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Annex

EK
to determine the income of each person in the
Community of need living person
(on Section 4 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 enclosures on the Internetwww.arbeitsagentur.d
at .
1. personal data e
1.1 My personal data
Stamp of receipt
Salutat First
ion name

Family name Date of birth

Number of the demand group (if available)

Office
1.2 Personal data of the person over 15 years in my needs-
to which the information in this Annex refers 9
Team
Salutat First
ion name

Family name Date of birth

2nd income 19

Pursuit of a self-employed activity (also in agriculture and forestry)

► Please fill in the Plant EKS out. Plant EKS
The following income is generated:
Income from employment (full-time and part-time/mini-job)
Currently the tax class is taken into account in the wage 29
► The job centre may ask you to choose atax.
tax class that is more favourable to you.
► Please let the Statement of income filled in by the employer or put Statement of income
a payroll accounting system. Payroll accounting
Name of the employer Company
address

The activity is/was performed as a holiday job. 30

charitable or honorary activity, for which (tax-free) expenses for the

damages are paid 31
type of work

► Please provide evidence of the specific activity, the type and amount of the allowance.
and the expenses incurred in this connection.

Unemployment benefit according to the Third Book of the Social

Code (SGB III)
The unemployment benefit was granted for the period
from - to.

Unemployment benefit
(Euro/day)

► Please submit a copy of the permit issued by the Agentur für Arbeit. Notification of unemployment
benefit
Entitlement to unemployment benefit is Blocking time from
suspended
a blocking due to in accordance with SGB III
period - to/ date
expiry
or
... has a 32
► Please submit the relevant notification. Notification

Jobcenter-EK.04.2019 Page 1 of 4
 Pensions (e.g. from statutory social insurance such as old-age pension, miners' pension,
etc.)
benefits, accident/injury pension, survivor's pension), occupational pensions, pensio- Processing notes
pensions, foreign pensions, labour market To be filled in only by the Jobcenter
pensions
Type of Monthly amount in Euro
pension

► Please submit a copy of the current pension statement. Pension notification

Maintenance payments or benefits under the Maintenance Advance

Payment Act
method of Monthly amount in Euro
payment

► Please provide evidence of the type and amount of payments received.

► If you have other current, regular income, please indicate the type of income and the
monthly amount in the table below and provide appropriate evidence.
Income from letting, subletting or leasing (including income from land and buildings)
forestry)
other compensation benefits (e.g. transitional allowance, sickness
benefit)
Remuneration in kind (e.g. free meals)

Housing allowance, social assistance, other

social benefits
BAföG, vocational training grant, training allowance

other current income (e.g. parental benefits, maternity benefits, care allowance, tips)

Type of income/benefit Monthly amount in Euro

Type of income/benefit Monthly amount in Euro

non-recurring 33 and irregular revenue 34 (e.g., tax refunds on

income
(e.g. bankruptcy money, interest, other investment income, inheritances, gifts)
Type of income Income level Payment receipt on

► Please use a separate sheet if you have more than one entry. Please indicate the amount of revenue
and the receipt of payment.

Child 35
benefit
First name of the person entitled to child 36 surname of the person entitled to child benefit
benefit

First name of the Monthly amount of child benefit in Euro

child

First name of the person entitled to child surname of the person entitled to child benefit
benefit

First name of the Monthly amount of child benefit in Euro

child

► Please create a bank statement with the child benefit payment or the child benefit notification
37 38 befo Notification of child
re. benefit/
Account
other income of a person under 15 years of age (e.g. orphan's pension, statement
accident/insurance
last pension)
pension, alimony, benefits under the alimony advance law, so
interest or capital gains), in accordance with Book Twelfth of the Social Code
Name of the child/name of the
children

Service Monthly amount in Euro

type

► Please submit appropriate proof.

Jobcenter-EK.04.2019
*S2 Page 2 of 4
3. deductions from income
3.1 Expenses in connection with the employment Processing notes
relationship
► The necessary expenses associated with the generation of income from employment are not covered by the To be filled in only by the Jobcenter
(income-related expenses) are taken into account with a reduction in income. For example, expenditure on
travel between home and place of work, as a rule at EUR 0.20 per kilometre of income
men.
► If you earn up to 400.00 Euro per month, 100.00 Euro will be deducted as a lump sum as expenses. In this Pau-
The advertising costs as well as the distance kilometres are already included in the price.
► If you earn more than 400,00 Euro per month and you have higher necessary expenses, we will
this on proof is taken into account. Only in this case the following information must be provided.
Expenditure for journeys between home and the place of work in a motor vehicle
Expenditure on travel between home and place of work for the use of public transport
tional means of transport (e.g. for a monthly
travel
Level pass)
of expenditure in Shortest distance between home and
euro Workplace in kilometres

