2 RENSEIGNEMENTS CONCERNANT L ASSURÉ SI CELUI-CI N EST PAS LE REQUÉRANT INFORMATION CONCERNING THE INSURED PERSON IF OTHER THAN THE APPLICANT

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1 SÉCURITÉ SOCIALE SOCIAL SECURITY ACCORD DU 9 FÉVRIER 1979 ENTRE LA FRANCE ET LE CANADA AGREEMENT OF FEBRUARY 9, 1979 BETWEEN FRANCE AND CANADA Formulaire FORM SE INSTRUCTION D UNE DEMANDE DE PENSION DE PROCESSING OF AN APPLICATION FOR vieillesse (1) an old age pension (1) survivant (1) a survivor s pension (1) Art : XII, XIII, XIV, XVII de l Accord Art. 17 et Art. 18 para. 4 de l Arrangement Administratif Art. XII, XIII, XIV, XVII of the Agreement Art. 17 and Art. 18, para. 4 of the Administrative Arrangement Références du dossier : File references en France :.. au Canada : in France : in Canada : Date du dépôt de la demande : Date of receipt of the application : Date postérieure fixée par le demandeur pour l entrée en jouissance de la pension :... Deffered date of entitlement as requested by the applicant : A A REMPLIR PAR L INSTITUTION D INSTRUCTION TO BE COMPLETED BY THE PROCESSING INSTITUTION 1- RENSEIGNEMENTS CONCERNANT LE REQUÉRANT INFORMATION CONCERNING THE APPLICANT Nom :. Surname Nom de jeune fille : Maiden name : Prénoms :..... Given names Date de naissance :... Lieu de naissance :. Date of birth : Place of birth : Nationalité :... Sexe : M F Nationality : Sex : Etat Civil : célibataire marié(e) (date du mariage). Marital Status : single married (date of marriage) divorcé(e) (date du divorce)... divorced (date of divorce) séparé(e) separated veuf(ve) widow(er) Adresse à la date de la demande : Address at the date of application : N d immatriculation en France :... Registration N in France : N d assurance sociale au Canada :.. Social Insurance N in Canada :

2 2 RENSEIGNEMENTS CONCERNANT L ASSURÉ SI CELUI-CI N EST PAS LE REQUÉRANT INFORMATION CONCERNING THE INSURED PERSON IF OTHER THAN THE APPLICANT Nom : Prénoms :. Surname : Given names : Nom de jeune fille :... Maiden name : Date de naissance :. Lieu de naissance :.. Date of birth : Place of birth Nationalité :... Sexe : M F Nationality : Sex : Date du décès :.. Date of death : N d immatriculation en France :... Registration N in France : N d assurance sociale au Canada :... Social Insurance N in Canada : Adresse à la date du décès :... Address at the date of death : 3 - PÉRIODES D ASSURANCE, PÉRIODES ÉQUIVALENTES OU PÉRIODES DE RÉSIDENCE ACCOMPLIES DANS LE PAYS DE L INSTITUTION D INSTRUCTION DE LA DEMANDE INSURANCE PERIODS, EQUIVALENT PERIODS OR PERIODS OF RESIDENCE CREDITED IN THE COUNTRY WHERE THE APPLICATION IS BEING PROCESSED d assurance périodes assimilées ou périodes de résidence assimilated periods or periods of residence d assurance assimilées (1) assimilated or résidence (1) résidence periods(1) Régime Scheme Profession Occupation Année Year du from au to Durée totale d assurance :.. Total periods of insurance : OBSERVATIONS : COMMENTS :

3 4-4.1 L intéressé ouvre droit à pension... (1) The interested person is eligible for a pension (1) au titre de la législation canadienne française under the législation of Canada France au titre des seules périodes d assurance accomplies dans le pays. based solely on insurance periods credited in that country. La pension s élève à :... par trimestre.. par an The amount of the pension is : quarter year à compter du... effective 4.2 L intéressé n ouvre pas droit à pension.. (1) The interested person is not entitled to a pension (1) au titre des seules périodes d assurance accomplies au Canada en France based solely on insurance periods credited in Canada in France Il y a lieu d effectuer une totalisation de périodes d assurance. Totalization of insurance periods is required. 5 - INDICATION SUR L ACTIVITÉ EXERCÉÉ DANS L AUTRE PAYS INFORMATION ON OCCUPATIONS IN THE OTHER COUNTRY Noms et adresses des employeurs Names and addresses of employers Dates des emplois Dates of employment. Date :.. Cachet de l institution Signature : Official Stamp of the Institution Signature :

4 B - A REMPLIR PAR L INSTITUTION DU SECOND PAYS TO BE COMPLETED BY THE INSTITUTION OF THE OTHER COUNTRY 6 - PÉRIODES D ASSURANCE, PÉRIODES ÉQUIVALENTES OU PÉRIODES DE RÉSIDENCE ACCOMPLIES DANS LE SECOND PAYS INSURANCE PERIODS, EQUIVALENT PERIODS OR PERIODS OF RESIDENCE CREDITED IN THE OTHER COUNTRY d assurance périodes assimilées ou périodes de résidence assimilated periods or periods of residence d assurance assimilées (1) assimilated or résidence (1) résidence periods (1) Régimes Schemes Profession Occupation Année Year du from au to Durée totale d assurance : Total periods of insurance : OBSERVATIONS : COMMENTS L institution française canadienne, ci-dessous désignée : The French Canadian institution, indicated below : Dénomination :... Name : Adresse :... Adress : 7 - informe l institution d instruction que : (1) advises that the interested person is eligible for a : (1) 7.1 L intéressé ouvre droit à pension... au titre de la législation qu elle applique, compte tenu des seules périodes accomplies sous ladite législation. under that legislation. pension under the applicable legislation, based solely on periods credited La pension s élève à :... par trimestre... par an The amount of the pension is : quarter year à compter du :... effective :

5 7.2 L intéressé ouvre droit à pension... par totalisation des périodes d assurance accomplies dans les deux pays. The interested person is eligible for a credited in both countries. La fraction de pension à charge de l institution s élève à : The portion of the pension paid by the institution amounts to : pension as a result of the totalization of insurance periods.... par trimestre par an quarter year à compter du : effective : 8 - VOIES ET DÉLAIS DE RECOURS PROCÉDURE AND TIME LIMITS FOR APPEALS Voies de recours mises à la disposition du demandeur : Appeal procedure available to the applicant : Délais à l expiration desquels le recours ne sera plus recevable :... Deadline for an appeal : Date : Cachet de l institution Signature : Official Stamp of the Institution Signature : (1) Cocher la case appropriée (1) Cross out item that does not apply

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