEC) No 574/72 (E 300 series)

(Text with EEA relevance and for the EU/Switzerland Agreement)

(2005/204/EC)

THE ADMINISTRATIVE COMMISSION ON SOCIAL SECURITY FOR MIGRANT WORKERS,

Having regard to Article 81(a) of Regulation (EEC) No 1408/71 of the Council of 14 June 1971 on the application of social security schemes to employed persons, to self-employed persons and to members of their families moving within the Community (1), 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 Regulation (EEC) No 574/72 of the Council of 21 March 1972 fixing the procedure for implementing Regulation (EEC) No 1408/71 on the application of social security schemes to employed persons and their families moving within the Community (2), under which it is the duty of the Administrative Commission to draw up models of documents necessary for the application of Regulations (EEC) No 1408/71 and (EEC) No 574/72,

Having regard to Decision No 154 of 8 February 1994 on the model forms necessary for the application of Council Regulations (EEC) No 1408/71 and (EEC) No 574/72 (E 301, E 302, E 303) (3),

Whereas:

(1) The enlargement of the European Union on 1 May 2004 requires forms E 301, E 302 and E 303 to be amended.

(2) The Agreement on the European Economic Area (EEA Agreement) of 2 May 1992, supplemented 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.

(3) The European Community and its Member States, and the Swiss Confederation have concluded an Agreement on the free movement of persons (Swiss Agreement) which entered into force on 1 June 2002. Annex II to the Agreement refers to Regulations (EEC) No 1408/71 and (EEC) No 574/72.

(4) For practical reasons, the forms used in the European Union and under the EEA and Swiss Agreements should be identical,

HAS DECIDED AS FOLLOWS:

The model forms E 301, E 302 and E 303 reproduced in Decision No 154 are replaced by the models appended hereto.

The competent authorities of the Member States shall make available to the parties concerned (rightful claimants, institutions, employers, etc.) the forms according to the models appended hereto.

These forms shall be available in the official languages of the Community and laid out in such manner that the different versions are perfectly superposable, thereby making it possible for all addressees (rightful claimants, institutions, employers, etc.) to receive the form printed in their own language.

This Decision, which replaces Decision No 154, shall be published in the

Official Journal of the European Union

. It shall be applicable from the first day of the month following its publication.

The Chairman

of the Administrative Commission

C.J. VAN DEN BERG

(1)

OJ L 149, 5.7.1971, p. 2

. Regulation last amended by Regulation (EC) No 631/2004 of the European Parliament and of the Council (

OJ L 100, 6.4.2004, p. 1

(2)

OJ L 74, 27.3.1972, p. 1

. Regulation last amended by Regulation (EC) No 631/2004 of the European Parliament and of the Council.

(3)

OJ L 244, 19.9.1994, p. 123

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THE ADMINISTRATIVE COMMISSION ON SOCIAL SECURITY FOR MIGRANT WORKERS

See ‘instructions’ on page 3

E 301

(1) CERTIFICATE CONCERNING THE PERIODS TO BE TAKEN INTO ACCOUNT FOR THE GRANTING OF UNEMPLOYMENT BENEFITS

Reg. 1408/71: Art. 67, Art. 68; Art. 71.1.a.ii, Art. 71.1.b.ii

Reg. 574/72: Art. 80; Art. 81; Art. 84.2

To be issued by the competent unemployment institution or the institution designated by the competent authority of the country where the unemployed person was previously insured. To be handed over to the person concerned or sent to the competent institution.

Employed person

1.1

Surname (1a) …

1.2

Forenames …

Previous names (1a) (1b) …

Date of birth …

1.3

Place of birth (2) …

Nationality …

D.N.I. (3) …

1.4

Address of the worker in the State to which the certificate is being sent (4) (14) …

1.5

Identification No (4) (5) …

1.6

Trade Union/Unemployment fund (6) …

The insured person named above completed the following periods in the course of

2.1

the year (7)

the two years (7)

the three years (7)

more than three years (7)

the four years (7)

preceding the end of his last employment

Periods of insurance relating to paid employment and periods treated as such

(8) 3.1

Periods of insurance

from

3.2

Periods treated as periods of insurance

from

Reason for treating as such (9)

Periods of employment and periods treated as such

(8) (8a)

4.1

Periods of employment

from

Occupation (10)

4.2

Periods treated as periods of employment

from

Reason for treating as such (9)

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E 301

Details of last employment (Article 68 1, second sentence)

Field of activity

Nature of work carried out (11) (e.g. ‘bricklayer’ not ‘building worker’)

Approximate wage per reference period (15)

5.1

Reason for termination

dismissal (11a)

resignation

expiry of contract

termination of contract by mutual consent

other …

The person concerned

6.1

has received or has still to receive wages for the period following termination of work, up to …

6.2

has received or has still to receive, on termination of work, compensation or other similar payment, amounting to …

6.3

has received or has still to receive payment in lieu of annual leave, amounting to … for … days (12)

6.4

has waived the following rights he enjoys under his contract of employment (13) …

Reason …

6.5

is in receipt of other benefits

Since the commencement of last employment in item 5 the person concerned received unemployment benefits

from

The person concerned is entitled to benefits under Art. 69 of Reg. 1408/71

(E 303 certificate from … to … drawn up on …)

The person concerned is not entitled to receive benefits under Art. 69 of Reg. 1408/71

9.1

because there is no entitlement under the legislation administered by the institution issuing this certificate

9.2

because he has not remained available to the employment services of the competent country for a period of four weeks from the day on which he became unemployed and because he was not authorized to leave that country before the end of that period

The person concerned is not entitled to benefits under Art. 71.1.a.i or Art. 71.1.b.i of Reg. 1408/71 from the institution issuing this certificate

10a

The person concerned is not entitled to Swiss unemployment insurance benefits in accordance with point I.I of the Protocol to Annex II to the EU/Switzerland Agreement on free movement of persons

Institution issuing the certificate

11.1

Name …

11.2

Address (14) …

11.3

Stamp

11.4

Date …

11.5

Signature …

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E 301

INSTRUCTIONS

Please complete this form in block letters, writing on the dotted lines only. It consists of three pages, none of which may be left out even if it does not contain any relevant information.

