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1 Personnel number Surname, forename or name at birth Date of birth Address Telephone number Landesamt für Besoldung und Versorgung NRW Düsseldorf Status declaration on the verification of social security and additional benefit Please place a cross as applicable. In order to avoid queries and delays, please answer all points. A. Pension insurance number The pension insurance number is of great significance for social security. The pension insurance number is issued by the German pension insurance company (e.g. Bund, Rheinland, Westfalen or Knappschaft-Bahn-See) by sending the social security card. My pension insurance number is 1 If no pension insurance number can be provided: Name at birth: Place of birth: Sex: female male Nationality: 2 B. Health insurance (details on the competent health insurance fund) Prior to the start of the employment, I was insured under statutory health insurance 3 no, with the following insurance fund type of insurance own membership family cover Please note: Please supply us or your office with the certificate of membership of your health insurance fund ( 175 SGB V) within two weeks of the start of the employment. If you are subject to the health insurance obligation and no certificate is received here or by your office within two weeks, the LBV will register you with the health insurance fund with which the last insurance was in place. If no information is made available to the LBV, you will be registered with the health insurance of our choice. I have student health insurance with _ (please attach your certificate of insurance.) 4 5 I am exempted from the sickness insurance obligations. (Please attach certificate of exemption.) Additional for voluntarily insured persons: the employer supplement for voluntary health and nursing insurance pursuant to 257 SGB V and 61 SGB XI can only be made upon submission of a corresponding declaration (the template is available from the LBV) and of certificates of contributions. The one-off supplement may no longer be waived for the duration of the employment, unless a sickness/nursing insurance obligation arises. I have been insured since with a private health insurance fund under a comprehensive health insurance policy. Previously, I was most recently insured with the following statutory health insurance fund: LBV(A)02_SV_2016_07 Page 1 of 6

2 Personnel number 6 On the effective date of 31 December 2002 a) I was an employee (not a public servant) in an employment relationship. b) I received an income above the annual earnings limit for 2012 ( 3375 per month or 40,500 per annum) and was therefore not required to hold insurance with the statutory health insurance fund (if, please attach evidence). 7 c) I held insurance with a private health insurance fund under a comprehensive health insurance policy (if, please attach evidence). C. Nursing insurance In social nursing insurance, a contribution must be collected from insured persons if they are not raising or have not raised children. I have a natural child. Please attach evidence, e.g. birth certificate, certificate of acknowledgement or proof of paternity etc. 8 I have (or have previously) taken a child into my household: a stepchild as evidence, please attach your marriage certificate and the birth certificate of the child and a registration certificate or certificate of common household a foster child as evidence, please attach the birth certificate of the child and a registration certificate or certificate of common household and a certificate of the Youth Welfare Office regarding the fostering. A sibling as evidence, please attach the birth certificate of the child and a registration certificate or certificate, and household. 9 D. Pension insurance For this employment, I am exempted from the statutory pension insurance obligation. Please supply the exemption certificate of the Deutsche Rentenversicherung for this employment relationship. I am a member of an occupational pension or insurance institute no, with (please attach membership certificate) membership/insurance number 10 E. Other employment I am not simultaneously exercising any other non-self-employed employment in Germany or abroad. in an employment relationship under private law. in public service under public law. I am taking unpaid leave (or parental leave) from this employment relationship/public service position., since most likely until gross monthly salary the activity has been carried out since weekly working hours hours, days EUR, if applicable, on a fixed-term basis until In the course of this employment, is there an insurance exemption from the statutory health/nursing insurance?, since I receive supplements for the voluntary health/nursing insurance from another employer. To which health insurance fund does the other employer pay the contributions to the pension/unemployment insurance? LBV(A)02_SV_2016_07 Page 2 of 6

3 Personnel number 11 I am simultaneously carrying out self-employed activities or hold an honorary position in Germany or abroad., since as my main employment as secondary employment I am in receipt of a start-up grant., from until _ I have registered a trade. I employ at least one employee earning more than a minimum income. The weekly hours worked in my self-employed activity (including all preparatory and subsequent work) are hours. Monthly employment income EUR. 12 F. Other income I am in receipt of a pension or have applied for a pension., type of pension: Insurance provider with address Insurance or pension number Health insurance of the pensioner with 13 I am in receipt of a pension or survivor's pension in line with the principles of service law., since 14 the payment is made by (name of office) G. Studies/placement reference/personnel number reason: age limit unfitness for work survivor's pension I am a student., since most likely until The following subjects are selected: I am in the semester (please provide current certificate of study and continue to submit subsequent ones without being requested to do so for the duration of the employment. The certificate of study must show the subject of study, the semester and target graduation time). I hope to graduate on: I have already a university examination., on in the subject: type of degree You must immediately notify us when your study comes to an end as a result of passing your examinations (submission of the examination certificate, you may obscure your grades if you wish). 15 I am taking leave from my studies., since 16 I am a placement student., since most likely until Is this a practical professional activity required by the study or examination regulations? (please include certificate of studies and extract from the study or examination regulations) 17 I am in receipt of payment as a placement student., since in the amount of EUR per month weekly working hours hours over _days per week LBV(A)02_SV_2016_07 Page 3 of 6

