# L_2015049EN.01000101.xml

| 20.2.2015 | EN | Official Journal of the European Union | L 49/1 |
| --- | --- | --- | --- |

20.2.2015

EN

Official Journal of the European Union

L 49/1

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COMMISSION IMPLEMENTING REGULATION (EU) 2015/228

of 17 February 2015

replacing Annexes I to VII to Council Regulation (EC) No 4/2009 on jurisdiction, applicable law, recognition and enforcement of decisions and cooperation in matters relating to maintenance obligations

THE EUROPEAN COMMISSION,

Having regard to the Treaty on the Functioning of the European Union,

Having regard to Council Regulation (EC) No 4/2009 of 18 December 2008 on jurisdiction, applicable law, recognition and enforcement of decisions and cooperation in matters relating to maintenance obligations (1), and in particular Article 72 thereof,

1

Whereas:

| (1) | Annexes I to VII to Regulation (EC) No 4/2009 were amended by Council Regulation (EU) No 517/2013 (2) to take account of the accession of Croatia to the European Union. Regulation (EU) No 517/2013 also took account of the change of currency in Estonia. |
| --- | --- |

(1)

Annexes I to VII to Regulation (EC) No 4/2009 were amended by Council Regulation (EU) No 517/2013 (2) to take account of the accession of Croatia to the European Union. Regulation (EU) No 517/2013 also took account of the change of currency in Estonia.

2

| (2) | Latvia and Lithuania changed currency on 1 January 2014 and 1 January 2015 respectively. Annexes I to IV and VII should be amended accordingly. |
| --- | --- |

(2)

Latvia and Lithuania changed currency on 1 January 2014 and 1 January 2015 respectively. Annexes I to IV and VII should be amended accordingly.

| (3) | In accordance with Article 4 of Protocol No 21 on the position of the United Kingdom and Ireland in respect of the Area of Freedom, Security and Justice, annexed to the Treaty on European Union and the Treaty on the Functioning of the European Union, the United Kingdom has informed the Commission of its wish to take part in the application of Regulation (EC) No 4/2009. References to the United Kingdom must therefore be included in Annexes II and IV to VII. |
| --- | --- |

(3)

In accordance with Article 4 of Protocol No 21 on the position of the United Kingdom and Ireland in respect of the Area of Freedom, Security and Justice, annexed to the Treaty on European Union and the Treaty on the Functioning of the European Union, the United Kingdom has informed the Commission of its wish to take part in the application of Regulation (EC) No 4/2009. References to the United Kingdom must therefore be included in Annexes II and IV to VII.

| (4) | In accordance with Articles 1 and 2 of Protocol No 22 on the position of Denmark, annexed to the Treaty on European Union and the Treaty on the Functioning of the European Union, Denmark did not take part in the adoption of Regulation (EC) No 4/2009 and is not taking part in the adoption of this Regulation; it is not bound by Regulation (EC) No 4/2009 or by this Regulation, nor is it subject to their application. |
| --- | --- |

(4)

In accordance with Articles 1 and 2 of Protocol No 22 on the position of Denmark, annexed to the Treaty on European Union and the Treaty on the Functioning of the European Union, Denmark did not take part in the adoption of Regulation (EC) No 4/2009 and is not taking part in the adoption of this Regulation; it is not bound by Regulation (EC) No 4/2009 or by this Regulation, nor is it subject to their application.

| (5) | In accordance with Article 3(2) of the agreement of 19 October 2005 between the European Community and the Kingdom of Denmark on jurisdiction and the recognition and enforcement of judgments in civil and commercial matters (3), Denmark has, however, notified (4) the Commission of its decision to partly implement the content of Regulation (EC) No 4/2009 in so far as that Regulation amends Council Regulation (EC) No 44/2001 (5), the subject of the abovementioned agreement of 19 October 2005. References to Denmark must therefore be included in Annexes II and IV. |
| --- | --- |

(5)

In accordance with Article 3(2) of the agreement of 19 October 2005 between the European Community and the Kingdom of Denmark on jurisdiction and the recognition and enforcement of judgments in civil and commercial matters (3), Denmark has, however, notified (4) the Commission of its decision to partly implement the content of Regulation (EC) No 4/2009 in so far as that Regulation amends Council Regulation (EC) No 44/2001 (5), the subject of the abovementioned agreement of 19 October 2005. References to Denmark must therefore be included in Annexes II and IV.

3

4

5

| (6) | Lastly, it is necessary to amend certain sections of Annexes VI and VII to facilitate their application. |
| --- | --- |

(6)

Lastly, it is necessary to amend certain sections of Annexes VI and VII to facilitate their application.

| (7) | The measures provided for in this Regulation are in accordance with the opinion of the committee established under Article 70 of Council Regulation (EC) No 2201/2003 (6). |
| --- | --- |

(7)

The measures provided for in this Regulation are in accordance with the opinion of the committee established under Article 70 of Council Regulation (EC) No 2201/2003 (6).

6

| (8) | For reasons of clarity, therefore, Annexes I to VII of Regulation (EC) No 4/2009 must be replaced, |
| --- | --- |

(8)

For reasons of clarity, therefore, Annexes I to VII of Regulation (EC) No 4/2009 must be replaced,

HAS ADOPTED THIS REGULATION:

Article 1

Annexes I to VII to Regulation (EC) No 4/2009 are replaced by the text in the annex to this Regulation.

Article 2

This Regulation shall enter into force on the twentieth day following its publication in the Official Journal of the European Union.

Official Journal of the European Union

This Regulation shall be binding in its entirety and directly applicable in the Member States in accordance with the Treaties.

Done at Brussels, 17 February 2015.

For the Commission

The President

Jean-Claude JUNCKER

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(1)  OJ L 7, 10.1.2009, p. 1.

1

(2)  Council Regulation (EU) No 517/2013 of 13 May 2013 adapting certain regulations and decisions in the fields of free movement of goods, freedom of movement for persons, company law, competition policy, agriculture, food safety, veterinary and phytosanitary policy, transport policy, energy, taxation, statistics, trans-European networks, judiciary and fundamental rights, justice, freedom and security, environment, customs union, external relations, foreign, security and defence policy and institutions, by reason of the accession of the Republic of Croatia (OJ L 158, 10.6.2013, p. 1).

2

(3)  OJ L 299, 16.11.2005, p. 62.

3

(4)  OJ L 149, 12.6.2009, p. 80.

4

(5)  Council Regulation (EC) No 44/2001 of 22 December 2000 on jurisdiction and the recognition and enforcement of judgments in civil and commercial matters (OJ L 12, 16.1.2001, p. 1).

5

(6)  Council Regulation (EC) No 2201/2003 of 27 November 2003 concerning jurisdiction and the recognition and enforcement of judgments in matrimonial matters and the matters of parental responsibility, repealing Regulation (EC) No 1347/2000 (OJ L 338, 23.12.2003, p. 1).

6

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ANNEX

ANNEX I

EXTRACT FROM A DECISION/COURT SETTLEMENT IN MATTERS RELATING TO MAINTENANCE OBLIGATIONS NOT SUBJECT TO PROCEEDINGS FOR RECOGNITION OR A DECLARATION OF ENFORCEABILITY

(Articles 20 and 48 of Council Regulation (EC) No 4/2009 of 18 December 2008 on jurisdiction, applicable law, recognition and enforcement of decisions and cooperation in matters relating to maintenance obligations (1))

IMPORTANT

To be issued by the court of origin

To be issued only if the decision or court settlement is enforceable in the Member State of origin

Mention only information which is given in the decision or court settlement or of which the court of origin has been made aware

1.   NATURE OF THE DOCUMENT

|  | Decision |  | Court settlement |
| --- | --- | --- | --- |



Decision



Court settlement

Date and reference number: ...

The decision/court settlement is recognised and enforceable in another Member State without any possibility of opposing its recognition and without the need for a declaration of enforceability (Articles 17 and 48 of Regulation (EC) No 4/2009).

2.   COURT OF ORIGIN

2.1.   Name: ...

2.2.   Address:

| 2.2.1. | Street and number/PO box: ... |
| --- | --- |

2.2.1.

Street and number/PO box: ...

| 2.2.2. | Place and postal code: ... |
| --- | --- |

2.2.2.

Place and postal code: ...

| 2.2.3. | Member State
   Belgium  Bulgaria  Czech Republic  Germany  Estonia  Ireland  Greece  Spain  France  Croatia  Italy  Cyprus  Latvia  Lithuania  Luxembourg  Hungary  Malta  Netherlands  Austria  Poland  Portugal  Romania  Slovenia  Slovakia  Finland  Sweden |
| --- | --- |

2.2.3.

Member State

 Belgium  Bulgaria  Czech Republic  Germany  Estonia  Ireland  Greece  Spain  France  Croatia  Italy  Cyprus  Latvia  Lithuania  Luxembourg  Hungary  Malta  Netherlands  Austria  Poland  Portugal  Romania  Slovenia  Slovakia  Finland  Sweden

2.3.   Telephone/Fax/E-mail: ...

3.   CLAIMANT(S) (2)
   (3)

3.1.   Person A

3.1.1.   Surname and given name(s): ...

3.1.2.   Date (dd/mm/yyyy) and place of birth: ...

3.1.3.   Identity number or social security number: ...

3.1.4.   Address:

| 3.1.4.1. | Street and number/PO box: ... |
| --- | --- |

3.1.4.1.

Street and number/PO box: ...

| 3.1.4.2. | Place and postal code: ... |
| --- | --- |

3.1.4.2.

Place and postal code: ...

| 3.1.4.3. | Country: ... |
| --- | --- |

3.1.4.3.

Country: ...

3.1.5.   Has benefited from

| 3.1.5.1. | legal aid:








   | Yes |  | No |
| --- | --- | --- | --- | --- |

3.1.5.1.

legal aid:



Yes



No

| 3.1.5.2. | exemption from costs and expenses:








   | Yes |  | No |
| --- | --- | --- | --- | --- |

3.1.5.2.

exemption from costs and expenses:



Yes



No

| 3.1.5.3. | free proceedings before an administrative authority listed in Annex X to Regulation (EC) No 4/2009:








   | Yes |  | No |
| --- | --- | --- | --- | --- |

3.1.5.3.

free proceedings before an administrative authority listed in Annex X to Regulation (EC) No 4/2009:



Yes



No

3.2.   Person B

3.2.1.   Surname and given name(s): ...

3.2.2.   Date (dd/mm/yyyy) and place of birth: ...

3.2.3.   Identity number or social security number: ...

3.2.4.   Address:

| 3.2.4.1. | Street and number/PO box: ... |
| --- | --- |

3.2.4.1.

Street and number/PO box: ...

| 3.2.4.2. | Place and postal code: ... |
| --- | --- |

3.2.4.2.

Place and postal code: ...

| 3.2.4.3. | Country: ... |
| --- | --- |

3.2.4.3.

Country: ...

3.2.5.   Has benefited from

| 3.2.5.1. | legal aid:








   | Yes |  | No |
| --- | --- | --- | --- | --- |

3.2.5.1.

legal aid:



Yes



No

| 3.2.5.2. | exemption from costs and expenses:








   | Yes |  | No |
| --- | --- | --- | --- | --- |

3.2.5.2.

exemption from costs and expenses:



Yes



No

| 3.2.5.3. | free proceedings before an administrative authority listed in Annex X to Regulation (EC) No 4/2009:








   | Yes |  | No |
| --- | --- | --- | --- | --- |

3.2.5.3.

free proceedings before an administrative authority listed in Annex X to Regulation (EC) No 4/2009:



Yes



No

3.3.   Person C

3.3.1.   Surname and given name(s): ...

3.3.2.   Date (dd/mm/yyyy) and place of birth: ...

3.3.3.   Identity number or social security number: ...

3.3.4.   Address:

| 3.3.4.1. | Street and number/PO box: ... |
| --- | --- |

3.3.4.1.

Street and number/PO box: ...

| 3.3.4.2. | Place and postal code: ... |
| --- | --- |

3.3.4.2.

Place and postal code: ...

| 3.3.4.3. | Country: ... |
| --- | --- |

3.3.4.3.

Country: ...