NOTES

(1) Symbol of the country in which the institution completing the form is situated: BE = Belgium; CZ = Czech Republic; DK = Denmark; DE = Germany; EE = Estonia; GR = Greece; ES = Spain; FR = France; IE = Ireland; IT = Italy; CY = Cyprus; LV = Latvia; LT = Lithuania; LU = Luxembourg; HU = Hungary; MT = Malta; NL = The Netherlands; AT = Austria; PL = Poland; PT = Portugal; SI = Slovenia; SK = Slovakia; FI = Finland; SE = Sweden; UK = United Kingdom; IS = Iceland; LI = Liechtenstein; NO = Norway; CH = Switzerland.

(1a) In the case of Spanish nationals state both names.

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.

(1b) Previous names include surname at birth.

(2) In the case of Portuguese districts, state also the parish and the local authority.

(3) In the case of Spanish nationals, state the number appearing on the national identity card (D.N.I.), if it exists, even if the identity card is out of date. Failing this, state ‘None’. For Slovenian citizens, state the tax number. In the case of Maltese nationals state the Identity Card number. For the purposes of Maltese Institutions, if not a Maltese national, state the Maltese social security number. In the case of Polish nationals, state the number of identity card or passport.

(4) If this is known.

(5) When the form is being sent to a Cypriot institution give the social insurance number, to a Czech, Danish, Estonian, Austrian, Finnish, Slovenian, Slovak or Swedish institution, give the personal identification number, to a Netherlands institution give the Sofi number, to a Polish institution give the PESEL and NIP numbers. When the form is being sent to a French institution, please give the Social Security Number (NIR). When the form is to be sent to a Belgian Institution, please give the Social Security Identification Number (INSZ-NISS)

(6) To be completed, if possible, only when the certificate is requested by a worker before departure to Estonia, Denmark, Finland, Iceland or Sweden and where the worker has been previously insured in one of those countries.

(7) One year

if the certificate is to be sent to a Luxembourg institution.

Two years

if it is to be sent to an Italian, Icelandic, Liechtenstein, or Swiss institution. Italy may also request information on the complete insurance periods abroad of the person concerned. For the purposes of Swiss institutions, four years in the case of child education or self-employment of short duration.

Three years

if it is to be sent to a Belgian, Danish, French, Greek, Irish, Portuguese or United Kingdom institution.

More than three years

if the certificate is to be sent to a Finnish (20 years), Spanish (6 years), German (7 years), Austrian (10, 15 or 25 years), Hungarian and Slovak (4 years), Swedish (8 years),

Estonian, Czech,

Cypriot,

Latvian,

Netherlands, Slovenian or Maltese institution (total insurance history). In some cases the Belgian institution requires information on the complete insurance periods. If necessary, as regards workers aged 52 or over, the Spanish institution may require information on supplementary periods preceding the last six years.

The last ended calendar year or the three last ended calendar years

if the form is to be sent to a Norwegian institution.

(8) If a breakdown of the details requested in items 3.1, 3.2, 4.1 and 4.2 is not available, state the total number of periods of insurance in item 3.1 or 4.1, as the case may be. Items 3.1 and 4.1 must be completed even if the periods overlap. It must be completed if sent to a Hungarian institution.

(8a) Periods of employment is to be understood as periods of employment only when these did not lead to unemployment insurance under the legislation of the State concerned.

(9) E.g. sickness, maternity, accident at work, military service, vocational training, recorded unemployment.

(10) State also the number of hours worked during these periods if known.

(11) Specify whether it is a seasonal activity. If the certificate is to be sent to a Belgian institution also state the weekly number of hours worked.

(11a) For the purposes of

Estonian, Latvian

and Swiss institutions indicate if the dismissal was caused by default of the person concerned.

(12) To be completed, if the certificate is to be sent to a Belgian, Cypriot, Danish, German, Spanish, French, Italian, Netherlands, Austrian, Liechtenstein, Slovenian, Swiss or Norwegian institution.

(13) To be completed, if the certificate is to be sent to a Belgian, Danish, Italian, Netherlands, Portuguese, Liechtenstein, Slovenian, Swiss or Norwegian institution.

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

(15) For the use of Belgian institutions, state the average gross monthly remuneration. For the use of Polish institutions, state actual remuneration. For the use of Czech and Hungarian institutions, state average net monthly remuneration. For the use of Slovak institutions, state average gross monthly remuneration for the time of duration of the employment.

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THE ADMINISTRATIVE COMMISSION ON SOCIAL SECURITY FOR MIGRANT WORKERS

See ‘instructions’ on page 3

E 302

(1) CERTIFICATE RELATING TO MEMBERS OF THE FAMILY OF AN UNEMPLOYED PERSON WHO MUST BE TAKEN INTO ACCOUNT FOR THE CALCULATION OF BENEFITS

Reg. 1408/71: Art. 68.2

Reg. 574/72: Art. 82

To be issued by the designated institution in the country of residence of the members of the family.

To be handed over to the unemployed person or sent to the competent institution.

Unemployed person

1.1

Surname (1a) …

1.2

Forenames …

Previous names (1a) (1b) …

Date of birth …

1.3

Place of birth (2) …

Nationality …

D.N.I. (3) …

1.4

Identification No (4) (5) …

1.5

Trade Union/Unemployment fund (6) …

Members of the family

Serial No

Surname (1a)

Forenames

Date of birth

Relationship

Place of residence

Where appropriate, income of members of the family (nature and monthly amount, including social benefits)

No (7)

Members of the family

Nature of income

Amount

Until he became unemployed, the unemployed person maintained the members of his family indicated under Serial Nos … aufgekommen.

4.1

The member of the family mentioned under Serial Number … is unable, owing to physical or mental disability, to work for his living (8).

