English Translation

(Only for the district administration concerned) Application for the grant of receipt-stempel ng-agbn insurance benefits. To the German civil servant-sickness insurance district administration Prague II, Bredauergasse 21 paying agency. In the case of hospital treatment: Is hospital treatment finished? oa d ede d d d D Is there any further costs for the repair of the consequences of the accident? In the case of weekly assistance applications: Should the newborn child be covered? (If yes, please submit an immediate admission application) 13. Is there still any other cover against disease damage, if yes, who? Seftrand Rüdseite, 14. Valid: 1 invoice and 1 receipt - Rezehte. — Set on the side. 15. I ask you to transfer the benefits according to the insurance conditions and the tariff tar dud chi Por to my postal account no. bet the post office to my savings bank cheque account No. 14 129 Prap f+ Athffeda Den 30.1.Y5 Drt (Won bier ab nur für die Zahlstelle) (Subsidient of the applicant) 16. Statement by the paying agency (Vertrauensmann) on the application: Until when are the contributions paid?, the (Drs) (Bon bier from only for the district administration) (Subsidiary of the Bertrauenemann) 17. Issue statement and income statement. NM. 93f. 989. $1. The cash register is instructed to pay the amount shown on the side at 1 in words 1. In issue 2. In receipt 2616 Npf. (a) Pfennige bezahlungsgemdß zu zablen - zu überiveisen — mit Behaltung der beistandend bet 2a) b) Contribution up to c) Declared accounting items. ( (date) 3rd edition remains pure: 18. Notes for the 19. L. B. for previous year Lfb. Jaht Combined Bfennigen 20. Paid d. Posscheck Seft No. No. decision issued Man Postaberw. Frau. am 8 Kind paid d. Bank Gched Sparkasse Überto. Nr. Kind child . at the ua V1 Grstattungsanirag.