3.3.5.   Has benefited from

| 3.3.5.1. | legal aid:








   | Yes |  | No |
| --- | --- | --- | --- | --- |

3.3.5.1.

legal aid:



Yes



No

| 3.3.5.2. | exemption from costs and expenses:








   | Yes |  | No |
| --- | --- | --- | --- | --- |

3.3.5.2.

exemption from costs and expenses:



Yes



No

| 3.3.5.3. | free proceedings before an administrative authority listed in Annex X to Regulation (EC) No 4/2009:








   | Yes |  | No |
| --- | --- | --- | --- | --- |

3.3.5.3.

free proceedings before an administrative authority listed in Annex X to Regulation (EC) No 4/2009:



Yes



No

4.   DEFENDANT(S) (4)
   (5)

4.1.   Person A

4.1.1.   Surname and given name(s): ...

4.1.2.   Date (dd/mm/yyyy) and place of birth: ...

4.1.3.   Identity number or social security number: ...

4.1.4.   Address:

| 4.1.4.1. | Street and number/PO box: ... |
| --- | --- |

4.1.4.1.

Street and number/PO box: ...

| 4.1.4.2. | Place and postal code: ... |
| --- | --- |

4.1.4.2.

Place and postal code: ...

| 4.1.4.3. | Country: ... |
| --- | --- |

4.1.4.3.

Country: ...

4.1.5.   Has benefited from

| 4.1.5.1. | legal aid:








   | Yes |  | No |
| --- | --- | --- | --- | --- |

4.1.5.1.

legal aid:



Yes



No

| 4.1.5.2. | exemption from costs and expenses:








   | Yes |  | No |
| --- | --- | --- | --- | --- |

4.1.5.2.

exemption from costs and expenses:



Yes



No

| 4.1.5.3. | free proceedings before an administrative authority listed in Annex X to Regulation (EC) No 4/2009:








   | Yes |  | No |
| --- | --- | --- | --- | --- |

4.1.5.3.

free proceedings before an administrative authority listed in Annex X to Regulation (EC) No 4/2009:



Yes



No

4.2.   Person B

4.2.1.   Surname and given name(s): ...

4.2.2.   Date (dd/mm/yyyy) and place of birth: ...

4.2.3.   Identity number or social security number: ...

4.2.4.   Address:

| 4.2.4.1. | Street and number/PO box: ... |
| --- | --- |

4.2.4.1.

Street and number/PO box: ...

| 4.2.4.2. | Place and postal code: ... |
| --- | --- |

4.2.4.2.

Place and postal code: ...

| 4.2.4.3. | Country: ... |
| --- | --- |

4.2.4.3.

Country: ...

4.2.5.   Has benefited from

| 4.2.5.1. | legal aid:








   | Yes |  | No |
| --- | --- | --- | --- | --- |

4.2.5.1.

legal aid:



Yes



No

| 4.2.5.2. | exemption from costs and expenses:








   | Yes |  | No |
| --- | --- | --- | --- | --- |

4.2.5.2.

exemption from costs and expenses:



Yes



No

| 4.2.5.3. | free proceedings before an administrative authority listed in Annex X to Regulation (EC) No 4/2009:








   | Yes |  | No |
| --- | --- | --- | --- | --- |

4.2.5.3.

free proceedings before an administrative authority listed in Annex X to Regulation (EC) No 4/2009:



Yes



No

4.3.   Person C

4.3.1.   Surname and given name(s): ...

4.3.2.   Date (dd/mm/yyyy) and place of birth: ...

4.3.3.   Identity number or social security number: ...

4.3.4.   Address:

| 4.3.4.1. | Street and number/PO box: ... |
| --- | --- |

4.3.4.1.

Street and number/PO box: ...

| 4.3.4.2. | Place and postal code: ... |
| --- | --- |

4.3.4.2.

Place and postal code: ...

| 4.3.4.3. | Country: ... |
| --- | --- |

4.3.4.3.

Country: ...

4.3.5.   Has benefited from

| 4.3.5.1. | legal aid:








   | Yes |  | No |
| --- | --- | --- | --- | --- |

4.3.5.1.

legal aid:



Yes



No

| 4.3.5.2. | exemption from costs and expenses:








   | Yes |  | No |
| --- | --- | --- | --- | --- |

4.3.5.2.

exemption from costs and expenses:



Yes



No

| 4.3.5.3. | free proceedings before an administrative authority listed in Annex X to Regulation (EC) No 4/2009:








   | Yes |  | No |
| --- | --- | --- | --- | --- |

4.3.5.3.

free proceedings before an administrative authority listed in Annex X to Regulation (EC) No 4/2009:



Yes



No

5.   TERMS OF THE DECISION/COURT SETTLEMENT

5.1.   Currency

 Euro (EUR)  Lev (BGN)  Czech koruna (CZK)  Kuna (HRK)  Forint (HUF)  Zloty (PLN)  Leu (RON)  Krona (SEK)  Other (please specify ISO code): ...

5.2.   Maintenance claim
   (6)

5.2.1.   Maintenance claim A

5.2.1.1.   The maintenance is to be paid

by ... (surname and given name(s))

to ... (surname and given name(s) of the person to whom the sum must actually be paid)

Person for whom maintenance is owed:

... (surname and given name(s))

5.2.1.2.    Amount to be paid in one sum

Period covered, where applicable:

...

(from date (dd/mm/yyyy) to date (dd/mm/yyyy) or event)

Due date: ... (dd/mm/yyyy)

Amount: ...

5.2.1.3.    Amount to be paid in instalments

| Maturity date
  (dd/mm/yyyy) | Amount |
| --- | --- |
| | |
| | |
| | |
| | |

Maturity date

(dd/mm/yyyy)

Amount

5.2.1.4.    Sum to be paid regularly

|  | Once a week |
| --- | --- |
|  | Once a month |
|  | Other (state frequency): ... |



Once a week



Once a month



Other (state frequency): ...

Amount: ...

From: ... (dd/mm/yyyy)

Due day/date: ...

 If applicable, until (date (dd/mm/yyyy) or event): ...

If the maintenance claim is subject to indexation, please indicate how that indexation is to be calculated: ...

...

Indexation applicable as from: ... (dd/mm/yyyy)

5.2.1.5.    Amount due retroactively

Period covered: ... ([dd/mm/yyyy] to [dd/mm/yyyy])

Amount: ...

Form of payment: ...

...

...

5.2.1.6.    Interest (if specified in the decision/court settlement)

If the maintenance claim is subject to interest, please indicate the rate: ...

Interest due as from: ... (dd/mm/yyyy)

5.2.1.7.    Payment in kind (please specify): ...

...

...

...

5.2.1.8.    Other form of payment (please specify): ...

...

...

...

5.2.2.   Maintenance claim B

5.2.2.1.   The maintenance is to be paid

by ... (surname and given name(s))

to ... (surname and given name(s) of the person to whom the sum must actually be paid)

Person for whom maintenance is owed:

... (surname and given name(s))

5.2.2.2.    Amount to be paid in one sum

Period covered, where applicable:

...

(from date (dd/mm/yyyy) to date (dd/mm/yyyy) or event)

Due date: ... (dd/mm/yyyy)

Amount: ...

5.2.2.3.    Amount to be paid in instalments

| Maturity date
  (dd/mm/yyyy) | Amount |
| --- | --- |
| | |
| | |
| | |
| | |

Maturity date

(dd/mm/yyyy)

Amount

5.2.2.4.    Sum to be paid regularly

|  | Once a week |
| --- | --- |
|  | Once a month |
|  | Other (state frequency): ... |



Once a week



Once a month



Other (state frequency): ...

Amount: ...

From: ... (dd/mm/yyyy)

Due day/date: ...

 If applicable, until (date (dd/mm/yyyy) or event): ...

If the maintenance claim is subject to indexation, please indicate how that indexation is to be calculated: ...

Indexation applicable as from: ... (dd/mm/yyyy)

5.2.2.5.    Amount due retroactively

Period covered: ... ([dd/mm/yyyy] to [dd/mm/yyyy])

Amount: ...

Form of payment: ...

...

...

5.2.2.6.    Interest (if specified in the decision/court settlement)

If the maintenance claim is subject to interest, please indicate the rate: ...

Interest due as from: ... (dd/mm/yyyy)

5.2.2.7.    Payment in kind (please specify): ...

...

...

...

5.2.2.8.    Other form of payment (please specify): ...

...

...

...

5.2.3.   Maintenance claim C

5.2.3.1.   The maintenance is to be paid

by ... (surname and given name(s))

to ... (surname and given name(s) of the person to whom the sum must actually be paid)

Person for whom maintenance is owed:

... (surname and given name(s))

5.2.3.2.    Amount to be paid in one sum

Period covered, where applicable:

...

(from date (dd/mm/yyyy) to date (dd/mm/yyyy) or event)

Due date: ... (dd/mm/yyyy)

Amount: ...

5.2.3.3.    Amount to be paid in instalments

| Maturity date
  (dd/mm/yyyy) | Amount |
| --- | --- |
| | |
| | |
| | |
| | |

Maturity date

(dd/mm/yyyy)

Amount

5.2.3.4.    Sum to be paid regularly

|  | Once a week |
| --- | --- |
|  | Once a month |
|  | Other (state frequency): ... |



Once a week



Once a month



Other (state frequency): ...

Amount: ...

From: ... (dd/mm/yyyy)

Due day/date: ...

 If applicable, until (date (dd/mm/yyyy) or event):

...

If the maintenance claim is subject to indexation, please indicate how that indexation is to be calculated: ...

Indexation applicable as from: ... (dd/mm/yyyy)

5.2.3.5.    Amount due retroactively

Period covered: ... ([dd/mm/yyyy] to [dd/mm/yyyy])

Amount: ...

Form of payment: ...

...

...

5.2.3.6.    Interest (if specified in the decision/court settlement)

If the maintenance claim is subject to interest, please indicate the rate: ...

Interest due as from: ... (dd/mm/yyyy)

5.2.3.7.    Payment in kind (please specify): ...

...

...

...

5.2.3.8.    Other form of payment (please specify): ...

...

...

...

5.3.   Costs and expenses

The decision/court settlement provides that

... (surname and given name(s))

must pay the sum of ...

to: ... [surname and given name(s)].

If additional pages have been attached, state the number of pages: ...

Done at: ... on: ... (dd/mm/yyyy)

Signature and/or stamp of the court of origin:

...

ANNEX II

EXTRACT FROM A DECISION/COURT SETTLEMENT IN MATTERS RELATING TO MAINTENANCE OBLIGATIONS SUBJECT TO PROCEEDINGS FOR RECOGNITION AND A DECLARATION OF ENFORCEABILITY

(Articles 28 and 75(2) of Council Regulation (EC) No 4/2009 of 18 December 2008 on jurisdiction, applicable law, recognition and enforcement of decisions and cooperation in matters relating to maintenance obligations (7))

IMPORTANT

To be issued by the court of origin

To be issued only if the decision or court settlement is enforceable in the Member State of origin

Mention only information which is given in the decision or court settlement or of which the court of origin has been made aware

1.   NATURE OF THE DOCUMENT

|  | Decision |  | Court settlement |
| --- | --- | --- | --- |



Decision



Court settlement

Date and reference number: ...

2.   COURT OF ORIGIN

2.1.   Name: ...

2.2.   Address:

| 2.2.1. | Street and number/PO box: ... |
| --- | --- |

2.2.1.

Street and number/PO box: ...

| 2.2.2. | Place and postal code: ... |
| --- | --- |

2.2.2.

Place and postal code: ...

| 2.2.3. | Member State
   Belgium  Bulgaria  Czech Republic  Denmark  Germany  Estonia  Ireland  Greece  Spain  France  Croatia  Italy  Cyprus  Latvia  Lithuania  Luxembourg  Hungary  Malta  Netherlands  Austria  Poland  Portugal  Romania  Slovenia  Slovakia  Finland  Sweden  United Kingdom |
| --- | --- |

2.2.3.

Member State

 Belgium  Bulgaria  Czech Republic  Denmark  Germany  Estonia  Ireland  Greece  Spain  France  Croatia  Italy  Cyprus  Latvia  Lithuania  Luxembourg  Hungary  Malta  Netherlands  Austria  Poland  Portugal  Romania  Slovenia  Slovakia  Finland  Sweden  United Kingdom

2.3.   Telephone/Fax/E-mail: ...

3.   CLAIMANT(S) (8)
   (9)

3.1.   Person A

3.1.1.   Surname and given name(s): ...

3.1.2.   Date (dd/mm/yyyy) and place of birth: ...

3.1.3.   Identity number or social security number: ...

3.1.4.   Address:

| 3.1.4.1. | Street and number/PO box: ... |
| --- | --- |

3.1.4.1.

Street and number/PO box: ...

| 3.1.4.2. | Place and postal code: ... |
| --- | --- |

3.1.4.2.

Place and postal code: ...

| 3.1.4.3. | Country: ... |
| --- | --- |

3.1.4.3.