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E 302

4.2

The family supplements for the members of the family mentioned under Serial Nos … have been paid to another person at the same time as unemployment benefits for the period from … to …

4.3

Information required only by United Kingdom and Finnish institutions: with the exception of employment in the United Kingdom and Finland the unemployed person and his/her spouse:

have been living under the same roof

have not been living under the same roof

4.4

This certificate is valid for 12 months from the date of issue

Institution issuing the certificate

5.1

Name …

5.2

Address (9) …

5.3

Stamp

5.4

Date …

5.5

Signature …

Statement from the unemployed person (10)

6.1

The unemployed person named in box 1 declares that the members of his family mentioned under Serial Nos … of box 2

are

are not

taken into consideration for the calculation of unemployment benefits due to another person under United Kingdom legislation

6.2

Date …

6.3

Signature of unemployed person …

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E 302

INSTRUCTIONS

Please complete this form in block letters, writing on the dotted lines only. It consists of three pages, none of which may be left out even if it does not contain any relevant information.

NOTES

(1a) In the case of Spanish nationals state both names.

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.

(1b) Previous names include surname at birth.

(2) In the case of Portuguese districts, state also the parish and the local authority.

(3) In the case of Spanish nationals, state the number appearing on the national identity card (D.N.I.), if it exists, even if the identity card is out of date. Failing this, state ‘None’. For Slovenian citizens state tax number. In the case of Maltese nationals state the Identity Card number. For the purposes of Maltese Institutions, if not a Maltese national, state the Maltese social security number. In the case of Polish nationals, state the number of identity card or passport.

(4) If this is known.

(5) When the form is being sent to an Austrian, Czech, Finnish, Icelandic, Slovenian, Slovak or Swedish institution, please give the personal identification number, to a Polish institution give the PESEL and NIP numbers.

(6) To be completed, if possible, only when the certificate is requested by a worker before departure to Denmark, Finland, Iceland or Sweden and where the worker has been previously insured in one of those countries.

(7) For each member of the family mentioned in this boy, retain the Serial Number shown in box 2.

(8) Complete if the form is to be sent to a Belgian, Cypriot, Greek, Spanish, French, United Kingdom, Austrian, Liechtenstein, Norwegian or Lithuanian institution.

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

(10) To be completed by the unemployed person only where the certificate is issued by a United Kingdom institution.

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THE ADMINISTRATIVE COMMISSION ON SOCIAL SECURITY FOR MIGRANT WORKERS

See ‘instructions’ overleaf

E 303/0

(1) CERTIFICATE CONCERNING RETENTION OF THE RIGHT TO UNEMPLOYMENT BENEFITS

Reg. 1408/71: Art. 69

Reg. 574/72: Art. 26.2; Art. 83.1, 2 and 3; Art. 97

Unemployed person

Identification No (4) (5) …

1.1

Surname (1a) …

1.2

Forenames …

Previous names (1a) (1b) …

Date of birth …

1.3

Place of birth (2) …

Nationality …

D.N.I. (3) …

1.4

Address of the unemployed person in the State to which the certificate is being sent (4) (11) …

1.5

Trade Union/Unemployment fund (6) …

Under the provisions of Art. 69 of Reg. 1408/71, the unemployed person named above is entitled to unemployment benefits from the time he/she registers with the employment services of the country where he/she is seeking employment.

The unemployed person may receive benefits, however, from (date) …, provided that he/she has registered as a person seeking employment at the latest by … with the employment services (7) of the country where he/she is seeking employment. (7a)

3.1

The unemployed person may receive benefits only from …, since, until that date, entitlement to benefits is suspended. (7a)

The unemployed person is entitled to benefits for a period of not more than … days, pursuant to Art. 69 of Reg. 1408/71, provided that the period does not extend beyond (date) …

4.1

The benefits are granted for every day of the week, except

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

The benefits are granted for … days per month.

4.2

Daily amount of unemployment benefits: … net,

which includes an increase for dependants of: … net,

and from (date) … : … net,

which includes an increase for dependants of: … net.

4.3

Weekly amount of unemployment benefits: … net,

and from (date) … : … net.

4.4

Monthly amount of unemployment benefits: … net (7b).

The payment of benefits must be suspended in the following circumstances (Reg. 574/72, Art. 83.1.e and Art. 83.3):

5.1

where the unemployed person has taken up ‘permanent’ gainful employment (8) or becomes self-employed;

5.2

where the unemployed person receives occasional earnings (8a) from an activity other than those mentioned in item 5.1 above (in this case, the payment of benefits must be suspended for the number of days during which the person concerned receives these occasional earnings);

5.3

where the unemployed person refuses an offer of employment or refuses to go for an interview with the employment services;

5.4

where the unemployed person refuses to participate in occupational rehabilitation (9);

5.5

where the unemployed person does not submit or no longer submits to control procedures;

5.6

where the unemployed person is suffering from permanent incapacity for work (10);

5.7

where the unemployed person is suffering from temporary incapacity for work (in this case, the payment of benefits is suspended until re-registration) (10a);

5.8

where the unemployed person is not available to the employment services;

5.9

where there is a decrease in the number of members of the family qualifying for an increase, or when one of these members receives an income referred to on the E 302 form (in this case, the family increase is deducted from the benefit) (10aa);

5.10

when the unemployed person is in receipt of State social security benefit (10b).

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E 303/0

Institution completing the form

6.1

Name …

6.2

Address (11) …

6.3

Stamp

6.4

Date …

6.5

Signature …

INSTRUCTIONS

The competent institution of the last country of employment should complete the relevant sections of the series of E 303/0 to E 303/4 forms; it should keep E 303/0 and send the rest of the series to the unemployed person, including E 303/5, or, if appropriate, send it to the competent unemployment institution in the place where the unemployed person is seeking employment.

