Get Formulier 121

Filling out the Formulier 121 online is a straightforward process that allows you to request a medical care agreement if you meet specific eligibility criteria. This guide provides clear, step-by-step instructions to help you complete the form accurately and efficiently.

Follow the steps to submit your Formulier 121 online

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling in your personal details. Provide your full first names, gender, last name, and maiden name if applicable. Enter your date of birth and your BSN or social security number in the designated fields.
3. Next, enter your address in your new country of residence. Include your street and house number, postal code, city, province, and country.
4. Indicate if you have emigrated or plan to emigrate by selecting 'yes' or 'no.' If applicable, provide your emigration date.
5. Detail the pension or benefit you are receiving. You will need to attach proof of this. Choose from the options provided and specify the start date of your pension or benefit.
6. If you are stopping work in the Netherlands, indicate the stop date or select 'I do not know yet.'
7. Review the requirements for submitting proof of your pension or benefit. Ensure you certify your information by signing and dating the form.
8. Fill in any additional information, including a mailing or correspondence address if different from your residence. Provide your contact details including phone number and email.
9. If applicable, include information for any family member moving with you who does not have independent income. Ensure all details are filled out accurately.
10. After completing the form, review all entries for accuracy. You can then save changes, download, print, or share the form as needed.

Start completing your Formulier 121 online today to ensure you receive the medical care benefits you are entitled to.