Country: ...

3.1.5.   Has benefited from

| 3.1.5.1. | legal aid:








   | Yes |  | No |
| --- | --- | --- | --- | --- |

3.1.5.1.

legal aid:



Yes



No

| 3.1.5.2. | exemption from costs and expenses:








   | Yes |  | No |
| --- | --- | --- | --- | --- |

3.1.5.2.

exemption from costs and expenses:



Yes



No

| 3.1.5.3. | free proceedings before an administrative authority listed in Annex X to Regulation (EC) No 4/2009 (10):








   | Yes |  | No |
| --- | --- | --- | --- | --- |

3.1.5.3.

free proceedings before an administrative authority listed in Annex X to Regulation (EC) No 4/2009 (10):



Yes



No

3.2.   Person B

3.2.1.   Surname and given name(s): ...

3.2.2.   Date (dd/mm/yyyy) and place of birth: ...

3.2.3.   Identity number or social security number: ...

3.2.4.   Address:

| 3.2.4.1. | Street and number/PO box: ... |
| --- | --- |

3.2.4.1.

Street and number/PO box: ...

| 3.2.4.2. | Place and postal code: ... |
| --- | --- |

3.2.4.2.

Place and postal code: ...

| 3.2.4.3. | Country: ... |
| --- | --- |

3.2.4.3.

Country: ...

3.2.5.   Has benefited from

| 3.2.5.1. | legal aid:








   | Yes |  | No |
| --- | --- | --- | --- | --- |

3.2.5.1.

legal aid:



Yes



No

| 3.2.5.2. | exemption from costs and expenses:








   | Yes |  | No |
| --- | --- | --- | --- | --- |

3.2.5.2.

exemption from costs and expenses:



Yes



No

| 3.2.5.3. | free proceedings before an administrative authority listed in Annex X to Regulation (EC) No 4/2009 (11):








   | Yes |  | No |
| --- | --- | --- | --- | --- |

3.2.5.3.

free proceedings before an administrative authority listed in Annex X to Regulation (EC) No 4/2009 (11):



Yes



No

3.3.   Person C

3.3.1.   Surname and given name(s): ...

3.3.2.   Date (dd/mm/yyyy) and place of birth: ...

3.3.3.   Identity number or social security number: ...

3.3.4.   Address:

| 3.3.4.1. | Street and number/PO box: ... |
| --- | --- |

3.3.4.1.

Street and number/PO box: ...

| 3.3.4.2. | Place and postal code: ... |
| --- | --- |

3.3.4.2.

Place and postal code: ...

| 3.3.4.3. | Country: ... |
| --- | --- |

3.3.4.3.

Country: ...

3.3.5.   Has benefited from

| 3.3.5.1. | legal aid:








   | Yes |  | No |
| --- | --- | --- | --- | --- |

3.3.5.1.

legal aid:



Yes



No

| 3.3.5.2. | exemption from costs and expenses:








   | Yes |  | No |
| --- | --- | --- | --- | --- |

3.3.5.2.

exemption from costs and expenses:



Yes



No

| 3.3.5.3. | free proceedings before an administrative authority listed in Annex X to Regulation (EC) No 4/2009 (12):








   | Yes |  | No |
| --- | --- | --- | --- | --- |

3.3.5.3.

free proceedings before an administrative authority listed in Annex X to Regulation (EC) No 4/2009 (12):



Yes



No

4.   DEFENDANT(S) (13)
   (14)

4.1.   Person A

4.1.1.   Surname and given name(s): ...

4.1.2.   Date (dd/mm/yyyy) and place of birth: ...

4.1.3.   Identity number or social security number: ...

4.1.4.   Address:

| 4.1.4.1. | Street and number/PO box: ... |
| --- | --- |

4.1.4.1.

Street and number/PO box: ...

| 4.1.4.2. | Place and postal code: ... |
| --- | --- |

4.1.4.2.

Place and postal code: ...

| 4.1.4.3. | Country: ... |
| --- | --- |

4.1.4.3.

Country: ...

4.1.5.   Has benefited from

| 4.1.5.1. | legal aid:








   | Yes |  | No |
| --- | --- | --- | --- | --- |

4.1.5.1.

legal aid:



Yes



No

| 4.1.5.2. | exemption from costs and expenses:








   | Yes |  | No |
| --- | --- | --- | --- | --- |

4.1.5.2.

exemption from costs and expenses:



Yes



No

| 4.1.5.3. | free proceedings before an administrative authority listed in Annex X to Regulation (EC) No 4/2009 (15):








   | Yes |  | No |
| --- | --- | --- | --- | --- |

4.1.5.3.

free proceedings before an administrative authority listed in Annex X to Regulation (EC) No 4/2009 (15):



Yes



No

4.2.   Person B

4.2.1.   Surname and given name(s): ...

4.2.2.   Date (dd/mm/yyyy) and place of birth: ...

4.2.3.   Identity number or social security number: ...

4.2.4.   Address:

| 4.2.4.1. | Street and number/PO box: ... |
| --- | --- |

4.2.4.1.

Street and number/PO box: ...

| 4.2.4.2. | Place and postal code: ... |
| --- | --- |

4.2.4.2.

Place and postal code: ...

| 4.2.4.3. | Country: ... |
| --- | --- |

4.2.4.3.

Country: ...

4.2.5.   Has benefited from

| 4.2.5.1. | legal aid:








   | Yes |  | No |
| --- | --- | --- | --- | --- |

4.2.5.1.

legal aid:



Yes



No

| 4.2.5.2. | exemption from costs and expenses:








   | Yes |  | No |
| --- | --- | --- | --- | --- |

4.2.5.2.

exemption from costs and expenses:



Yes



No

| 4.2.5.3. | free proceedings before an administrative authority listed in Annex X to Regulation (EC) No 4/2009 (16):








   | Yes |  | No |
| --- | --- | --- | --- | --- |

4.2.5.3.

free proceedings before an administrative authority listed in Annex X to Regulation (EC) No 4/2009 (16):



Yes



No

4.3.   Person C

4.3.1.   Surname and given name(s): ...

4.3.2.   Date (dd/mm/yyyy) and place of birth: ...

4.3.3.   Identity number or social security number: ...

4.3.4.   Address:

| 4.3.4.1. | Street and number/PO box: ... |
| --- | --- |

4.3.4.1.

Street and number/PO box: ...

| 4.3.4.2. | Place and postal code: ... |
| --- | --- |

4.3.4.2.

Place and postal code: ...

| 4.3.4.3. | Country: ... |
| --- | --- |

4.3.4.3.

Country: ...

4.3.5.   Has benefited from

| 4.3.5.1. | legal aid:








   | Yes |  | No |
| --- | --- | --- | --- | --- |

4.3.5.1.

legal aid:



Yes



No

| 4.3.5.2. | exemption from costs and expenses:








   | Yes |  | No |
| --- | --- | --- | --- | --- |

4.3.5.2.

exemption from costs and expenses:



Yes



No

| 4.3.5.3. | free proceedings before an administrative authority listed in Annex X to Regulation (EC) No 4/2009 (17):








   | Yes |  | No |
| --- | --- | --- | --- | --- |

4.3.5.3.

free proceedings before an administrative authority listed in Annex X to Regulation (EC) No 4/2009 (17):



Yes



No

5.   TERMS OF THE DECISION/COURT SETTLEMENT

5.1.   Currency

 Euro (EUR)  Lev (BGN)  Czech koruna (CZK)  Danish krone (DKK)  Pound sterling (GBP)  Kuna (HRK)  Forint (HUF)  Zloty (PLN)  Leu (RON)  Krona (SEK)  Other (please specify ISO code): ...

5.2.   Maintenance claim
   (18)

5.2.1.   Maintenance claim A

5.2.1.1.   The maintenance is to be paid

by ... (surname and given name(s))

to ... (surname and given name(s) of the person to whom the sum must actually be paid)

Person for whom maintenance is owed:

... (surname and given name(s))

5.2.1.2.    Amount to be paid in one sum

Period covered, where applicable:

...

(from date (dd/mm/yyyy) to date (dd/mm/yyyy) or event)

Due date: ... (dd/mm/yyyy)

Amount: ...

5.2.1.3.    Amount to be paid in instalments

| Maturity date
  (dd/mm/yyyy) | Amount |
| --- | --- |
| | |
| | |
| | |
| | |

Maturity date

(dd/mm/yyyy)

Amount

5.2.1.4.    Sum to be paid regularly

|  | Once a week |
| --- | --- |
|  | Once a month |
|  | Other (state frequency): ... |



Once a week



Once a month



Other (state frequency): ...

Amount: ...

From: ... (dd/mm/yyyy)

Due day/date: ...

 If applicable, until (date (dd/mm/yyyy) or event):

...

If the maintenance claim is subject to indexation, please indicate how that indexation is to be calculated:

...

Indexation applicable as from: ... (dd/mm/yyyy)

5.2.1.5.    Amount due retroactively

Period covered: ... ((dd/mm/yyyy) to (dd/mm/yyyy))

Amount: ...

Form of payment: ...

...

...

5.2.1.6.    Interest (if specified in the decision/court settlement)

If the maintenance claim is subject to interest, please indicate the rate: ...

Interest due as from: ... (dd/mm/yyyy)

5.2.1.7.    Payment in kind (please specify): ...

...

...

...

5.2.1.8.    Other form of payment (please specify): ...

...

...

...

5.2.2.   Maintenance claim B

5.2.2.1.   The maintenance is to be paid

by ... (surname and given name(s))

to ... (surname and given name(s) of the person to whom the sum must actually be paid)

Person for whom maintenance is owed:

... (surname and given name(s))

5.2.2.2.    Amount to be paid in one sum

Period covered, where applicable:

...

(from date (dd/mm/yyyy) to date (dd/mm/yyyy) or event)

Due date: ... (dd/mm/yyyy)

Amount: ...

5.2.2.3.    Amount to be paid in instalments

| Maturity date
  (dd/mm/yyyy) | Amount |
| --- | --- |
| | |
| | |
| | |
| | |

Maturity date

(dd/mm/yyyy)

Amount

5.2.2.4.    Sum to be paid regularly

|  | Once a week |
| --- | --- |
|  | Once a month |
|  | Other (state frequency): ... |



Once a week



Once a month



Other (state frequency): ...

Amount: ...

From: ... (dd/mm/yyyy)

Due day/date: ...

 If applicable, until (date (dd/mm/yyyy) or event):

...

If the maintenance claim is subject to indexation, please indicate how that indexation is to be calculated: ...

Indexation applicable as from: ... (dd/mm/yyyy)

5.2.2.5.    Amount due retroactively

Period covered: ... ((dd/mm/yyyy) to (dd/mm/yyyy))

Amount: ...

Form of payment: ...

...

...

5.2.2.6.    Interest (if specified in the decision/court settlement)

If the maintenance claim is subject to interest, please indicate the rate: ...

Interest due as from: ... (dd/mm/yyyy)

5.2.2.7.    Payment in kind (please specify): ...

...

...

...

5.2.2.8.    Other form of payment (please specify): ...

...

...

...

5.2.3.   Maintenance claim C

5.2.3.1.   The maintenance is to be paid

by ... (surname and given name(s))

to ... (surname and given name(s) of the person to whom the sum must actually be paid)

Person for whom maintenance is owed:

... (surname and given name(s))

5.2.3.2.    Amount to be paid in one sum

Period covered, where applicable:

...

(from date (dd/mm/yyyy) to date (dd/mm/yyyy) or event)

Due date: ... (dd/mm/yyyy)

Amount: ...

5.2.3.3.    Amount to be paid in instalments

| Maturity date
  (dd/mm/yyyy) | Amount |
| --- | --- |
| | |
| | |
| | |
| | |

Maturity date

(dd/mm/yyyy)

Amount

5.2.3.4.    Sum to be paid regularly

|  | Once a week |
| --- | --- |
|  | Once a month |
|  | Other (state frequency): ... |



Once a week



Once a month



Other (state frequency): ...

Amount: ...

From: ... (dd/mm/yyyy)

Due day/date: ...

 If applicable, until (date (dd/mm/yyyy) or event):

...

If the maintenance claim is subject to indexation, please indicate how that indexation is to be calculated: ...

Indexation applicable as from: ... (dd/mm/yyyy)

5.2.3.5.    Amount due retroactively

Period covered: ... ((dd/mm/yyyy) to (dd/mm/yyyy))

Amount: ...

Form of payment: ...

...

...