4 Personnel number H. Unemployment I am/have been in receipt of payments from the Agentur für Arbeit in the course of this calendar year or have registered as a jobseeker., from until competent Agentur für Arbeit master number Please attach the approval document of the Agentur für Arbeit (you may obscure the amount information if you wish). I. School education Before taking up the employment, I was at school. (please attach school certificate) After the end of the employment, - I will continue my schooling., class - I will continue/begin University., semester - I will begin an apprenticeship., apprenticeship for Please attach certificates or other supporting documents (e.g. school or study certificate, apprenticeship contract). 20 J. Additional old-age and survivor's pension (VBL or other supplemental pension organisation) I was previously insured with the Versorgungsanstalt des Bundes und der Länder (VBL) or another supplemental pension organisation., with insurance Have contributions from a previous supplemental pension scheme been reimbursed? 21 I am exempted from the requirement to hold supplemental pension insurance. (please attach certificate of exemption) number. Weiter mit Seite 5 LBV(A)02_SV_2016_07 Page 4 of 6

5 LBV-Personalnummer K. For low-earning employees In social insurance, certain employment situations must be carefully examined. These are a) low-paid employment, in which the regular monthly income does not exceed the level of (annual one-off payments are taken into account proportionately); b) employment within an income-related transition zone, in which the regular monthly income is between and ; c) short-term employment, which - irrespective of the level of income - is limited to no more than three months or 70 working days per calendar year; For low-earning employees ( mini-jobbers) 22 I am simultaneously in low-paid employment in Germany or abroad., since, if applicable, until level of gross monthly salary this is a low-paid employment position with pension insurance co-payment without pension insurance co-payment If more than one low-paid position is held, these will be combined to calculate the social insurance obligation 23 Declaration Should my employment be assessed as low-paid employment, I shall apply for pension insurance exemption. tes on applying for pension insurance exemption: The employer pays fixed amounts. Once pension insurance exemption has been applied for, this cannot be revoked. The exemption basically takes effect at the start of the calendar month of entering the employment and no earlier than the beginning of the employment. The precondition is that the employer notifies the Minijob-Zentrale of the exemption by the time the payroll is next calculated and no later than within six weeks of receipt of the exemption application. Otherwise, the exemption may not begin until after the end of the calendar month following the calendar month in which the notification was received by the Minijob-Zentrale. I am aware that the exemption application applies across all low-paid positions I hold at the same time. I undertake to inform all other employees with whom I hold a low-paid position of this exemption application. For employees in the transition zone 24 Declaration Should the LBV conclude that my income falls within the transition zone, I declare that I waive the right to reduced pension insurance and wish to pay the full pension insurance contribution. My waiver on reducing the pay subject to contributions for the field of pension insurance should take effect at the start of the employment. with effect from If more than one position is held at the same time, these shall be taken together for calculation purposes. If more than one position is held in application of the rules on the transition zone, the waiver may be applied for only to cover all positions jointly. The waiver shall remain binding for the entire duration of the employment. LBV(A)02_SV_2016_07 Page 5 of 6

6 LBV-Personalnummer 25 For short-term employment Since January of this year, I have already held one or more fixed-term position in Germany or abroad. in an employment relationship in public service in a low-paid employment position as per the information in the following table (if necessary, continue onto a separate sheet) From Until Days actually worked in this period Weekly working time (in hours) Gross monthly salary (including proportionate one-off payments) Below 450 EUR Below 450 EUR Below 450 EUR above 450 EUR above 450 EUR above 450 EUR L. Annexes I attach the following supporting documents: Certificate of membership the health insurance fund pursuant to 175 SGB V birth certificate(s) of child(ren) Certificate of study I confirm that my information is complete and correct. I am aware that I am required to immediately notify the Landesamt für Besoldung und Versorgung NRW, Düsseldorf of any changes to the above relationships and that I will be required to pay back any excess payments that I receive as the result of failing to make a notification, making a late notification or an incorrect notification. For low-paid employees: I have read and understood the annexed information leaflet on low-paid employment and employment in transition zone. Place, Date Signature of the employee Please note: The personal data raised in this printout will be processed in line with 29 of the Data Protection Act for the Land of rdrhein-westfalen (DSG NRW). Your information is required in order to be able to calculate your social security and supplemental pension obligation correctly and to calculate your salary to the correct level. Your obligation to cooperate arises from 28 o of Book 4 of the Social Security Code (SGB IV). LBV(A)02_SV_2016_07 Page 6 of 6