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

NOTES

(1) Symbol of the country to which the institution completing the form belongs: BE = Belgium; CZ = Czech Republic; DK = Denmark; DE = Germany; EE = Estonia; GR = Greece; ES = Spain; FR = France; IE = Ireland; IT = Italy; CY = Cyprus; LV = Latvia; LT = Lithuania; LU = Luxembourg; HU = Hungary; MT = Malta; NL = The Netherlands; AT = Austria; PL = Poland; PT = Portugal; SI = Slovenia; SK = Slovakia; FI = Finland; SE = Sweden; UK = United Kingdom; IS = Iceland; LI = Liechtenstein; NO = Norway; CH = Switzerland.

(1a) In the case of Spanish nationals state both names.

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.

(1b) Previous names include surname at birth.

(2) In the case of Portuguese districts, state also the parish and the local authority.

(3) In the case of Spanish nationals state the number appearing on the national identity card (D.N.I.), if it exists, even if the card is out of date. Failing this, state ‘None’. For Slovenian citizens state the tax number. In the case of Maltese nationals state the Identity Card number. For the purposes of Maltese Institutions, if not a Maltese national, state the Maltese social security number. In the case of Polish nationals, state the number of identity card or passport.

(4) If this is known.

(5) When the form is sent to a Belgian institution, give the Social Security Identification Number (INSZ-NISS), to a Cypriot institution give the social insurance number, to a Czech, Danish, Estonian, Austrian, Finnish, Icelandic, Slovenian, Slovak or Swedish institution, please give the personal identification number, to a Polish institution give the PESEL and NIP numbers.

(6) To be completed, if possible, only when the certificate is requested by a worker before departure to Denmark, Estonia, Finland, Iceland or Sweden and where the worker has been previously insured in one of those countries.

(7) In Estonia, France, Italy, the Netherlands and Portugal, the unemployed person must also submit a claim for benefits to the competent unemployment insurance institution through the placement office. In Belgium the unemployed person must also submit a claim for benefits at the competent unemployment institution through a paying agency.

(7a) Delete as appropriate.

(7b) Delete this line where no monthly amount is provided for in respect of unemployment benefits by the legislation applied by the institution providing the benefits on behalf of the other institution.

(8) Under Italian legislation, permanent employment is any employment of more than five days; under Estonian legislation permanent employment is any employment, under Belgian, Spanish and Dutch legislation, permanent employment is any employment of at least one normal working day; under Greek legislation permanent employment is any employment of at least three working days per week. Under United Kingdom legislation, permanent employment is any employment where earnings reach or exceed the minimum level for liability to pay social security contributions. In Poland, employment-based relationship, labour-based relationship and cottage industry contract are considered to be permanent employment.

(8a) Under United Kingdom legislation, ‘occasional earnings’ are any earnings which do not reach or exceed the minimum level for liability to pay social security contributions. In Poland, undertaking another paid work, non-agricultural activity or to receive income at the amount higher than half of the lowest monthly salary are considered to be ‘irregular incomes’, which result in loss of the right to benefit.

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E 303/0

(9) This situation does not entail suspension of benefits where the certificate is issued by a Danish institution. According to Polish legislation, retention of benefit occurs when the unemployed refuses to accept proposed training or public work without justified reason.

(10) Or when the unemployed person receives an old-age pension, where the certificate is drawn up by a Czech, Slovak, Estonian, German, Luxembourgish, Slovenian or Swiss institution or an invalidity pension where the certificate is drawn up by a French, German, Luxembourgish, Slovenian or Swiss institution or if the unemployed person receives an invalidity pension and at the same time is unable to work full time even under the exceptional conditions, where the certificate is drawn up by a Czech institution. Or when the unemployed person receives an old-age pension, or a partial invalidity pension at higher rate where the certificate is drawn up by a Cypriot institution.

(10a) This situation does not entail the suspension of benefits where the certificate has been issued by an Estonian, Luxembourgish, Slovenian, Polish or Portuguese institution. If the form is issued by a Czech or Slovak institution, the payment of benefits must be suspended only if the person is receiving sickness insurance benefits.

(10aa)

Under Czech, Estonian Hungarian and Slovak law, an unemployed person’s family members are not taken into consideration when benefits are calculated.

(10b) Under Slovak law, it is a parental allowance.

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

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THE ADMINISTRATIVE COMMISSION ON SOCIAL SECURITY FOR MIGRANT WORKERS

See ‘instructions’ overleaf

E 303/1

(1) CERTIFICATE CONCERNING RETENTION OF THE RIGHT TO UNEMPLOYMENT BENEFITS

Reg. 1408/71: Art. 69

Reg. 574/72: Art. 26.2; Art. 83.1, 2 and 3; Art. 97

This copy should be sent to the unemployment insurance institution of the place where the unemployed personis seeking employment. It must be used as the basis for payment of unemployment benefits (Reg. 574/72: Art. 83.1).

Unemployed person

Identification No (4) (5) …

1.1

Surname (1a) …

1.2

Forenames …

Previous names (1a) (1b) …

Date of birth …

1.3

Place of birth (2) …

Nationality …

D.N.I. (3) …

1.4

Address of the unemployed person in the State to which the certificate is being sent (4) (11) …

1.5

Trade Union/Unemployment fund (6) …

3.1

The unemployed person may receive benefits only from …, since, until that date, entitlement to benefits is suspended. (7a)

The unemployed person is entitled to benefits for a period of not more than … days, pursuant to Art. 69 of Reg. 1408/71, provided that the period does not extend beyond (date) …

4.1

The benefits are granted for every day of the week, except

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

The benefits are granted for … days per month.

4.2

Daily amount of unemployment benefits: … net,

which includes an increase for dependants of: … net,

and from (date) … : … net,

which includes an increase for dependants of: … net.

4.3

Weekly amount of unemployment benefits: … net,

and from (date) … : … net.

4.4

Monthly amount of unemployment benefits: … net (7b).