5.2.3.6.    Interest (if specified in the decision/court settlement)

If the maintenance claim is subject to interest, please indicate the rate: ...

Interest due as from: ... (dd/mm/yyyy)

5.2.3.7.    Payment in kind (please specify): ...

...

...

...

5.2.3.8.    Other form of payment (please specify): ...

...

...

...

5.3.   Costs and expenses

The decision/court settlement provides that

... (surname and given name(s))

must pay the sum of ...

to: ... (surname and given name(s)).

If additional pages have been attached, state the number of pages: ...

Done at: ... on: ... (dd/mm/yyyy)

Signature and/or stamp of the court of origin:

...

ANNEX III

EXTRACT FROM AN AUTHENTIC INSTRUMENT IN MATTERS RELATING TO MAINTENANCE OBLIGATIONS NOT SUBJECT TO PROCEEDINGS FOR RECOGNITION OR A DECLARATION OF ENFORCEABILITY

(Article 48 of Council Regulation (EC) No 4/2009 of 18 December 2008 on jurisdiction, applicable law, recognition and enforcement of decisions and cooperation in matters relating to maintenance obligations (19))

IMPORTANT

To be issued by the competent authority in the Member State of origin

To be issued only if the authentic instrument is enforceable in the Member State of origin

Mention only information which is given in the authentic instrument or of which the competent authority has been made aware

1.   DATE AND REFERENCE NUMBER OF THE AUTHENTIC INSTRUMENT: ...

The authentic instrument is recognised and enforceable in another Member State without any possibility of opposing its recognition and without the need for a declaration of enforceability (Article 48 of Regulation (EC) No 4/2009).

2.   NATURE OF THE AUTHENTIC INSTRUMENT

2.1.   Instrument formally drawn up or registered on: ... (dd/mm/yyyy)

|  | Agreement concluded or authenticated on: ... (dd/mm/yyyy) |
| --- | --- |



Agreement concluded or authenticated on: ... (dd/mm/yyyy)

2.2.   Competent authority:

| 2.2.1. | Name: ... |
| --- | --- |

2.2.1.

Name: ...

| 2.2.2. | Address:






  2.2.2.1. | Street and number/PO box: ... |
| --- | --- | --- |

2.2.2.

Address:

2.2.2.1.

Street and number/PO box: ...

| 2.2.2.2. | Place and postal code: ... |
| --- | --- |

2.2.2.2.

Place and postal code: ...

| 2.2.2.3. | Member State
   Belgium  Bulgaria  Czech Republic  Germany  Estonia  Ireland  Greece  Spain  France  Croatia  Italy  Cyprus  Latvia  Lithuania  Luxembourg  Hungary  Malta  Netherlands  Austria  Poland  Portugal  Romania  Slovenia  Finland  Sweden |
| --- | --- |

2.2.2.3.

Member State

 Belgium  Bulgaria  Czech Republic  Germany  Estonia  Ireland  Greece  Spain  France  Croatia  Italy  Cyprus  Latvia  Lithuania  Luxembourg  Hungary  Malta  Netherlands  Austria  Poland  Portugal  Romania  Slovenia  Finland  Sweden

| 2.2.3. | Telephone/Fax/E-mail: ... |
| --- | --- |

2.2.3.

Telephone/Fax/E-mail: ...

3.   CREDITOR(S) (20)

3.1.   Person A

3.1.1.   Surname and given name(s): ...

3.1.2.   Date (dd/mm/yyyy) and place of birth: ...

3.1.3.   Identity number or social security number: ...

3.1.4.   Address:

| 3.1.4.1. | Street and number/PO box: ... |
| --- | --- |

3.1.4.1.

Street and number/PO box: ...

| 3.1.4.2. | Place and postal code: ... |
| --- | --- |

3.1.4.2.

Place and postal code: ...

| 3.1.4.3. | Country: ... |
| --- | --- |

3.1.4.3.

Country: ...

3.2.   Person B

3.2.1.   Surname and given name(s): ...

3.2.2.   Date (dd/mm/yyyy) and place of birth: ...

3.2.3.   Identity number or social security number: ...

3.2.4.   Address:

| 3.2.4.1. | Street and number/PO box: ... |
| --- | --- |

3.2.4.1.

Street and number/PO box: ...

| 3.2.4.2. | Place and postal code: ... |
| --- | --- |

3.2.4.2.

Place and postal code: ...

| 3.2.4.3. | Country: ... |
| --- | --- |

3.2.4.3.

Country: ...

3.3.   Person C

3.3.1.   Surname and given name(s): ...

3.3.2.   Date (dd/mm/yyyy) and place of birth: ...

3.3.3.   Identity number or social security number: ...

3.3.4.   Address:

| 3.3.4.1. | Street and number/PO box: ... |
| --- | --- |

3.3.4.1.

Street and number/PO box: ...

| 3.3.4.2. | Place and postal code: ... |
| --- | --- |

3.3.4.2.

Place and postal code: ...

| 3.3.4.3. | Country: ... |
| --- | --- |

3.3.4.3.

Country: ...

4.   DEBTOR(S) (21)

4.1.   Person A

4.1.1.   Surname and given name(s): ...

4.1.2.   Date (dd/mm/yyyy) and place of birth: ...

4.1.3.   Identity number or social security number: ...

4.1.4.   Address:

| 4.1.4.1. | Street and number/PO box: ... |
| --- | --- |

4.1.4.1.

Street and number/PO box: ...

| 4.1.4.2. | Place and postal code: ... |
| --- | --- |

4.1.4.2.

Place and postal code: ...

| 4.1.4.3. | Country: ... |
| --- | --- |

4.1.4.3.

Country: ...

4.2.   Person B

4.2.1.   Surname and given name(s): ...

4.2.2.   Date (dd/mm/yyyy) and place of birth: ...

4.2.3.   Identity number or social security number: ...

4.2.4.   Address:

| 4.2.4.1. | Street and number/PO box: ... |
| --- | --- |

4.2.4.1.

Street and number/PO box: ...

| 4.2.4.2. | Place and postal code: ... |
| --- | --- |

4.2.4.2.

Place and postal code: ...

| 4.2.4.3. | Country: ... |
| --- | --- |

4.2.4.3.

Country: ...

4.3.   Person C

4.3.1.   Surname and given name(s): ...

4.3.2.   Date (dd/mm/yyyy) and place of birth: ...

4.3.3.   Identity number or social security number: ...

4.3.4.   Address:

| 4.3.4.1. | Street and number/PO box: ... |
| --- | --- |

4.3.4.1.

Street and number/PO box: ...

| 4.3.4.2. | Place and postal code: ... |
| --- | --- |

4.3.4.2.

Place and postal code: ...

| 4.3.4.3. | Country: ... |
| --- | --- |

4.3.4.3.

Country: ...

5.   CONTENTS OF THE AUTHENTIC INSTRUMENT

5.1.   Currency

 Euro (EUR)  Lev (BGN)  Czech koruna (CZK)  Kuna (HRK)  Forint (HUF)  Zloty (PLN)  Leu (RON)  Krona (SEK)  Other (please specify ISO code): ...

5.2.   Maintenance claim
   (22)

5.2.1.   Maintenance claim A

5.2.1.1.   The maintenance is to be paid

by ... (surname and given name(s))

to ... (surname and given name(s) of the person to whom the sum must actually be paid)

Person for whom maintenance is owed:

... (surname and given name(s))

5.2.1.2.    Amount to be paid in one sum

Period covered, where applicable:

...

(from date (dd/mm/yyyy) to date (dd/mm/yyyy) or event)

Due date: ... (dd/mm/yyyy)

Amount: ...

5.2.1.3.    Amount to be paid in instalments

| Maturity date
  (dd/mm/yyyy) | Amount |
| --- | --- |
| | |
| | |
| | |
| | |

Maturity date

(dd/mm/yyyy)

Amount

5.2.1.4.    Sum to be paid regularly

|  | Once a week |
| --- | --- |
|  | Once a month |
|  | Other (state frequency): ... |



Once a week



Once a month



Other (state frequency): ...

Amount: ...

From: ... (dd/mm/yyyy)

Due day/date: ...

 If applicable, until (date (dd/mm/yyyy) or event):

...

If the maintenance claim is subject to indexation, please indicate how that indexation is to be calculated:

...

Indexation applicable as from: ... (dd/mm/yyyy)

5.2.1.5.    Amount due retroactively

Period covered: ... ((dd/mm/yyyy) to (dd/mm/yyyy))

Amount: ...

Form of payment: ...

...

...

5.2.1.6.    Interest (if specified in the authentic instrument)

If the maintenance claim is subject to interest, please indicate the rate: ...

Interest due as from: ... (dd/mm/yyyy)

5.2.1.7.    Payment in kind (please specify): ...

...

...

...

5.2.1.8.    Other form of payment (please specify): ...

...

...

...

5.2.2.   Maintenance claim B

5.2.2.1.   The maintenance is to be paid

by ... (surname and given name(s))

to ... (surname and given name(s) of the person to whom the sum must actually be paid)

Person for whom maintenance is owed:

... (surname and given name(s))

5.2.2.2.    Amount to be paid in one sum

Period covered, where applicable:

...

(from date (dd/mm/yyyy) to date (dd/mm/yyyy) or event)

Due date: ... (dd/mm/yyyy)

Amount: ...

5.2.2.3.    Amount to be paid in instalments

| Maturity date
  (dd/mm/yyyy) | Amount |
| --- | --- |
| | |
| | |
| | |
| | |

Maturity date

(dd/mm/yyyy)

Amount

5.2.2.4.    Sum to be paid regularly

|  | Once a week |
| --- | --- |
|  | Once a month |
|  | Other (state frequency): ... |



Once a week



Once a month



Other (state frequency): ...

Amount: ...

From: ... (dd/mm/yyyy)

Due day/date: ...

 If applicable, until (date (dd/mm/yyyy) or event):

...

If the maintenance claim is subject to indexation, please indicate how that indexation is to be calculated:

...

Indexation applicable as from: ... (dd/mm/yyyy)

5.2.2.5.    Amount due retroactively

Period covered: ... ((dd/mm/yyyy) to (dd/mm/yyyy))

Amount: ...

Form of payment: ...

...

...

5.2.2.6.    Interest (if specified in the authentic instrument)

If the maintenance claim is subject to interest, please indicate the rate: ...

Interest due as from: ... (dd/mm/yyyy)

5.2.2.7.    Payment in kind (please specify): ...

...

...

...

5.2.2.8.    Other form of payment (please specify): ...

...

...

...

5.2.3.   Maintenance claim C

5.2.3.1.   The maintenance is to be paid

by ... (surname and given name(s))

to ... (surname and given name(s) of the person to whom the sum must actually be paid)

Person for whom maintenance is owed:

... (surname and given name(s))

5.2.3.2.    Amount to be paid in one sum

Period covered, where applicable:

...

(from date (dd/mm/yyyy) to date (dd/mm/yyyy) or event)

Due date: ... (dd/mm/yyyy)

Amount: ...

5.2.3.3.    Amount to be paid in instalments

| Maturity date
  (dd/mm/yyyy) | Amount |
| --- | --- |
| | |
| | |
| | |
| | |

Maturity date

(dd/mm/yyyy)

Amount

5.2.3.4.    Sum to be paid regularly

|  | Once a week |
| --- | --- |
|  | Once a month |
|  | Other (state frequency): ... |



Once a week



Once a month



Other (state frequency): ...

Amount: ...

From: ... (dd/mm/yyyy)

Due day/date: ...

 If applicable, until (date (dd/mm/yyyy) or event):

...

If the maintenance claim is subject to indexation, please indicate how that indexation is to be calculated: ...

Indexation applicable as from: ... (dd/mm/yyyy)

5.2.3.5.    Amount due retroactively

Period covered: ... ((dd/mm/yyyy) to (dd/mm/yyyy))

Amount: ...

Form of payment: ...

...

...

5.2.3.6.    Interest (if specified in the authentic instrument)

If the maintenance claim is subject to interest, please indicate the rate: ...

Interest due as from: ... (dd/mm/yyyy)

5.2.3.7.    Payment in kind (please specify): ...

...

...

...

5.2.3.8.    Other form of payment (please specify): ...

...

...

...

5.3.   Costs

The authentic instrument provides that

... (surname and given name(s))

must pay the sum of ...

to: ... (surname and given name(s)).

If additional pages have been attached, state the number of pages: ...

Done at: ... on: ... (dd/mm/yyyy)

Signature and/or stamp of the competent authority:

...

