Information form for payment of child and youth benefits for citizens

Send to
Udbetaling Danmark
Kongens Vænge 8
3400 Hillerød
A. Your information
Family benefits
Information form for
payment of child and
youth benefits for citizens
of EU/EEA countries and
Switzerland
Danish civil registration (CPR) number
Name
Address in Denmark
Postcode and city in Denmark
Foreign address - current or most recent address
Foreign postcode and city
Country
ID number in this country
Citizenship
Telephone number
Please complete the form on the following pages, and enclose the following documentation
Information form – completed and signed
Copy of the child’s birth certificate (not applicable if the child has a Danish birth certificate)
Enclose a copy of your employment contract(s) if you are:
• an employee
• seconded abroad by a public-sector company
• working on a ship
Copy of any decision on social security/A1 form if you are:
• seconded abroad by a private-sector company
• employed as a pilot or cabin crew
• working in several countries
If you work offshore in the Danish part of the North Sea, please enclose the following documentation:
• Your employment certificate
• Confirmation from your employer concerning working periods in Danish waters
• Your international bank account number
• Copy of your passport
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B. Employment details
B1. If you are employed
I am a salaried employee
I am self-employed
I work as a pilot or cabin crew
I work on a ship or offshore
I am a public-sector employee seconded abroad
I am seconded for a private-sector company
Where is the work carried out in practice?
in Denmark
abroad
both in Denmark and abroad
Employer/company details
Name of the company
Central business registration number or RUT (Register of Foreign Service Providers) no.
Company address
Country
Employment/self-employment start date
Employment period (if for a limited period)
Number of working hours per month in Denmark
If you are self-employed, please describe in which sector
If you are self-employed, please describe your work tasks
B2. If you are uemployed
Do you receive other benefits from the Danish state
Yes
No
if yes, please specify
which benefits
Maternaty/paternity benefits
Sick pay
Unemployment benefits
Early retirement pension
Pension
Education grant from the Danish state (SU)
Welfare benefits
Other ___________________________________________
Benefit start date: ___________________________________________
Do you receive one of the above benefits from a country/-ies abroad?
Yes
If yes, please specify which benefits
Benefit start date
No
C. Information about the child
Name
Danish civil reg. (CPR) number or date of birth
Address in Denmark
Postcode and city in Denmark
Foreign address - current or most recent address
Foreign postcode and city
Country
ID number in this country
Child’s gender
Boy
Girl
Custody of the child
Mother
Father
Joint custody
Other
Yes, abroad
Yes, in Denmark
No
Do you live in the same household as the child?
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D. Information about the child’s other parent
Name
Danish civil reg. (CPR) number or date of birth
Address in Denmark
Postcode and city in Denmark
Foreign address - current or most recent address
Foreign postcode and city
Country
ID number in this country
Citizenship
Employment detalis:
Salaried employee or self-employed in ______________________________(specify country)
Recieve unemployment/sickness/maternaty benefits from ______________________(specify country)
Seconded by public-sector or private-sector comoany in _____________________________(specify country)
Recieve pension from ________________________________(specify country)
Not working (e.g. student, work in the home)
Other ______________________________________________
E. Your relationship with the child’s other parent
Married
Cohabitant
Divorced
Other _____________________________
Do not live with the child’s other parent (neither in Denmark nor abroad)
F. Supplementary information about residence and employment in EU/EEA countries, Switzerland, Greenland or the Faroe Islands within the past ten years.
Have you and/or the child’s other parent lived and/or worked in an EU/EEA
country, Switzerland, Greenland or the Faroe Islands within the past ten
years?
Yes
No
If yes, please specify
Your periods of residence and employment:
Country
ID number in this country
Most recent address in this country
Period of residence (year(s), from-to)
Period of employment (year(s), from-to)
Country
ID number in this country
Most recebt address in this country
Period of residence (year(s), from-to)
Period of employment (year(s), from-to)
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Other parent’s periods of residence and employment:
Country
ID numer in this country
Most recent address in this country
Period of residence (year(s), from-to)
Period of employment (year(s), from-to)
Country
ID number in this country
Most recent address in this country
Period of residence (year(s), from-to)
Period of employment (year(s), from-to)
G. Other information
Do you receive family benefits from another EU/EEA country or Switzerland
Yes
No
If yes, please specify:
Country
Foreign authority
Monthly amount
Most recent payment was for (specify month)
File no. of foreign case
Any other information
H. Payment to Nemkonto (automatically assigned personal bank account)
Do you have a NemKonto?