The payment of benefits must be suspended in the following circumstances (Reg. 574/72, Art. 83.1.e and Art. 83.3):

5.1

where the unemployed person has taken up ‘permanent’ gainful employment (8) or becomes self-employed;

5.2

5.3

where the unemployed person refuses an offer of employment or refuses to go for an interview with the employment services;

5.4

where the unemployed person refuses to participate in occupational rehabilitation (9);

5.5

where the unemployed person does not submit or no longer submits to control procedures;

5.6

where the unemployed person is suffering from permanent incapacity for work (10);

5.7

where the unemployed person is suffering from temporary incapacity for work (in this case, the payment of benefits is suspended until re-registration) (10a);

5.8

where the unemployed person is not available to the employment services;

5.9

5.10

when the unemployed person is in receipt of State social security benefit (10b).

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E 303/1

Institution completing the form

6.1

Name …

6.2

Address (11) …

6.3

Stamp

6.4

Date …

6.5

Signature …

INSTRUCTIONS

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

NOTES

(1) Symbol of the country to which the institution completing the form belongs: BE = Belgium; CZ = Czech Republic; DK = Denmark; DE = Germany; EE = Estonia; GR = Greece; ES = Spain; FR = France; IE = Ireland; IT = Italy; CY = Cyprus; LV = Latvia; LT = Lithuania; LU = Luxembourg; HU = Hungary; MT = Malta; NL = The Netherlands; AT = Austria, PL = Poland; PT = Portugal; SI = Slovenia; SK = Slovakia; FI = Finland; SE = Sweden; UK = United Kingdom; IS = Iceland; LI = Liechtenstein; NO = Norway; CH = Switzerland.

(1a) In the case of Spanish nationals state both names.

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.

(1b) Previous names include surname at birth.

(2) In the case of Portuguese districts, state also the parish and the local authority.

(4) If this is known.

(7a) Delete as appropriate.

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E 303/1

(9) This situation does not entail suspension of benefits where the certificate is issued by a Danish institution.

According to Polish legislation, retention of benefit occurs when the unemployed refuses to accept proposed training or public work without justified reason.

(10aa)

Under Czech, Estonian, Hungarian and Slovak law, an unemployed person’s family members are not taken into consideration when benefits are calculated.

(10b) Under Slovak law, it is a parental allowance.

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

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THE ADMINISTRATIVE COMMISSION ON SOCIAL SECURITY FOR MIGRANT WORKERS

See ‘instructions’ on page 3

E 303/2

(1) CERTIFICATE CONCERNING RETENTION OF THE RIGHT TO UNEMPLOYMENT BENEFITS

Reg. 1408/71: Art. 69

Reg. 574/72: Art. 26.2; Art. 83.1, 2 and 3; Art. 97

This copy must be returned to the competent institution as evidence of the registration of the unemployed person and of the commencement of payment of benefits (Reg. 574/72: Art. 83.3).

Unemployed person

Identification No (4) (5) …

1.1

Surname (1a) …

1.2

Forenames …

Previous names (1a) (1b) …

Date of birth …

1.3

Place of birth (2) …

Nationality …

D.N.I. (3) …

1.4

Address of the unemployed person in the State to which the certificate is being sent (4) (11) …

1.5

Trade Union/Unemployment fund (6) …

3.1

The unemployed person may receive benefits only from …, since, until that date, entitlement to benefits is suspended. (7a)

The unemployed person is entitled to benefits for a period of not more than … days, pursuant to Art. 69 of Reg. 1408/71, provided that the period does not extend beyond (date) …

4.1

The benefits are granted for every day of the week, except

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

The benefits are granted for … days per month.

4.2

Daily amount of unemployment benefits: … net,

which includes an increase for dependants of: … net,

and from (date) … : … net,

which includes an increase for dependants of: … net.

4.3

Weekly amount of unemployment benefits: … net,

and from (date) … : … net.

4.4

Monthly amount of unemployment benefits: … net (7b).

The payment of benefits must be suspended in the following circumstances (Reg. 574/72, Art. 83.1.e and Art. 83.3):

5.1

where the unemployed person has taken up ‘permanent’ gainful employment (8) or becomes self-employed;

5.2

5.3

where the unemployed person refuses an offer of employment or refuses to go for an interview with the employment services;

5.4

where the unemployed person refuses to participate in occupational rehabilitation (9);

5.5

where the unemployed person does not submit or no longer submits to control procedures;

5.6

where the unemployed person is suffering from permanent incapacity for work (10);

5.7

where the unemployed person is suffering from temporary incapacity for work (in this case, the payment of benefits is suspended until re-registration) (10a);

5.8

where the unemployed person is not available to the employment services;

5.9

5.10

when the unemployed person is in receipt of State social security benefit (10b).

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E 303/2

Institution completing the form

6.1

Name …

6.2

Address (11) …

To be completed by the institution in the country where the unemployed person is seeking employment

We certify

7.1

that the unemployed person named above registered as seeking employment on … (date)

7.2

and has been receiving unemployment benefits since … (date)

Institution of the country where the unemployed person is seeking employment

8.1

Name …

8.2

Address (11) …

8.3

Stamp

8.4

Date …

8.5

Signature …

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E 303/2

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.

NOTES

(1) Symbol of the country to which the institution completing the form belongs: BE = Belgium; CZ = Czech Republic, DK = Denmark; DE = Germany; EE = Estonia, GR = Greece; ES = Spain; FR = France; IE = Ireland; IT = Italy; CY = Cyprus, LV = Latvia, LT = Lithuania, LU = Luxembourg; HU = Hungary, MT = Malta, NL = The Netherlands; AT = Austria, PL = Poland, PT = Portugal; SI = Slovenia, SK = Slovakia, FI = Finland, SE = Sweden, UK = United Kingdom; ; IS = Iceland; LI = Liechtenstein; NO = Norway; CH = Switzerland.

(1a) In the case of Spanish nationals state both names.

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.

(1b) Previous names include surname at birth.

(2) In the case of Portuguese districts, state also the parish and the local authority.

(4) If this is known.

(5) When the form is sent to a Belgian institution, give the Social Security Identification Number (INSZ-NISS), to a Cypriot institution give the social insurance number, to a Czech, Danish, Estonian, Austrian, Finnish, Icelandic, Slovenian, Slovak or Swedish institution, please give the personal identification number., to a Polish institution give the PESEL and NIP numbers.