ANNEX IV

EXTRACT FROM AN AUTHENTIC INSTRUMENT IN MATTERS RELATING TO MAINTENANCE OBLIGATIONS SUBJECT TO PROCEEDINGS FOR RECOGNITION AND A DECLARATION OF ENFORCEABILITY

(Articles 48 and 75(2) of Council Regulation (EC) No 4/2009 of 18 December 2008 on jurisdiction, applicable law, recognition and enforcement of decisions and cooperation in matters relating to maintenance obligations (23))

IMPORTANT

To be issued by the competent authority in the Member State of origin

To be issued only if the authentic instrument is enforceable in the Member State of origin

Mention only information which is given in the authentic instrument or of which the competent authority has been made aware

1.   DATE AND REFERENCE NUMBER OF THE AUTHENTIC INSTRUMENT: ...

2.   NATURE OF THE AUTHENTIC INSTRUMENT

2.1.    Instrument formally drawn up or registered on: ... (dd/mm/yyyy)

|  | Agreement concluded or authenticated on: ... (dd/mm/yyyy) |
| --- | --- |



Agreement concluded or authenticated on: ... (dd/mm/yyyy)

2.2.   Competent authority:

| 2.2.1. | Name: ... |
| --- | --- |

2.2.1.

Name: ...

| 2.2.2. | Address:






  2.2.2.1. | Street and number/PO box: ... |
| --- | --- | --- |

2.2.2.

Address:

2.2.2.1.

Street and number/PO box: ...

| 2.2.2.2. | Place and postal code: ... |
| --- | --- |

2.2.2.2.

Place and postal code: ...

| 2.2.2.3. | Member State:
   Belgium  Bulgaria  Czech Republic  Denmark  Germany  Estonia Ireland  Greece  Spain  France  Croatia  Italy  Cyprus  Latvia  Lithuania  Luxembourg  Hungary  Malta  Netherlands  Austria  Poland  Portugal  Romania  Slovenia  Slovakia  Finland  Sweden  United Kingdom |
| --- | --- |

2.2.2.3.

Member State:

 Belgium  Bulgaria  Czech Republic  Denmark  Germany  Estonia Ireland  Greece  Spain  France  Croatia  Italy  Cyprus  Latvia  Lithuania  Luxembourg  Hungary  Malta  Netherlands  Austria  Poland  Portugal  Romania  Slovenia  Slovakia  Finland  Sweden  United Kingdom

| 2.2.3. | Telephone/Fax/E-mail: ... |
| --- | --- |

2.2.3.

Telephone/Fax/E-mail: ...

3.   CREDITOR(S) (24)

3.1.   Person A

3.1.1.   Surname and given name(s): ...

3.1.2.   Date (dd/mm/yyyy) and place of birth: ...

3.1.3.   Identity number or social security number: ...

3.1.4.   Address:

| 3.1.4.1. | Street and number/PO box: ... |
| --- | --- |

3.1.4.1.

Street and number/PO box: ...

| 3.1.4.2. | Place and postal code: ... |
| --- | --- |

3.1.4.2.

Place and postal code: ...

| 3.1.4.3. | Country: ... |
| --- | --- |

3.1.4.3.

Country: ...

3.2.   Person B

3.2.1.   Surname and given name(s): ...

3.2.2.   Date (dd/mm/yyyy) and place of birth: ...

3.2.3.   Identity number or social security number: ...

3.2.4.   Address:

| 3.2.4.1. | Street and number/PO box: ... |
| --- | --- |

3.2.4.1.

Street and number/PO box: ...

| 3.2.4.2. | Place and postal code: ... |
| --- | --- |

3.2.4.2.

Place and postal code: ...

| 3.2.4.3. | Country: ... |
| --- | --- |

3.2.4.3.

Country: ...

3.3.   Person C

3.3.1.   Surname and given name(s): ...

3.3.2.   Date (dd/mm/yyyy) and place of birth: ...

3.3.3.   Identity number or social security number: ...

3.3.4.   Address:

| 3.3.4.1. | Street and number/PO box: ... |
| --- | --- |

3.3.4.1.

Street and number/PO box: ...

| 3.3.4.2. | Place and postal code: ... |
| --- | --- |

3.3.4.2.

Place and postal code: ...

| 3.3.4.3. | Country: ... |
| --- | --- |

3.3.4.3.

Country: ...

4.   DEBTOR(S) (25)

4.1.   Person A

4.1.1.   Surname and given name(s): ...

4.1.2.   Date (dd/mm/yyyy) and place of birth: ...

4.1.3.   Identity number or social security number: ...

4.1.4.   Address:

| 4.1.4.1. | Street and number/PO box: ... |
| --- | --- |

4.1.4.1.

Street and number/PO box: ...

| 4.1.4.2. | Place and postal code: ... |
| --- | --- |

4.1.4.2.

Place and postal code: ...

| 4.1.4.3. | Country: ... |
| --- | --- |

4.1.4.3.

Country: ...

4.2.   Person B

4.2.1.   Surname and given name(s): ...

4.2.2.   Date (dd/mm/yyyy) and place of birth: ...

4.2.3.   Identity number or social security number: ...

4.2.4.   Address:

| 4.2.4.1. | Street and number/PO box: ... |
| --- | --- |

4.2.4.1.

Street and number/PO box: ...

| 4.2.4.2. | Place and postal code: ... |
| --- | --- |

4.2.4.2.

Place and postal code: ...

| 4.2.4.3. | Country: ... |
| --- | --- |

4.2.4.3.

Country: ...

4.3.   Person C

4.3.1.   Surname and given name(s): ...

4.3.2.   Date (dd/mm/yyyy) and place of birth: ...

4.3.3.   Identity number or social security number: ...

4.3.4.   Address:

| 4.3.4.1. | Street and number/PO box: ... |
| --- | --- |

4.3.4.1.

Street and number/PO box: ...

| 4.3.4.2. | Place and postal code: ... |
| --- | --- |

4.3.4.2.

Place and postal code: ...

| 4.3.4.3. | Country: ... |
| --- | --- |

4.3.4.3.

Country: ...

5.   CONTENTS OF THE AUTHENTIC INSTRUMENT

5.1.   Currency

 Euro (EUR)  Lev (BGN)  Czech koruna (CZK)  Danish krone (DKK)  Pound sterling (GBP)  Kuna (HRK)  Forint (HUF)  Zloty (PLN)  Leu (RON)  Krona (SEK)  Other (please specify ISO code): ...

5.2.   Maintenance claim
   (26)

5.2.1.   Maintenance claim A

5.2.1.1.   The maintenance is to be paid

by ... (surname and given name(s))

to ... (surname and given name(s) of the person to whom the sum must actually be paid)

Person for whom maintenance is owed:

... (surname and given name(s))

5.2.1.2.    Amount to be paid in one sum

Period covered, where applicable:

...

(from date (dd/mm/yyyy) to date (dd/mm/yyyy) or event)

Due date: ... (dd/mm/yyyy)

Amount: ...

5.2.1.3.    Amount to be paid in instalments

| Maturity date
  (dd/mm/yyyy) | Amount |
| --- | --- |
| | |
| | |
| | |
| | |

Maturity date

(dd/mm/yyyy)

Amount

5.2.1.4.    Sum to be paid regularly

|  | Once a week |
| --- | --- |
|  | Once a month |
|  | Other (state frequency): ... |



Once a week



Once a month



Other (state frequency): ...

Amount: ...

From: ... (dd/mm/yyyy)

Due day/date: ...

 If applicable, until (date (dd/mm/yyyy) or event):

...

If the maintenance claim is subject to indexation, please indicate how that indexation is to be calculated: ...

...

Indexation applicable as from: ... (dd/mm/yyyy)

5.2.1.5.    Amount due retroactively

Period covered: ... ((dd/mm/yyyy) to (dd/mm/yyyy))

Amount: ...

Form of payment: ...

...

...

5.2.1.6.    Interest (if specified in the authentic instrument)

If the maintenance claim is subject to interest, please indicate the rate: ...

...

Interest due as from: ... (dd/mm/yyyy)

5.2.1.7.    Payment in kind (please specify): ...

...

...

...

5.2.1.8.    Other form of payment (please specify): ...

...

...

...

5.2.2.   Maintenance claim B

5.2.2.1.   The maintenance is to be paid

by ... (surname and given name(s))

to ... (surname and given name(s) of the person to whom the sum must actually be paid)

...

Person for whom maintenance is owed: ... (surname and given name(s))

5.2.2.2.    Amount to be paid in one sum

Period covered, where applicable:

...

(from date (dd/mm/yyyy) to date (dd/mm/yyyy) or event)

Due date: ... (dd/mm/yyyy)

Amount: ...

5.2.2.3.    Amount to be paid in instalments

| Maturity date
  (dd/mm/yyyy) | Amount |
| --- | --- |
| | |
| | |
| | |
| | |

Maturity date

(dd/mm/yyyy)

Amount

5.2.2.4.    Sum to be paid regularly

|  | Once a week |
| --- | --- |
|  | Once a month |
|  | Other (state frequency): ... |



Once a week



Once a month



Other (state frequency): ...

Amount: ...

From: ... (dd/mm/yyyy)

Due day/date: ...

 If applicable, until (date (dd/mm/yyyy) or event):

...

If the maintenance claim is subject to indexation, please indicate how that indexation is to be calculated: ...

Indexation applicable as from: ... (dd/mm/yyyy)

5.2.2.5.    Amount due retroactively

Period covered: ... ((dd/mm/yyyy) to (dd/mm/yyyy))

Amount: ...

Form of payment: ...

...

...

5.2.2.6.    Interest (if specified in the authentic instrument)

If the maintenance claim is subject to interest, please indicate the rate: ...

Interest due as from: ... (dd/mm/yyyy)

5.2.2.7.    Payment in kind (please specify): ...

...

...

...

5.2.2.8.    Other form of payment (please specify): ...

...

...

...

5.2.3.   Maintenance claim C

5.2.3.1.   The maintenance is to be paid

by ... (surname and given name(s))

to ... (surname and given name(s) of the person to whom the sum must actually be paid)

...

Person for whom maintenance is owed: ... (surname and given name(s))

5.2.3.2.    Amount to be paid in one sum

Period covered, where applicable:

...

(from date (dd/mm/yyyy) to date (dd/mm/yyyy) or event)

Due date: ... (dd/mm/yyyy)

Amount: ...

5.2.3.3.    Amount to be paid in instalments

| Maturity date
  (dd/mm/yyyy) | Amount |
| --- | --- |
| | |
| | |
| | |
| | |

Maturity date

(dd/mm/yyyy)

Amount

5.2.3.4.    Sum to be paid regularly

|  | Once a week |
| --- | --- |
|  | Once a month |
|  | Other (state frequency): ... |



Once a week



Once a month



Other (state frequency): ...

Amount: ...

From: ... (dd/mm/yyyy)

Due day/date: ...

 If applicable, until (date (dd/mm/yyyy) or event):

...

If the maintenance claim is subject to indexation, please indicate how that indexation is to be calculated: ...

...

Indexation applicable as from: ... (dd/mm/yyyy)

5.2.3.5.    Amount due retroactively

Period covered: ... ((dd/mm/yyyy) to (dd/mm/yyyy))

Amount: ...

Form of payment: ...

...

...

5.2.3.6.    Interest (if specified in the authentic instrument)

If the maintenance claim is subject to interest, please indicate the rate: ...

Interest due as from: ... (dd/mm/yyyy)

5.2.3.7.    Payment in kind (please specify): ...

...

...

...

5.2.3.8.    Other form of payment (please specify): ...

...

...

...

5.3.   Costs

The authentic instrument provides that

... (surname and given name(s))

must pay the sum of ...

to ... (surname and given name(s)).

If additional pages have been attached, state the number of pages: ...

Done at: ... on: ... (dd/mm/yyyy)

Signature and/or stamp of the competent authority:

...

ANNEX V

REQUEST FOR SPECIFIC MEASURES

(Article 53 of Council Regulation (EC) No 4/2009 of 18 December 2008 on jurisdiction, applicable law, recognition and enforcement of decisions and cooperation in matters relating to maintenance obligations (27))

PART A

To be completed by the requesting Central Authority

1.   REQUESTING CENTRAL AUTHORITY

1.1.   Name: ...

1.2.   Address:

| 1.2.1. | Street and number/PO box: ... |
| --- | --- |

1.2.1.

Street and number/PO box: ...

| 1.2.2. | Place and postal code: ... |
| --- | --- |

1.2.2.

