Subscribe to DeepL Pro to edit this document.

Visit www.DeepL.com/Pro for more information.

Annex

VM
to establish the financial circumstances of the applicant
Applicant and persons living in the consumer association
(on Section 5 of the main
application) 2
Applicable Find more information
plea to the respective number Processing notes
To be filled in only by the Jobcenter
se
tick in the completion notes
You will find the filling instructions and other attachments on the Internet at www.arbeitsagentur.de.
If you need more space, please use a separate sheet and attach it to your application.

1. my personal data Stamp of receipt

Salutat First
ion name

Family name Date of birth

Number of the demand group (if available)

Office

2. exemption orders 40
Team
The following exemption orders for capital/interest income (e.g. from credit
institutions,
Building societies, life insurance companies, federal/state debt-
administrations) were
issued:
Name of the Name of the financial
person institution/insurance company

Valid from - to BIC of the financial 3

institution/insurance company

Name of the Name of the financial

person institution/insurance company

Valid from - to BIC of the financial

institution/insurance company

The following domestic and/or foreign assets are available: 20

3. accounts and cash

investments
3.1 Accounts for processing payment transactions (e.g. current account,
PayPal)
Name of the Account balance in
person Euro

3
IBAN

Name of the Account balance in

person Euro

IBAN

Name of the Account balance in

person Euro

IBAN

► Please provide appropriate evidence, e.g. bank statements 37 before. When specifying Pay-
Pal accounts, the fields BIC and IBAN are not to be filled in.

Jobcenter-VM.01.2017 Page 1 of 4
3.2 Cash
Name of the Total amount in Euro Processing notes
person To be filled in only by the Jobcenter

Name of the Total amount in Euro

person

3.3 Savings deposits (e.g. savings books, overnight money,

premium savings)
Name of the Total amount in Euro Interest in the last
person year

IBAN

Name of the Total amount in Euro Interest in the last

person year

IBAN

Name of the Total amount in Euro Interest in the last

person year

IBAN

► Please provide appropriate supporting documents.

3.4 Savings bonds or other securities (e.g. shares, bonds, fund units)
Name of the kind of investment
person

current value in euro Income in the last year Credit interest

rate

Security number Credit

institution

Name of the kind of investment

person

current value in euro Income in the last year Credit interest

rate

Security number Credit

institution

► Please provide appropriate supporting documents.

3.5 Building loan

agreements
Name of the Building
person society

Building society current balance of the credit balance

number in euro

The building saving contract is assigned to a credit institution as security for a loan.

Name of the Building

person society

Building society current balance of the credit balance

number in euro

The building saving contract is assigned to a credit institution as security for a loan.
► Please provide appropriate supporting documents.

Jobcenter-VM.01.2017 *S2 Page 2 of 4

3.6 Endowment insurance, private pension insurance and/or Processing notes
Accident insurance with premium refund To be filled in only by the Jobcenter
Name of the Insurance companies
person

Insurance number Sum insured in Euro

previously paid in Euro Repurchase or sale value in

Euro

Name of the Insurance companies

person

Insurance number Sum insured in Euro

previously paid in Euro Repurchase or sale value in

Euro

► Please provide appropriate supporting documents.

4. government-sponsored pension
provision
► Fiscal sponsored Pension assets are z. B. Payments to "Riester Pension"or to a
Pension funds, a Pension Fund or a Direct insurance to Structur a funded
occupational pension scheme, accident pension. e

Name of the Total amount in Euro

person

Name of the Total amount in Euro

person

► Please present the contract and prove the current account balance.

5. exemption from compulsory pension

insurance
Exempt from compulsory pension is .
insurance
The financial investments of the aforementioned person indicated under item 3 of this
Annexfor
nents areold-age
the-
provision.
► Please submit proof of exemption from the pension insurance obligation.

6. land and/or residential property

developed plot undeveloped plot condominium

Name of the
person

Property size in m 2
Market value in Euro 41 Charges in Euro

2 2
Living space in Own use in m Rental/leasing income in Euro
m

developed plot undeveloped plot condominium

Name of the
person

2
Property size in m Market value in Euro Charges in Euro

2 2
Living space in Own use in m Rental/leasing income in Euro
m

► Please provide appropriate supporting documents.

Jobcenter-VM.01.2017
*S3 Page 3 of 4
7. other assets
► Other assets include precious metals, antiques, paintings and jewellery.
Name of the Kind of the object of Asset value in Euro Processing notes
To be filled in only by the Jobcenter
person value

Name of the Kind of the object of Asset value in Euro

person value

► Please provide appropriate supporting documents.

8. motor vehicles
Name of the owner

Make/Model existing loan liabilities in Euro

registration mark date of first Mileage

registration

Name of the owner

Make/Model existing loan liabilities in Euro

registration mark date of first Mileage

registration

► Please provide appropriate supporting documents.

9. gifts/donations/transfers
► Donations/donations/transfers made within the last 10 years from the contract must be entered here.
may have taken place at home or abroad for a person living in the community of need.
Name of the
person

Amount in Date of the donation/donation/transfer

Euro

Intended use Recipient

The data are subject to social secrecy (see "Merkblatt SGB II"). Your information will be treated according to §§ 60-65
First Book of the Social Code (SGB I) and §§ 67a, b, c Tenth Book of the Social Code (SGB X) for the
benefits according to the Second Book of the Social Code (SGB II).
For each member of your demand group, a call request can be submitted to the Federal Central Tax Office for the tax authorities.
(BZSt) in order to clarify the income and financial circumstances of your community of need
(Article 93(8) and (9) of the General Tax Code). The BZSt transmits the account master data of your accounts and for
Existence of a concrete suspicion - possibly also of accounts of third parties, where you are considered to be the authorized or
the beneficial owner within the meaning of Article 1 paragraph 6 of the Money Laundering Act (under
other name of the account holder, date of birth, IBAN and authority to dispose of the account) This
concerns accounts that have been closed for no longer than three years.
I confirm that the information provided is
correct.
Place/Dat Signature Applicant
e (for minors: Signature of the legal representative)

M confirm th Correctne the throu me or th Employees of

e
Jobcenter madee changes
ss gh to the sections: e
and additions

Place/Dat Signature Applicant

e (for minors: Signature of the legal representative)

Print form Reset form

Jobcenter-VM.01.2017 *S4 Page 4 of 4