(7a) Delete as appropriate.

(10aa)

Under Czech, Estonian, Hungarian and Slovak law, an unemployed person’s family members are not taken into consideration when benefits are calculated.

(10b) Under Slovak law, it is a parental allowance.

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

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THE ADMINISTRATIVE COMMISSION ON SOCIAL SECURITY FOR MIGRANT WORKERS

See ‘instructions’ on page 3

E 303/3

(1) CERTIFICATE CONCERNING RETENTION OF THE RIGHT TO UNEMPLOYMENT BENEFITS

Reg. 1408/71: Art. 69

Reg. 574/72: Art. 26.2; Art. 83.1, 2 and 3; Art. 97

This copy must be sent to the sickness insurance institution of the place where the unemployed person is seeking employment. (Reg. 574/72: Art. 26.2).

Unemployed person

Identification No (4) (5) …

1.1

Surname (1a) …

1.2

Forenames …

Previous names (1a) (1b) …

Date of birth …

1.3

Place of birth (2) …

Nationality …

D.N.I. (3) …

1.4

Address of the unemployed person in the State to which the certificate is being sent (4) (11) …

1.5

Trade Union/Unemployment fund (6) …

3.1

The unemployed person may receive benefits only from …, since, until that date, entitlement to benefits is suspended. (7a)

The unemployed person is entitled to benefits for a period of not more than … days, pursuant to Art. 69 of Reg. 1408/71, provided that the period does not extend beyond (date) …

4.1

The benefits are granted for every day of the week, except

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

The benefits are granted for … days per month.

4.2

Daily amount of unemployment benefits: … net,

which includes an increase for dependants of: … net,

and from (date) … : … net,

which includes an increase for dependants of: … net.

4.3

Weekly amount of unemployment benefits: … net,

and from (date) … : … net.

4.4

Monthly amount of unemployment benefits: … net (7b).

The payment of benefits must be suspended in the following circumstances (Reg. 574/72, Art. 83.1.e and Art. 83.3):

5.1

where the unemployed person has taken up ‘permanent’ gainful employment (8) or becomes self-employed;

5.2

5.3

where the unemployed person refuses an offer of employment or refuses to go for an interview with the employment services;

5.4

where the unemployed person refuses to participate in occupational rehabilitation (9);

5.5

where the unemployed person does not submit or no longer submits to control procedures;

5.6

where the unemployed person is suffering from permanent incapacity for work (10);

5.7

where the unemployed person is suffering from temporary incapacity for work (in this case, the payment of benefits is suspended until re-registration) (10a);

5.8

where the unemployed person is not available to the employment services;

5.9

5.10

when the unemployed person is in receipt of State social security benefit (10b).

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E 303/3

Institution completing the form

6.1

Name …

6.2

Address (11) …

To be completed by the institution in the country where the unemployed person is seeking employment

We certify

7.1

that the unemployed person named above registered as seeking employment on … (date)

7.2

and has been receiving unemployment benefits since … (date)

Institution of the country where the unemployed person is seeking employment

8.1

Name …

8.2

Address (11) …

8.3

Stamp

8.4

Date …

8.5

Signature …

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E 303/3

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.

NOTES

(1) Symbol of the country to which the institution completing the form belongs: BE= Belgium; CZ = Czech Republic; DK = Denmark; DE = Germany; EE = Estonia; GR = Greece; ES = Spain; FR = France; IE = Ireland; IT = Italy; CY = Cyprus; LV = Latvia; LT = Lithuania; LU = Luxembourg; HU = Hungary; MT = Malta; NL = The Netherlands; AT = Austria; PL = Poland; PT = Portugal; SI = Slovenia; SK = Slovakia; FI = Finland; SE = Sweden; UK = United Kingdom; IS = Iceland; LI = Liechtenstein; NO = Norway; CH = Switzerland.

(1a) In the case of Spanish nationals state both names. 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.

(1b) Previous names include surname at birth.

(2) In the case of Portuguese districts, state also the parish and the local authority.

(3) In the case of Spanish nationals state the number appearing on the national identity card (D.N.I.), if it exists, even if the card is out of date. Failing this, state ‘None’. For Slovenian citizens state tax number. In the case of Maltese nationals state the Identity Card number. For the purposes of Maltese Institutions, if not a Maltese national, state the Maltese social security number. In the case of Polish nationals, state the number of identity card or passport.

(4) If this is known.

(7a) Delete as appropriate.

(9) This situation does not entail suspension of benefits where the certificate is issued by a Danish institution.

According to Polish legislation, retention of benefit occurs when the unemployed refuses to accept proposed training or public work without justified reason.

(10aa)

Under Czech, Estonian, Hungarian and Slovak law, an unemployed person’s family members are not taken into consideration when benefits are calculated.

(10b) Under Slovak law, it is a parental allowance.

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

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THE ADMINISTRATIVE COMMISSION ON SOCIAL SECURITY FOR MIGRANT WORKERS

See ‘instructions’ on page 3

E 303/4

(1) CERTIFICATE CONCERNING RETENTION OF THE RIGHT TO UNEMPLOYMENT BENEFITS

Reg. 1408/71: Art. 69

Reg. 574/72: Art. 26.2; Art. 83.1, 2 and 3; Art. 97

This copy must be returned to the competent institution, to serve as the basis for refund of unemployment benefits paid on behalf of that institution (Reg. 574/72: Art. 97).

Unemployed person

Identification No (4) (5) …

1.1

Surname (1a) …

1.2

Forenames …

Previous names (1a) (1b) …

Date of birth …

1.3

Place of birth (2) …

Nationality …

D.N.I. (3) …

1.4

Address of the unemployed person in the State to which the certificate is being sent (4) (11) …

1.5

Trade Union/Unemployment fund (6) …

3.1

The unemployed person may receive benefits only from …, since, until that date, entitlement to benefits is suspended. (7a)

The unemployed person is entitled to benefits for a period of not more than … days, pursuant to Art. 69 of Reg. 1408/71, provided that the period does not extend beyond (date) …

4.1

The benefits are granted for every day of the week, except

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

The benefits are granted for … days per month.