Place and postal code: ...

| 1.2.3. | Member State
   Belgium  Bulgaria  Czech Republic  Germany  Estonia  Ireland  Greece  Spain  France  Croatia  Italy  Cyprus  Latvia  Lithuania  Luxembourg  Hungary  Malta  Netherlands  Austria  Poland  Portugal  Romania  Slovenia  Slovakia  Finland  Sweden  United Kingdom |
| --- | --- |

1.2.3.

Member State

 Belgium  Bulgaria  Czech Republic  Germany  Estonia  Ireland  Greece  Spain  France  Croatia  Italy  Cyprus  Latvia  Lithuania  Luxembourg  Hungary  Malta  Netherlands  Austria  Poland  Portugal  Romania  Slovenia  Slovakia  Finland  Sweden  United Kingdom

1.3.   Telephone: ...

1.4.   Fax ...

1.5.   E-mail: ...

1.6.   Reference number: ...

1.7.   Person responsible for following up the request:

| 1.7.1. | Surname and given name(s): ... |
| --- | --- |

1.7.1.

Surname and given name(s): ...

| 1.7.2. | Telephone: ... |
| --- | --- |

1.7.2.

Telephone: ...

| 1.7.3. | E-mail: ... |
| --- | --- |

1.7.3.

E-mail: ...

2.   REQUESTED CENTRAL AUTHORITY

2.1.   Name: ...

2.2.   Address:

| 2.2.1. | Street and number/PO box: ... |
| --- | --- |

2.2.1.

Street and number/PO box: ...

| 2.2.2. | Place and postal code: ... |
| --- | --- |

2.2.2.

Place and postal code: ...

| 2.2.3. | Member State
   Belgium  Bulgaria  Czech Republic  Germany  Estonia  Ireland  Greece  Spain  France  Croatia  Italy  Cyprus  Latvia  Lithuania  Luxembourg  Hungary  Malta  Netherlands  Austria  Poland  Portugal  Romania  Slovenia  Slovakia  Finland  Sweden  United Kingdom |
| --- | --- |

2.2.3.

Member State

 Belgium  Bulgaria  Czech Republic  Germany  Estonia  Ireland  Greece  Spain  France  Croatia  Italy  Cyprus  Latvia  Lithuania  Luxembourg  Hungary  Malta  Netherlands  Austria  Poland  Portugal  Romania  Slovenia  Slovakia  Finland  Sweden  United Kingdom

3.   REQUEST

3.1.   The purpose of the specific measure requested is to:

| 3.1.1. |  help locate the debtor or the creditor (see points 3.3. and 3.4.) |
| --- | --- |

3.1.1.

 help locate the debtor or the creditor (see points 3.3. and 3.4.)

| 3.1.2. |  facilitate the search for information on the income or assets of the debtor or the creditor (see points 3.3. and 3.4.) |
| --- | --- |

3.1.2.

 facilitate the search for information on the income or assets of the debtor or the creditor (see points 3.3. and 3.4.)

| 3.1.3. |  facilitate the obtaining of documentary or other evidence |
| --- | --- |

3.1.3.

 facilitate the obtaining of documentary or other evidence

| 3.1.4. |  obtain assistance in establishing parentage |
| --- | --- |

3.1.4.

 obtain assistance in establishing parentage

| 3.1.5. |  initiate or facilitate the institution of proceedings to obtain a necessary provisional measure which is territorial in nature |
| --- | --- |

3.1.5.

 initiate or facilitate the institution of proceedings to obtain a necessary provisional measure which is territorial in nature

| 3.1.6. |  facilitate service of a document |
| --- | --- |

3.1.6.

 facilitate service of a document

3.2.   Grounds for the request:

...

...

...

...

...

3.3.   The information requested relates to:

3.3.1.    the following debtor

3.3.1.1.   Surname and given name(s): ...

3.3.1.2.   Date (dd/mm/yyyy) and place of birth (28): ...

3.3.1.3.   Last known address: ...

3.3.1.4.   Identity number or social security number (29): ...

3.3.1.5.   Any other information which may be useful (30):

...

...

3.3.2.    the following creditor

3.3.2.1.   Surname and given name(s): ...

3.3.2.2.   Date (dd/mm/yyyy) and place of birth (31): ...

3.3.2.3.   Last known address: ...

3.3.2.4.   Identity number or social security number (32): ...

3.3.2.5.   Any other information which may be useful (33):

...

...

3.4.   Information requested

3.4.1.    Current address of the debtor/creditor

3.4.2.    Income of the debtor/creditor

3.4.3.    Assets of the debtor/creditor, including the location of the assets of the debtor/creditor

The creditor has produced a copy of the decision, court settlement or authentic instrument to be enforced, if appropriate accompanied by the relevant form.

|  | Yes |  | No |
| --- | --- | --- | --- |



Yes



No

 There is a risk that notifying the person concerned by the collection of this information may prejudice the effective recovery of the maintenance claim (Article 63(2) of Regulation (EC) No 4/2009).

Done at ..., on ... (dd/mm/yyyy)

Name and signature of the authorised official of the requesting Central Authority:

...

PART B

To be completed by the requested Central Authority

4.   REFERENCE NUMBER OF THE REQUESTED CENTRAL AUTHORITY:

5.   PERSON RESPONSIBLE FOR FOLLOWING UP THE REQUEST: ...

5.1.   Surname and given name(s): ...

5.2.   Telephone: ...

5.3.   Fax ...

5.4.   E-mail: ...

6.   MEASURES TAKEN AND RESULTS OBTAINED

...

...

...

...

7.   INFORMATION COLLECTED:

7.1.   Without recourse to Articles 61, 62 and 63 of Regulation (EC) No 4/2009:

7.1.1.   Debtor’s/creditor’s address:

|  | No |  | Yes (please specify): |
| --- | --- | --- | --- |



No



Yes (please specify):

...

...

7.1.2.   Debtor’s/creditor’s revenue:

|  | No |  | Yes (please specify): |
| --- | --- | --- | --- |



No



Yes (please specify):

...

...

7.1.3.   Debtor’s/creditor’s assets:

|  | No |  | Yes (please specify): |
| --- | --- | --- | --- |



No



Yes (please specify):

...

...

7.2.   Pursuant to Articles 61, 62 and 63 of Regulation (EC) No 4/2009:

7.2.1.   Debtor’s/creditor’s address:

|  | No |  | Yes (please specify): |
| --- | --- | --- | --- |



No



Yes (please specify):

...

...

...

7.2.2.   Existence of debtor’s income:

|  | No |  | Yes |
| --- | --- | --- | --- |



No



Yes

7.2.3.   Existence of debtor’s assets:

|  | No |  | Yes |
| --- | --- | --- | --- |



No



Yes

IMPORTANT

(In the event of the application of Articles 61, 62 and 63 of Regulation (EC) No 4/2009)

Except for information merely indicating the existence of an address, income or assets in the requested Member State, the information referred to in Article 61(1) may not be disclosed to the person having applied to the requesting Central Authority, subject to the application of procedural rules before a court (Article 62(2), second subparagraph, of Regulation (EC) No 4/2009).

8.   INABILITY TO COMMUNICATE THE REQUESTED INFORMATION

The requested Central Authority is not able to provide the information requested, for the following reasons:

...

...

...

Done at ..., on ... (dd/mm/yyyy)

Name and signature of the authorised official of the requested Central Authority:

...

ANNEX VI

APPLICATION FORM WITH A VIEW TO THE RECOGNITION, DECLARATION OF ENFORCEABILITY OR ENFORCEMENT OF A DECISION IN MATTERS RELATING TO MAINTENANCE OBLIGATIONS

(Articles 56 and 57 of Council Regulation (EC) No 4/2009 of 18 December 2008 on jurisdiction, applicable law, recognition and enforcement of decisions and cooperation in matters relating to maintenance obligations (34))

PART A

To be completed by the requesting Central Authority

1.   APPLICATION

|  | Application for recognition or for recognition and declaration of enforceability of a decision (Article 56(1)(a)) |
| --- | --- |
|  | Application for recognition of a decision (Article 56(2)(a)) |
|  | Application for enforcement of a decision given or recognised in the requested Member State (Article 56(1)(b)) |



Application for recognition or for recognition and declaration of enforceability of a decision (Article 56(1)(a))



Application for recognition of a decision (Article 56(2)(a))



Application for enforcement of a decision given or recognised in the requested Member State (Article 56(1)(b))

2.   REQUESTING CENTRAL AUTHORITY

2.1.   Name: ...

2.2.   Address:

| 2.2.1. | Street and number/PO box: ... |
| --- | --- |

2.2.1.

Street and number/PO box: ...

| 2.2.2. | Place and postal code: ... |
| --- | --- |

2.2.2.

Place and postal code: ...

| 2.2.3. | Member State
   Belgium  Bulgaria  Czech Republic  Germany  Estonia  Ireland  Greece  Spain  France  Croatia  Italy  Cyprus  Latvia  Lithuania  Luxembourg  Hungary  Malta  Netherlands  Austria  Poland  Portugal  Romania  Slovenia  Slovakia  Finland  Sweden  United Kingdom |
| --- | --- |

2.2.3.

Member State

 Belgium  Bulgaria  Czech Republic  Germany  Estonia  Ireland  Greece  Spain  France  Croatia  Italy  Cyprus  Latvia  Lithuania  Luxembourg  Hungary  Malta  Netherlands  Austria  Poland  Portugal  Romania  Slovenia  Slovakia  Finland  Sweden  United Kingdom

2.3.   Telephone: ...

2.4.   Fax ...

2.5.   E-mail: ...

2.6.   Reference number of the application: ...

Application to be handled with the application(s) bearing the following reference number(s): ...

2.7.   Person responsible for following up the application:

| 2.7.1. | Surname and given name(s): ... |
| --- | --- |

2.7.1.

Surname and given name(s): ...

| 2.7.2. | Telephone: ... |
| --- | --- |

2.7.2.

Telephone: ...

| 2.7.3. | E-mail: ... |
| --- | --- |

2.7.3.

E-mail: ...

3.   REQUESTED CENTRAL AUTHORITY

3.1.   Name: ...

3.2.   Address:

| 3.2.1. | Street and number/PO box: ... |
| --- | --- |

3.2.1.

Street and number/PO box: ...

| 3.2.2. | Place and postal code: ... |
| --- | --- |

3.2.2.

Place and postal code: ...

| 3.2.3. | Member State
   Belgium  Bulgaria  Czech Republic  Germany  Estonia  Ireland  Greece  Spain  France  Croatia  Italy  Cyprus  Latvia  Lithuania  Luxembourg  Hungary  Malta  Netherlands  Austria  Poland  Portugal  Romania  Slovenia  Slovakia  Finland  Sweden  United Kingdom |
| --- | --- |

3.2.3.

Member State

 Belgium  Bulgaria  Czech Republic  Germany  Estonia  Ireland  Greece  Spain  France  Croatia  Italy  Cyprus  Latvia  Lithuania  Luxembourg  Hungary  Malta  Netherlands  Austria  Poland  Portugal  Romania  Slovenia  Slovakia  Finland  Sweden  United Kingdom

4.   DOCUMENTS ATTACHED (35) TO THE APPLICATION IN THE CASE OF A DECISION MADE IN A MEMBER STATE

|  | A copy of the decision/court settlement/authentic instrument |
| --- | --- |
|  | An extract from the decision/court settlement/authentic instrument using the form set out in Annex I, Annex II, Annex III or Annex IV |
|  | A transliteration or translation of the contents of the form set out in Annex I, Annex II, Annex III or Annex IV |
|  | Where appropriate, a copy of the decision on the declaration of enforceability |
|  | A document showing the amount of any arrears and the date such amount was calculated |
|  | A document indicating that the applicant has benefited from legal aid or from exemption from costs and expenses |
|  | A document indicating that the applicant has benefited from free proceedings before an administrative authority in the Member State of origin, and confirming that the applicant fulfils the financial requirements to qualify for legal aid or exemption from costs and expenses |
|  | A document establishing the right of the public body to apply for reimbursement of benefits paid to the creditor and justifying the payment of such benefits |
|  | Other (please specify): ...
  ...
  ...
  ... |



A copy of the decision/court settlement/authentic instrument



An extract from the decision/court settlement/authentic instrument using the form set out in Annex I, Annex II, Annex III or Annex IV



A transliteration or translation of the contents of the form set out in Annex I, Annex II, Annex III or Annex IV



Where appropriate, a copy of the decision on the declaration of enforceability



A document showing the amount of any arrears and the date such amount was calculated



A document indicating that the applicant has benefited from legal aid or from exemption from costs and expenses



A document indicating that the applicant has benefited from free proceedings before an administrative authority in the Member State of origin, and confirming that the applicant fulfils the financial requirements to qualify for legal aid or exemption from costs and expenses



A document establishing the right of the public body to apply for reimbursement of benefits paid to the creditor and justifying the payment of such benefits



Other (please specify): ...