7 Low-paid employment Information leaflet Employment is considered to be low-paid if the contractually agreed salary regularly falls below the level of per month. In this calculation, one-off payments (e.g. Christmas bonus) are to be taken into account at the level of the proportionate share calculated for one calendar month. If more than one low-paid position is held, these will be combined to calculate the social insurance obligation. If an employee holds more than one low-paid position and the total income (including one-off payments) exceeds the limit of , then the overall income from all employment is subject to the usual contribution obligation. In such cases, the employee social security contribution will be deducted and paid to the health insurance fund together with the employer contribution. A low-paid position with a different employer may be carried out in addition to a non-low-paid main occupation subject to insurance obligations without the two positions being added together for calculation purposes (the low-paid employment therefore remains insurance-exempt). If, on the other hand, more than one low-paid position is held in addition to a non-low-paid main occupation subject to insurance obligations, then the low-paid position entered into first shall be left out of account and all other positions added to the main occupation for calculation purposes, meaning that in most cases, there is a contribution obligation to all branches of social security for the second and all subsequent low-paid positions. In all cases, the employer is required to pay fixed contributions to the pension and, if applicable, health insurance funds for all low-paid employment positions. There is no entitlement to claims within the health insurance fund as a result of low-paid employment. Since 1 January 2013, employees in low-paid positions ( 450 mini-job) have theoretically been subject to the insurance and full contribution obligation to the statutory pension insurance. The share of the pension insurance contribution to be borne by the employee currently stands at 3.7% of the employment income. This arises from the difference between the fixed contribution of the employer (currently 15%) and the full pension insurance contribution of 18.7% currently. The advantages of the insurance obligation for the employee arise from the acquisition of compulsory contribution periods to the pension insurance. This means that the employment period is taken into account in full in order to fulfil the various waiting periods (minimum insurance periods). Compulsory contribution periods are a precondition for following, for example: taking early retirement, claims for rehabilitation benefits (both medical and professional), claims for a transitional allowance in the event of rehabilitation measures under statutory pension insurance, making or keeping a claim to a pension on the grounds of reduction in earning capacity. Additionally, the employment earnings are taken into account not just proportionately, but at their full level, when calculating the pension. If the pension obligation is not wanted, the employee may apply for an exemption. In such cases, he or she must notify the employer in this case LBV NRW as income payment agency - in writing that he or she wishes to be exempted from the pension insurance obligation. If the employee holds more than one low-paid position, the application for an exemption may be granted only across all low-paid positions held at the same time. The employee must notify all additional and future employees with whom he or she holds a low-paid position of the exemption application. The exemption from the insurance obligation is binding for the entire duration of the employment position or positions; it cannot be revoked. The exemption basically takes effect at the start of the calendar month of entering the employment of the employer or LBV NRW as paying agency, and no earlier than the beginning of the employment. The precondition is that the employer notifies the Minijob-Zentrale of the exemption by the time the payroll is next calculated and no later than within six weeks of receipt of the exemption application. Otherwise, the exemption may not begin until after the end of the calendar month following the calendar month in which the notification was received by the Minijob-Zentrale. te to pension insurance institutes: Low-paid employees applying for an exemption from the pension insurance obligation voluntarily waive the right to the advantages listed above. With the exemption, only the employer pays the fixed-rate amount at 15% of the employment income. Before an employee makes a decision in favour of an exemption from the pension insurance obligation, an individual consultation is recommended regarding the pension-law effects, with the information and advisory services of the Deutsche Rentenversicherung. Merkblatt zu LBV(A)02_SV_2016_07 Seite 1 von 2

8 Income in the transition zone An employment relationship is considered to be in the transition zone if the income earnings received from the employment are regularly between and per month. If more than one position is held at the same time, these must be taken together for calculation purposes. For employees holding a position subject to an insurance obligation with earnings within the transition zone, the specific rules for the calculation of the contribution basis and for the distribution of the contributions to the health, nursing, pension and unemployment insurance funds apply to both employer and employee. Consequently, the employee bears the "full" proportionate contribution to the individual branches of insurance; the employee, on the other hand, bears only a reduced proportionate contribution. In pension insurance, the level of the pension claim is based on the income earnings subject to contributions. On the basis of a reduction of the income subject to a contribution obligation in the event of employment in the transition zone, only the reduced income will be used as a basis for the subsequent pension calculation for this period, meaning that the employer will receive only reduced pension rights. In order to avoid this reduction, the option exists in the field of pension insurance to waive the right to reduce the level of employment income subject to the contribution obligation and to pay the full employee contribution. The decision to waive the application of the specific rules on the transition zone must be notified to the employer in writing and will not usually take effect until the day on which the declaration was received by the employer. The employee may also appoint a later point in time for the waiver to take effect. If the waiver is received by the employee within two weeks of starting the employment, the waiver may also take effect from the start of the employment, if this is expressly requested by the employee. If more than one position is held under the transition zone rules, the waiver may only be applied to all of these positions taken together. The waiver remains binding for the entire duration of the employment. Merkblatt zu LBV(A)02_SV_2016_07 Seite 2 von 2