4.2

Daily amount of unemployment benefits: … net,

which includes an increase for dependants of: … net,

and from (date) … : … net,

which includes an increase for dependants of: … net.

4.3

Weekly amount of unemployment benefits: … net,

and from (date) … : … net.

4.4

Monthly amount of unemployment benefits: … net (7b).

The payment of benefits must be suspended in the following circumstances (Reg. 574/72, Art. 83.1.e and Art. 83.3):

5.1

where the unemployed person has taken up ‘permanent’ gainful employment (8) or becomes self-employed;

5.2

5.3

where the unemployed person refuses an offer of employment or refuses to go for an interview with the employment services;

5.4

where the unemployed person refuses to participate in occupational rehabilitation (9);

5.5

where the unemployed person does not submit or no longer submits to control procedures;

5.6

where the unemployed person is suffering from permanent incapacity for work (10);

5.7

where the unemployed person is suffering from temporary incapacity for work (in this case, the payment of benefits is suspended until re-registration) (10a);

5.8

where the unemployed person is not available to the employment services;

5.9

5.10

when the unemployed person is in receipt of State social security benefit (10b).

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E 303/4

Institution completing the form

6.1

Name …

6.2

Address (11) …

To be completed by the institution in the country where the unemployed person is seeking employment

The following sums have been paid to the unemployed person on the basis of this certificate:

Periods to which the payments relate

No of days for which benefits are provided

Date of payment

Rate of exchange

Per diem amount in … (12)

Per diem amount in … (13)

Total payments in … (13)

from

Total

Reason for suspension or stoppage of payments: …

Institution of the country where the unemployed person is seeking employment

8.1

Name …

8.2

Address (11) …

8.3

Stamp

8.4

Date …

8.5

Signature …

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E 303/4

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.

NOTES

(1b) Previous names include surname at birth.

(2) In the case of Portuguese districts, state also the parish and the local authority.

(4) If this is known.

(5) When the form is sent to a Belgian institution, give the Social Security Identification Number (INSZ-NISS), to a Cypriot institution give the social insurance number, to a Czech, Danish, Austrian, Finnish, Icelandic, Slovenian, Slovak or Swedish institution, give the personal identification number, to a Polish institution give the PESEL and NIP numbers.

(7) In France, Italy, the Netherlands and Portugal, the unemployed person must also submit a claim for benefits to the competent unemployment insurance institution through the placement office. In Belgium the unemployed person must also submit a claim for benefits at the competent unemployment institution through a paying agency.

(7a) Delete as appropriate.

(8) Under Italian legislation, permanent employment is any employment of more than five days; under Belgian, Spanish and Dutch legislation, permanent employment is any employment of at least one normal working day; under Greek legislation permanent employment is any employment of at least three working days per week. Under United Kingdom legislation, permanent employment is any employment where earnings reach or exceed the minimum level for liability to pay social security contributions. In Poland, employment-based relationship, labour-based relationship and cottage industry contract are considered to be permanent employment.

(9) This situation does not entail suspension of benefits where the certificate is issued by a Danish institution.

According to Polish legislation, retention of benefit occurs when the unemployed refuses to accept proposed training or public works without justified reason.

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E 303/4

(10) The same applies in case of an old-age pension where the certificate is drawn up by a Czech, Slovak, Estonian, German, Luxembourgish, Slovenian or Swiss institution or an invalidity pension where the certificate is drawn up by a French, German, Luxembourgish, Slovenian or Swiss institution or if the unemployed person receives an invalidity pension and at the same time is unable to work full time even under the exceptional conditions, where the certificate is drawn up by a Czech institution. Or when the unemployed person receives an old-age pension, or a partial invalidity pension at higher rate where the certificate is drawn up by a Cypriot institution.

(10a) This situation does not entail the suspension of benefits where the certificate has been issued by a Luxembourgish, Slovenian, Polish or Portuguese institution. If the form is issued by a Czech or Slovak institution, the payment of benefits must be suspended only if the person is receiving sickness insurance benefits.

(10aa)

Under Czech, Estonian, Hungarian and Slovak law, an unemployed person’s family members are not taken into consideration when benefits are calculated.

(10b) Under Slovak law, it is a parental allowance.

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

(12) Currency of the State issuing the E 303 from.

(13) Currency of the State where the unemployed person is seeking employment.

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THE ADMINISTRATIVE COMMISSION ON SOCIAL SECURITY FOR MIGRANT WORKERS

E 303/5

Information for unemployed persons who intend to go to another Member State to seek employment

Before leaving,

complete all the necessary formalities to ensure that where necessary you will receive sickness and maternity insurance benefits for yourself and for the members of your family, even while you are seeking employment.

Accordingly, you should go to the sickness fund with which you are or were last insured, which will issue European Health Insurance Cards for yourself and for the members of your family. With regard to sickness cash benefits, the sickness fund will give you, on production of an E 303 form which you can obtain from the unemployment insurance institution, an E 119 certificate. In the case of sickness or maternity, you should present this certificate to the sickness fund in the country where you are seeking employment.

On arrival,

in the place where you are seeking employment, you should go to the employment office; in Liechtenstein you must also go to the unemployment insurance office; in Cyprus, Finland Latvia and Malta you must also go to the local office of the social Insurance Institution. These offices are the following:

Belgium: the local offices of the ‘Office national de l'emploi’ ‘Rijksdienst voor arbeidsvoorziening’ (national employment office); In Belgium the unemployment person must submit a claim for benefits at this competent unemployment institution through a paying agency and register as job-seeker in one of the following employment offices VDAB, FOREM, BGDA, ORBEM or ADG;

the Czech Republic: local „úřad práce“ (labour office);

Denmark: the local ‘Arbejdsformidlingskontor’ (labour exchange office);

Estonia: the ‘Tööhõiveamet’ (the local Employment Office);

Germany: the local "Agentur für Arbeit" (agency for employment );