...

...

...

5.   DOCUMENTS ATTACHED (36) TO THE APPLICATION IN THE CASE OF A DECISION MADE IN A THIRD STATE

|  | The complete text of the decision. |
| --- | --- |
|  | A summary of or extract from the decision drawn up by the competent authority of the State of origin. |
|  | A document stating that the decision is enforceable in the State of origin and, in the case of a decision by an administrative authority, a document stating that the requirements of Article 19(3) of the 2007 Hague Convention are met. |
|  | If the defendant did not appear and was not represented in the proceedings in the State of origin, a document or documents attesting, as appropriate, either that the defendant had proper notice of the proceedings and an opportunity to be heard, or that the defendant had proper notice of the decision and the opportunity to challenge it or appeal it in fact and law. |
|  | A document showing the amount of any arrears and the date such amount was calculated. |
|  | A document providing the information necessary to make appropriate calculations in the case of a decision providing for automatic adjustment by indexation. |
|  | A document showing the extent to which the applicant received free legal assistance in the State of origin. |
|  | Other (please specify): ...
  ...
  ...
  ... |



The complete text of the decision.



A summary of or extract from the decision drawn up by the competent authority of the State of origin.



A document stating that the decision is enforceable in the State of origin and, in the case of a decision by an administrative authority, a document stating that the requirements of Article 19(3) of the 2007 Hague Convention are met.



If the defendant did not appear and was not represented in the proceedings in the State of origin, a document or documents attesting, as appropriate, either that the defendant had proper notice of the proceedings and an opportunity to be heard, or that the defendant had proper notice of the decision and the opportunity to challenge it or appeal it in fact and law.



A document showing the amount of any arrears and the date such amount was calculated.



A document providing the information necessary to make appropriate calculations in the case of a decision providing for automatic adjustment by indexation.



A document showing the extent to which the applicant received free legal assistance in the State of origin.



Other (please specify): ...

...

...

...

Total number of documents attached to the application form: ...

Done at: ... on ... (dd/mm/yyyy)

Name and signature of the authorised official of the requesting Central Authority: ...

PART B

To be completed by the applicant or, as appropriate, by the person/authority authorised in the requesting Member State to complete the form on the applicant’s behalf

6.   APPLICATION

6.1.    Application for recognition or for recognition and declaration of enforceability of a decision

The application is based on:

| 6.1.1. |  Chapter IV, Section 2, of Regulation (EC) No 4/2009 |
| --- | --- |

6.1.1.

 Chapter IV, Section 2, of Regulation (EC) No 4/2009

| 6.1.2. |  The 2007 Hague Convention






  6.1.2.1. | Indicate the basis for recognition and enforcement under Article 20 of the 2007 Hague Convention: |
| --- | --- | --- |

6.1.2.

 The 2007 Hague Convention

6.1.2.1.

Indicate the basis for recognition and enforcement under Article 20 of the 2007 Hague Convention:

| 6.1.2.2. | The defendant has appeared or been represented in the proceedings in the State of origin:








  Yes |  | No |  |
| --- | --- | --- | --- | --- |

6.1.2.2.

The defendant has appeared or been represented in the proceedings in the State of origin:

Yes



No



| 6.1.3. |  The national law of the requested Member State |
| --- | --- |

6.1.3.

 The national law of the requested Member State

| 6.1.4. |  Other (please specify): ...
  ...
  ... |
| --- | --- |

6.1.4.

 Other (please specify): ...

...

...

6.2.    Application for enforcement of a decision given or recognised in the requested Member State

7.   DECISION

7.1.   Date and reference number: ...

7.2.   Name of the court of origin: ...

8.   APPLICANT

8.1.   Natural person

8.1.1.   Surname and given name(s): ...

8.1.2.   Date (dd/mm/yyyy) and place of birth: ...

8.1.3.   Identity number or social security number (37): ...

8.1.4.   Nationality: ...

8.1.5.   Occupation: ...

8.1.6.   Civil status: ...

8.1.7.   Address:

|  | The address given below is the applicant’s personal address. |
| --- | --- |
|  | The applicant is in a situation of family violence (38). The address given below is an address care of: ... (surname and given name(s)) |



The address given below is the applicant’s personal address.



The applicant is in a situation of family violence (38). The address given below is an address care of: ... (surname and given name(s))

8.1.7.1.   Street and number/PO box: ...

8.1.7.2.   Place and postal code: ...

8.1.7.3.   Member State

 Belgium  Bulgaria  Czech Republic  Germany  Estonia  Ireland  Greece  Spain  France  Croatia  Italy  Cyprus  Latvia  Lithuania  Luxembourg  Hungary  Malta  Netherlands  Austria  Poland  Portugal  Romania  Slovenia  Slovakia  Finland  Sweden  United Kingdom

8.1.8.   Telephone/E-mail: ...

8.1.9.   Has benefited from:

| 8.1.9.1. | legal aid:








   | Yes |  | No |
| --- | --- | --- | --- | --- |

8.1.9.1.

legal aid:



Yes



No

| 8.1.9.2. | exemption from costs and expenses:








   | Yes |  | No |
| --- | --- | --- | --- | --- |

8.1.9.2.

exemption from costs and expenses:



Yes



No

| 8.1.9.3. | free proceedings before an administrative authority listed in Annex X to Regulation (EC) No 4/2009:








   | Yes |  | No |
| --- | --- | --- | --- | --- |

8.1.9.3.

free proceedings before an administrative authority listed in Annex X to Regulation (EC) No 4/2009:



Yes



No

8.1.10.   If applicable, surname, given name(s) and contact details of the applicant’s representative (lawyer, etc. ...): ...

...

8.2.   Public body:

8.2.1.   Name: ...

8.2.2.   Address:

| 8.2.2.1. | Street and number/PO box: ... |
| --- | --- |

8.2.2.1.

Street and number/PO box: ...

| 8.2.2.2. | Place and postal code: ... |
| --- | --- |

8.2.2.2.

Place and postal code: ...

| 8.2.2.3. | Member State
   Belgium  Bulgaria  Czech Republic  Germany  Estonia  Ireland  Greece  Spain  France  Croatia  Italy  Cyprus  Latvia  Lithuania  Luxembourg  Hungary  Malta  Netherlands  Austria  Poland  Portugal  Romania  Slovenia  Slovakia  Finland  Sweden  United Kingdom |
| --- | --- |

8.2.2.3.

Member State

 Belgium  Bulgaria  Czech Republic  Germany  Estonia  Ireland  Greece  Spain  France  Croatia  Italy  Cyprus  Latvia  Lithuania  Luxembourg  Hungary  Malta  Netherlands  Austria  Poland  Portugal  Romania  Slovenia  Slovakia  Finland  Sweden  United Kingdom

8.2.3.   Telephone/Fax/E-mail: ...

8.2.4.   Name of the person representing the body in the proceedings (39):

...

8.2.5.   Person responsible for following up the application:

| 8.2.5.1. | Surname and given name(s): ... |
| --- | --- |

8.2.5.1.

Surname and given name(s): ...

| 8.2.5.2. | Telephone: ... |
| --- | --- |

8.2.5.2.

Telephone: ...

| 8.2.5.3. | Fax ... |
| --- | --- |

8.2.5.3.

Fax ...

| 8.2.5.4. | E-mail: ... |
| --- | --- |

8.2.5.4.

E-mail: ...

9.   DEFENDANT

9.1.   Surname and given name(s): ...

9.2.   Date (dd/mm/yyyy) and place of birth (40): ...

9.3.   Identity number or social security number (41): ...

9.4.   Nationality (42): ...

9.5.   Occupation (43): ...

9.6.   Civil status (44): ...

9.7.   Address (45):

9.7.1.   Street and number/PO box: ...

9.7.2.   Place and postal code: ...

9.7.3.   Member State

 Belgium  Bulgaria  Czech Republic  Germany  Estonia  Ireland  Greece  Spain  France  Croatia  Italy  Cyprus  Latvia  Lithuania  Luxembourg  Hungary  Malta  Netherlands  Austria  Poland  Portugal  Romania  Slovenia  Slovakia  Finland  Sweden  United Kingdom

10.   ANY OTHER INFORMATION THAT MAY HELP LOCATE THE DEFENDANT: ...

...

...

...

11.   PERSON(S) FOR WHOM MAINTENANCE IS SOUGHT OR OWED (46)

11.1.    The person is the same as the applicant named in point 8

11.2.    The person is the same as the defendant named in point 9

|  | The applicant |  | The defendant |
| --- | --- | --- | --- |



The applicant



The defendant

is the representative (47) defending the interests of the following person(s):

11.3.1.   Person A

11.3.1.1.   Surname and given name(s): ...

11.3.1.2.   Date (dd/mm/yyyy) and place of birth: ...

11.3.1.3.   Identity number or social security number (48): ...

11.3.1.4.   Nationality (49): ...

11.3.1.5.   Occupation (50): ...

11.3.1.6.   Civil status (51): ...

11.3.2.   Person B

11.3.2.1.   Surname and given name(s): ...

11.3.2.2.   Date (dd/mm/yyyy) and place of birth: ...

11.3.2.3.   Identity number or social security number (52): ...

11.3.2.4.   Nationality (53): ...

11.3.2.5.   Occupation (54): ...

11.3.2.6.   Civil status (55): ...

11.3.3.   Person C

11.3.3.1.   Surname and given name(s): ...

11.3.3.2.   Date (dd/mm/yyyy) and place of birth: ...

11.3.3.3.   Identity number or social security number (56): ...

11.3.3.4.   Nationality (57): ...

11.3.3.5.   Occupation (58): ...

11.3.3.6.   Civil status (59): ...

12.   DEBTOR

12.1.    The person is the same as the applicant named in point 8

12.2.    The person is the same as the defendant named in point 9

|  | The applicant |  | The defendant |
| --- | --- | --- | --- |



The applicant



The defendant

is the representative (60) defending the interests of the following person:

| 12.3.1. | Surname and given name(s): ... |
| --- | --- |

12.3.1.

Surname and given name(s): ...

| 12.3.2. | Date (dd/mm/yyyy) and place of birth: ... |
| --- | --- |

12.3.2.

Date (dd/mm/yyyy) and place of birth: ...

| 12.3.3. | Identity number or social security number (61): ... |
| --- | --- |

12.3.3.

Identity number or social security number (61): ...

| 12.3.4. | Nationality (62): ... |
| --- | --- |

12.3.4.

Nationality (62): ...

| 12.3.5. | Occupation (63): ... |
| --- | --- |

12.3.5.

Occupation (63): ...

| 12.3.6. | Civil status (64): ... |
| --- | --- |

12.3.6.

Civil status (64): ...

13.   INFORMATION REGARDING PAYMENT, IF THE APPLICATION IS MADE BY THE CREDITOR

13.1.   Payment by electronic means

13.1.1.   Name of bank: ...

13.1.2.   BIC or other relevant bank code: ...

13.1.3.   Account holder: ...

13.1.4.   International Bank Account Number (IBAN): ...

13.2.   Payment by cheque

13.2.1.   Cheque payable to: ...

13.2.2.   Cheque to be sent to

13.2.2.1.   Surname and given name(s): ...

13.2.2.2.   Address:

| 13.2.2.2.1. | Street and number/PO box: ... |
| --- | --- |

13.2.2.2.1.

Street and number/PO box: ...

| 13.2.2.2.2. | Place and postal code: ... |
| --- | --- |

13.2.2.2.2.

Place and postal code: ...

| 13.2.2.2.3. | Country: ... |
| --- | --- |

13.2.2.2.3.

Country: ...

14.   ADDITIONAL INFORMATION (WHERE APPLICABLE):

...

...

...

Done at: ... on ... (dd/mm/yyyy)

Applicant’s signature: ...

and/or, where appropriate:

Name and signature of the person/authority authorised in the requesting Member State to complete the form on the applicant’s behalf:

...