Yes
No
In order for us to be able to pay the money to you, you must set up a NemKonto with your bank.
You can also set up a foreign NemKonto account. See more at www.nemkonto.dk/borger.dk
J. Declaration, consent and signature
I declare that the information I have provided is correct and that I am aware of the following:
•
Date
I am obliged to help procure information in the matter
and notify Udbetaling Danmark immediately of any
changes in the information provided which may affect my entitlement to the benefit.
•
I consent to Udbetaling Danmark obtaining information from employers, unemployment funds, local authorities and other public authorities in Denmark and
abroad.
Signature
Remenber to submit all the necessary documents - see the front page
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Information
Information form
The form must be sent to Udbetaling Danmark so that we
can determine whether your child is entitled to child and
youth benefits from Denmark, or whether you are entitled
to any benefits for your child form another country.
You must provide the information necessary to enable
Udbetaling Danmark to determine which benefit you can
get. If you do not help Udbetaling Danmark by providing
the information we need, your case will be processed on
the basis of the information we have. Potentialle, this may
mean that you will be granted a lower benefit than what
you applied for.
Payouts
If you are entitled to child and youth benefits from Denmark, the benefits will be paid out via your personal bank
account, NemKonto. You must therefore establish a
NemKonto if you do not already have one.
Duty of disclosure
You must notify us immediately of any changes that
have an impact on your right to receive child and youth
benefits, including changes in your og your child’s family
situation. For example, it makes a difference if you move
to another country, or if the child is being maintained by
means of public benefits. You must also let us know if you
get a job in another country or stop working in Denmark.
Repayment
If you provide incorrect information or fail to inform us of
relevant changes, you may be required to repay the child
and youth benefits. If you, through gross negligence or
intentionally, provide incorrect og misleading information,
the courts may impose a fine under section 14 of the
Danish Act on Udbetaling Danmark (Udbetaling Danmark-loven), or you may beliable to a fine or imprisonment
under section 7 of the Danish Child and Youth Benefit Act
(Lov om en børne- og ungeydelse) or under the provisions
set out in the Danish Criminal Code (Straffeloven).
Udbetaling Danmark checks
To check whether you are entitled to a specific benefit,
Udbetaling Danmark may, without your consent, obtain
and correlate necessary non-sensitive personal data from
other public authorities and unemployment funds.
Correlation may take place with data from Udbetaling Danmark’s own registers. If the correlation reveals
information that is necessary for the municipality’s check,
Udbetaling Danmark is required to disclose such information to the municipality. The municipality and Udbetaling
Danmark may, without your consent, exchange information for use in connection with adustments, recalculations,
deductions or setoffs or for performing other types of
follow-up and for checking cases of misuse in relation to
the payment of benefits.
If necessary for processing a case on the repayment of
benefits, Udbetaling Danmark may, without your consent,
obtain information from other authorities, employers,
banks etc.
The municipality has access to a business’s premises in
order to check the wage/salary payments that form the
basis of social or occupational benefits. If, in this context,
the municipality obtains information which is important for
Udbetaling Danmark’s check of wether there has been
any cases of misuse in relation to the payment of benefits,
the municipality must disclose this information to Udbetaling Danmark.
Registration
You have the right to know what information Udbetaling
Danmark has registered about you. You may demand
that we correct any incorrect information.
Further information
If you need further information, you are welcome to contact Udbetaling Danmark. You can also read more about
the child and youth benefits at www.borger.dk/familieydelser.
Legal framework
Sections 10-12 of the Danish Consolidation Act on Legal
Protection and Administration in Social Matters (Lov om
retssikkerhed og administration på det sociale område),
5(5) of the Danish Child and Youth Benefit Act, parts 9
and 10 of the Danish Act on Processing of Personal Data
(Persondataloven) and sections 4-12 of the Danish Act
on Udbetlaing Danmark. Articles 11-16 and Article 68 of
Regulation (EC) 883/2004.
You can find more information at www.retsinfo.dk.
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