Greece: the local employment office of the ‘Organismos Apascholiseos Ergatikou Dynamikou’, or, where this does not exist, the local office of the IKA;

Hungary: the Local Employment Office in the County centre, except for Pest County where the local office is Vac, and Budapest where the local office is XVI district;

Spain: the "Dirección Provincial del Servicio Publico de Empleo Estatal (Instituto de l'Empleo, INEM);

France: the ‘Agence locale pour l'emploi’ (ANPE) (local employment office);

Ireland: the nearest local office of the Department of Social Welfare;

Italy: the ‘Sezione circoscrizionale per l'impiego’ (local authority employment office) where you must also submit your claim for unemployment benefits;

Cyprus : Public Employment services (any district Labour Office);

Latvia: the "Nodarbinātības valsts aģentūra" (State Employment Agency) and the "Valsts sociālās apdrošināšanas aģentūra" (State Social Insurance Agency). After registration with the local office of the State Employment Agency, the job-seeker must submit forms E 303 to the State Social Insurance Agency to retain the right to unemployment benefit;

Luxembourg: the ‘Administration de l'emploi’ (employment office);

Malta the Employment and Training Corporation, Triq Birzebbugia, Hal Far;

the Netherlands: a local office of CWI ( Centrum voor werk en inkomen);

Poland: the local Voivodship Employment office (WUP);

Portugal: for metropolitan Portugal: the ‘Centro de Emprego’ (Employment Centre) of the place of stay; for Madeira: the ‘Direcção Regional de Emprego’ (Regional Employment Directorate) in Funchal; for the Azores: the ‧Centro de Emprego‧ (Employment Centre) of the place of stay;

the United Kingdom: the local Unemployment Benefit Office of the Employment Service Agency or the Local Social Security Office of the Northern Ireland Social Security Agency as appropriate;

Austria: the ‘regionale Geschäftsstelle des Arbeitsmarktservice’ (local employment office);

Finland: the ‘Työvoimatoimisto’ (employment office) and the local office for Social Insurance Institution;

Iceland: the ‘Atvinnuleysistryggingasjodur’ (the Unemployment Insurance Fund) in Reykjavik;

Liechtenstein: the ‘Amt für Volkswirtschaft’ (Office of National Economy) in Vaduz;

Norway: Arbeidsformidlingen or ‘Arbeidskontoret’ (the local Employment Office);

Sweden: Arbetsförmedlingen (the local Employment Office);

Switzerland: the ‘office régional de placement’ (ORP) (regional employment office – in German ‘Regionales Arbeitsvermittlungszentrum RAV’, in Italian ‘Ufficio regionale di collocamento URC’);

Lithuania: the local offices of the ‘Lietuvos darbo bir ž a’ (Lithuanian Labour Exchange);

the Slovak Republic: after registration with the local office of labour, social affairs and family “úrad práce, sociálnych vecí a rodiny”, the job-seeker must submit form E 303 to the branch of Social Insurance Agency “pobočka Sociálnej poisťovne” to retain the rights to unemployment benefit;

Slovenia: Local Labour Office of the Employment Service of Slovenia.

Hand to the relevant office all the copies of Form E 303 in your possession, with the exception of Form E 303/5, which you should retain. In the case of Denmark, the competent Danish institution always sends the form direct to the institution of the country in which the person concerned in seeking employment. The job-seeker therefore receives only a copy.

Please note the final date, indicated on the E 303, by which you must attend if you still wish to receive unemployment benefits from the moment when you ceased to be registered as seeking employment in the country you are leaving.

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E 303/5

While you are seeking employment

you will be subject to the supervision of the employment services and unemployed insurance bodies just like all other unemployed persons in the area. You must inform the institution to which you gave an E 303 form of any change of circumstances that may affect your entitlement to unemployment benefits; the same applies if you become unfit for work.

Where this change in circumstances may entitle you to increased benefits (e.g. when you get married or in the case of the birth of a child), you may also directly inform the institution which issued you with an E 303 form, attaching the appropriate documents as proof.

If you return to the country in which you were last employed before the deadline indicated in heading 4 of the E 303 form, you continue to enjoy unemployment benefits in accordance with the legislation of that country. You should, however, inform the placement services and the unemployment insurance institution of that country of the periods during which you received unemployment benefits in the country to which you went to seek employment. Before you return to the country in which you were last employed, the unemployment insurance institution should issue you with the certificate on page 3 of this form stating the periods during which you received benefits in the country in which you sought employment.

If you received only a part of these benefits, or none at all, you can appoint a trustworthy person to collect the money owed to you. In the Slovak Republic this is not possible, benefits are received exclusively by the competent person.

If, however, you return after the deadline set in item 4 of the E 303 form, you may lose all entitlement to unemployment benefits.

If your failure to return in time is due to exceptional circumstances, the institution which issued you with an E 303 form may decide to pay you benefits on your return.

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E 303/5

To be completed by the institution of the country where the unemployed person is seeking employment

Unemployed person

Identification No (1b) (1c) …

1.1

Surname (1) …

1.2

Forenames …

Previous names (1) (1a) …

Date of birth …

E 303 dated … issued by the institution

2.1

(name) …

2.2

(address) …

On the basis of the above-mentioned E 303

3.1

unemployment benefit was paid for the following periods:

from …

to …

number of days …

3.2

no unemployment benefit was paid for the following periods:

from …

to …

number of days …

for the following reasons (e.g. end of period; new employment; illness; return to … etc.): …

Institution in the country where the unemployed person is seeking employment

4.1

Name …

4.2

Address …

4.3

Stamp

4.4

Date …

4.5

Signature …

NOTES

(1) In the case of Spanish nationals state both names.

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.

(1a) Previous names includes surname at birth.

(1b) If this is known.

(1c) When the form is being sent to a Czech, Danish, Estonian, Austrian, Finnish, Icelandic, Slovenian, Slovak or Swedish institution please give the personal identification, number, to a Polish institution give the PESEL and NIP numbers. When the form is to be sent to a Belgian institution, please give the Identification Number Social Security (INSZ-NISS).