Address of the place of work (street, house number, postcode,

town)

The route is regularly updated working days per week.

on
► Regardless of the type of travel costs, please provide information on the address of the place of work, the freelance
The most important distance between home and place of work in kilometres and to the working days. Please lay
If you use public transport, you must present a corresponding proof.
grants for travel expenses
are paid by the employer/third parties have been
requested
Amount of the grant paid in euro

► Please submit appropriate proof. If the grant has not yet been awarded but is requested
you do not need to enter the amount of the subsidy.
other expenses arising from an employment relationship (e.g. double budgeting,
employment
medium) which are not reimbursed by the
employer
Type of output Monthly amount in Euro

► If there are different editions, please list the individual items on a separate sheet
and enter the total amount here.
Additional expenses for meals due to a daily absence of at least
12 hours from home and the usual place of employment, without any doped
tion of the budget
Number of working days per
month

► For days with an absence of at least 12 hours, the actual expenses can be charged against subsequent payment.
up to 12,00 Euro and in case of full day absence up to 24,00 Euro.
to be sighted. Without proof a lump sum of 6.00 Euro per day will be applied.

3.2 Other deductions

payments to a dependant outside the means-tested community on
Reason for a maintenance
title
Dependent person Relationship Monthly maintenance-
tions in Euro

► Please submit a copy of the maintenance title (e.g. judgment, court settlement, maintenance certificate) and Supporting titles
provide evidence of actual payments. 39 Account
in the case of training assistance (vocational training allowance, training allowance, statements
BAföG)
Child for a
considered parental income
Name of the child Amount taken into account each month
in euro

► Please submit the relevant notification. Notification

Jobcenter-EK.04.2019
*S3 Page 3 of 4
3.3 Expenses for statutory insurance - also for other insurance
according to Processing notes
► Forincome
private insurances, which are appropriate in terms of reason and amount and which do not fall under the below-mentionedTo be filled in only by the Jobcenter
(e.g. liability, household contents) are deducted from the income on a monthly basis as a lump sum.
30,00 Euro deducted.
You therefore do not need to provide any information or evidence to receive this flat rate.
► If you have taken out special insurance for your child under 18, please indicate this
after.
► If you are not required to take out insurance under the statutory health insurance or pension insurance scheme, you may be entitled to
contributions to the provision for the event of illness, the need for long-term care and for old-age provision from income
can be dropped. Please provide the relevant supporting documents.
The following insurance premiums are paid:
► Please indicate the intervals (payment frequency, e.g. monthly, 1/4-yearly, 1/2-yearly, etc.) in which you would like to receive the
payment.and the amount of insurance paid and provide proof of this
annual)
befo
re.
Motor vehicle liability insurance (without partial coverage, fully
comprehensive, cover note)
Payment frequency of the insurance premium Insurance premium in Euro

motor third party

other legally required insurances (e.g. liability insurance for liability insurance
certain professional groups such as lawyers or midwives)
Payment frequency of the insurance premium Insurance premium in Euro

Contributions to the subsidized pension plan according to § 82 of the

Income
► Taxfor
These are, Actexample, contributions to the "Riester pension" or payments to a pension fund, a pension fund
or a direct insurance policy for the purpose of building up a funded occupational pension scheme, accident insurance or a
pensioinsurance policy for the purpose of building up a funded occupational pension scheme, accident insurance or a direct
direct
n.
Payment frequency of the insurance premium Insurance premium in Euro

Pension
provision
private insurance for underage children

Name of the child/name of the type of insurance

children

Payment frequency of the insurance premium Insurance premium in Euro

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 Leis-
tions according to the Second Book of the Social Code (SGB II). You will receive data protection information
at the job centre responsible for you and on the Internet at www.arbeitsagentur.de/datenerhebun .
In the event of changes in income levels (e.g. pay) or expenditure, including
g under-employment, the
payments, you or the members of your consumer association are obliged to immediately inform the
and provide appropriate evidence.
I confirm that the information provided is
correct.
Place/Dat Signature Applicant
e (for minors: Signature of the legal representative)

► To be completed only in the event of amendments and additions:

I confirm the correctness of the information provided by me or the employees of the Job-
centers made changes and additions to the sections:

Place/Dat Signature Applicant

e (for minors: Signature of the legal representative)

Print form Reset form

Jobcenter-EK.04.2019
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