ANNEX VII

APPLICATION FORM TO OBTAIN OR HAVE MODIFIED A DECISION IN MATTERS RELATING TO MAINTENANCE OBLIGATIONS

(Articles 56 and 57 of Council Regulation (EC) No 4/2009 of 18 December 2008 on jurisdiction, applicable law, recognition and enforcement of decisions and cooperation in matters relating to maintenance obligations (65))

PART A

To be completed by the requesting Central Authority

1.   APPLICATION

|  | Application to obtain a decision (Article 56(1)(c)) |
| --- | --- |
|  | Application to obtain a decision (Article 56(1)(d)) |
|  | Application for the modification of a decision (Article 56(1)(e)) |
|  | Application for the modification of a decision (Article 56(1)(f)) |
|  | Application for the modification of a decision (Article 56(2)(b)) |
|  | Application for the modification of a decision (Article 56(2)(c)) |



Application to obtain a decision (Article 56(1)(c))



Application to obtain a decision (Article 56(1)(d))



Application for the modification of a decision (Article 56(1)(e))



Application for the modification of a decision (Article 56(1)(f))



Application for the modification of a decision (Article 56(2)(b))



Application for the modification of a decision (Article 56(2)(c))

2.   REQUESTING CENTRAL AUTHORITY

2.1.   Name: ...

2.2.   Address:

| 2.2.1. | Street and number/PO box: ... |
| --- | --- |

2.2.1.

Street and number/PO box: ...

| 2.2.2. | Place and postal code: ... |
| --- | --- |

2.2.2.

Place and postal code: ...

| 2.2.3. | Member State
   Belgium  Bulgaria  Czech Republic  Germany  Estonia  Ireland  Greece  Spain  France  Croatia  Italy  Cyprus  Latvia  Lithuania  Luxembourg  Hungary  Malta  Netherlands  Austria  Poland  Portugal  Romania  Slovenia  Slovakia  Finland  Sweden  United Kingdom |
| --- | --- |

2.2.3.

Member State

 Belgium  Bulgaria  Czech Republic  Germany  Estonia  Ireland  Greece  Spain  France  Croatia  Italy  Cyprus  Latvia  Lithuania  Luxembourg  Hungary  Malta  Netherlands  Austria  Poland  Portugal  Romania  Slovenia  Slovakia  Finland  Sweden  United Kingdom

2.3.   Telephone: ...

2.4.   Fax ...

2.5.   E-mail: ...

2.6.   Reference number of the application: ...

Application to be handled with the application(s) bearing the following reference number(s): ...

2.7.   Person responsible for following up the application:

| 2.7.1. | Surname and given name(s): ... |
| --- | --- |

2.7.1.

Surname and given name(s): ...

| 2.7.2. | Telephone: ... |
| --- | --- |

2.7.2.

Telephone: ...

| 2.7.3. | E-mail: ... |
| --- | --- |

2.7.3.

E-mail: ...

3.   REQUESTED CENTRAL AUTHORITY

3.1.   Name: ...

3.2.   Address:

| 3.2.1. | Street and number/PO box: ... |
| --- | --- |

3.2.1.

Street and number/PO box: ...

| 3.2.2. | Place and postal code: ... |
| --- | --- |

3.2.2.

Place and postal code: ...

| 3.2.3. | Member State
   Belgium  Bulgaria  Czech Republic  Germany  Estonia  Ireland  Greece  Spain  France  Croatia  Italy  Cyprus  Latvia  Lithuania  Luxembourg  Hungary  Malta  Netherlands  Austria  Poland  Portugal  Romania  Slovenia  Slovakia  Finland  Sweden  United Kingdom |
| --- | --- |

3.2.3.

Member State

 Belgium  Bulgaria  Czech Republic  Germany  Estonia  Ireland  Greece  Spain  France  Croatia  Italy  Cyprus  Latvia  Lithuania  Luxembourg  Hungary  Malta  Netherlands  Austria  Poland  Portugal  Romania  Slovenia  Slovakia  Finland  Sweden  United Kingdom

4.   DOCUMENTS ATTACHED (66) TO THE APPLICATION, AS APPROPRIATE

|  | Decision of the requested Member State refusing recognition or a declaration of enforceability |
| --- | --- |
|  | Copy of the decision to be modified |
|  | Extract from the decision to be modified |
|  | Document(s) proving a change in income or any other change in circumstances |
|  | Birth certificate(s) or equivalent |
|  | Debtor’s acknowledgement of parentage |
|  | Document(s) proving biological parentage |
|  | Decision by a competent authority in relation to parentage |
|  | Results of genetic tests |
|  | Adoption certificate |
|  | Certificate of marriage or similar relationship |
|  | Document(s) proving the date of divorce/separation |
|  | Document(s) proving that the parties live together |
|  | Certificate(s) regarding schooling |
|  | Document(s) relevant to the financial situation |
|  | Other (please specify): ...
  ...
  ...
  ... |



Decision of the requested Member State refusing recognition or a declaration of enforceability



Copy of the decision to be modified



Extract from the decision to be modified



Document(s) proving a change in income or any other change in circumstances



Birth certificate(s) or equivalent



Debtor’s acknowledgement of parentage



Document(s) proving biological parentage



Decision by a competent authority in relation to parentage



Results of genetic tests



Adoption certificate



Certificate of marriage or similar relationship



Document(s) proving the date of divorce/separation



Document(s) proving that the parties live together



Certificate(s) regarding schooling



Document(s) relevant to the financial situation



Other (please specify): ...

...

...

...

Total number of documents attached to the application form: ...

Done at: ... on ... (dd/mm/yyyy)

Name and signature of the authorised official of the requesting Central Authority:

...

PART B

To be completed by the applicant or, as appropriate, by the person/authority authorised in the requesting Member State to complete the form on the applicant’s behalf

5.   APPLICATION

5.1.    Application to obtain a decision

5.1.1.    Parentage has not been established

5.1.2.    No decision exists

5.1.3.    Recognition and a declaration of enforceability of an existing decision are not possible

5.1.4.    Amount requested:

...

...

...

5.2.    Application for modification of a decision

5.2.1.    The decision was given in the requested Member State

5.2.2.    The decision was given in a State other than the requested Member State

5.2.3.   Date (dd/mm/yyyy) and reference number of the decision: ...

5.2.4.   Name of the court of origin: ...

5.2.5.   Changes in circumstances which have occurred:

|  | Change in income:






   | of the person(s) for whom maintenance is sought or owed |
| --- | --- | --- |
|  | of the person primarily responsible for the person(s) for whom maintenance is sought or owed |
|  | of the debtor |



Change in income:



of the person(s) for whom maintenance is sought or owed



of the person primarily responsible for the person(s) for whom maintenance is sought or owed



of the debtor



Change in expenses and charges:

|  | of the person(s) for whom maintenance is sought or owed |
| --- | --- |
|  | of the person primarily responsible for the person(s) for whom maintenance is sought or owed |
|  | of the debtor |



of the person(s) for whom maintenance is sought or owed



of the person primarily responsible for the person(s) for whom maintenance is sought or owed



of the debtor



Change in the situation of the child/children



Change in civil status:

|  | of the person(s) for whom maintenance is sought or owed |
| --- | --- |
|  | of the person primarily responsible for the person(s) for whom maintenance is sought or owed |
|  | of the debtor |



of the person(s) for whom maintenance is sought or owed



of the person primarily responsible for the person(s) for whom maintenance is sought or owed



of the debtor



Other (please specify): ...

...

...

5.2.6.   Modification(s) requested:

|  | Increase in the amount of maintenance:






   | The amount of maintenance should be increased by (please specify): ... |
| --- | --- | --- |
|  | The new amount of maintenance should be (please specify):

  Currency

   Euro (EUR)  Lev (BGN)  Czech koruna (CZK)  Pound sterling (GBP)  Kuna (HRK)  Forint (HUF)  Zloty (PLN)  Leu (RON)  Krona (SEK)  Other (please specify ISO code): ... |



Increase in the amount of maintenance:



The amount of maintenance should be increased by (please specify): ...



The new amount of maintenance should be (please specify):

Currency

 Euro (EUR)  Lev (BGN)  Czech koruna (CZK)  Pound sterling (GBP)  Kuna (HRK)  Forint (HUF)  Zloty (PLN)  Leu (RON)  Krona (SEK)  Other (please specify ISO code): ...



Reduction in the amount of maintenance:

|  | The amount of maintenance should be reduced by (please specify): ... |
| --- | --- |
|  | The new amount of maintenance should be (please specify):

  Currency

   Euro (EUR)  Lev (BGN)  Czech koruna (CZK)  Pound sterling (GBP)  Kuna (HRK)  Forint (HUF)  Zloty (PLN)  Leu (RON)  Krona (SEK)  Other (please specify ISO code): ... |



The amount of maintenance should be reduced by (please specify): ...



The new amount of maintenance should be (please specify):

Currency

 Euro (EUR)  Lev (BGN)  Czech koruna (CZK)  Pound sterling (GBP)  Kuna (HRK)  Forint (HUF)  Zloty (PLN)  Leu (RON)  Krona (SEK)  Other (please specify ISO code): ...



Modification of the frequency of payments (please specify): ...



Modification of the arrangements for payment (please specify): ...



Modification of the nature of payments (please specify): ...



Termination of the maintenance obligation (please specify): ...



Other (please specify): ...

...

6.   APPLICANT

6.1.   Surname and given name(s): ...

6.2.   Address:

|  | The address given below is the applicant’s personal address. |
| --- | --- |
|  | The applicant is in a situation of family violence (67). The address given below is an address care of: ... (surname and given name(s)) |



The address given below is the applicant’s personal address.



The applicant is in a situation of family violence (67). The address given below is an address care of: ... (surname and given name(s))

6.2.1.   Street and number/PO box: ...

6.2.2.   Place and postal code: ...

6.2.3.   Member State

 Belgium  Bulgaria  Czech Republic  Germany  Estonia  Ireland  Greece  Spain  France  Croatia  Italy  Cyprus  Latvia  Lithuania  Luxembourg  Hungary  Malta  Netherlands  Austria  Poland  Portugal  Romania  Slovenia  Slovakia  Finland  Sweden  United Kingdom

6.3.   Telephone/E-mail: ...

6.4.   Date (dd/mm/yyyy) and place of birth: ...

6.5.   Identity number or social security number (68): ...

6.6.   Nationality: ...

6.7.   Occupation: ...

6.8.   Civil status: ...

6.9.   If applicable, surname, given name(s) and contact details of the applicant’s representative (lawyer, etc. ...):

...

...

7.   DEFENDANT

7.1.   Surname and given name(s): ...

7.2.   Address (69):

| 7.2.1. | Street and number/PO box: ... |
| --- | --- |

7.2.1.

Street and number/PO box: ...

| 7.2.2. | Place and postal code: ... |
| --- | --- |

7.2.2.

Place and postal code: ...

| 7.2.3. | Member State
   Belgium  Bulgaria  Czech Republic  Germany  Estonia  Ireland  Greece  Spain  France  Croatia  Italy  Cyprus  Latvia  Lithuania  Luxembourg  Hungary  Malta  Netherlands  Austria  Poland  Portugal  Romania  Slovenia  Slovakia  Finland  Sweden  United Kingdom |
| --- | --- |

7.2.3.

Member State

 Belgium  Bulgaria  Czech Republic  Germany  Estonia  Ireland  Greece  Spain  France  Croatia  Italy  Cyprus  Latvia  Lithuania  Luxembourg  Hungary  Malta  Netherlands  Austria  Poland  Portugal  Romania  Slovenia  Slovakia  Finland  Sweden  United Kingdom

7.3.   Date (dd/mm/yyyy) and place of birth (70): ...

7.4.   Identity number or social security number (71): ...

7.5.   Nationality (72): ...

7.6.   Occupation (73): ...

7.7.   Civil status (74): ...

8.   ANY OTHER INFORMATION THAT MAY HELP LOCATE THE DEFENDANT:

...

...

...

9.   PERSON(S) FOR WHOM MAINTENANCE IS SOUGHT OR OWED (75)

9.1.    The person is the same as the applicant named in point 6

9.2.    The person is the same as the defendant named in point 7

|  | The applicant |  | The defendant |
| --- | --- | --- | --- |



The applicant



The defendant

is the representative (76) defending the interests of the following person(s):

9.3.1.   Person A

9.3.1.1.   Surname and given name(s): ...

9.3.1.2.   Date (dd/mm/yyyy) and place of birth: ...

9.3.1.3.   Identity number or social security number (77): ...

9.3.1.4.   Nationality (78): ...

9.3.1.5.   Occupation (79): ...

9.3.1.6.   Civil status (80): ...

9.3.1.7.   Maintenance is on the basis of the following relationship:

|  | Parentage (please specify relationship): ... |
| --- | --- |
|  | Marriage |
|  | Analogous relationship to marriage |
|  | Alliance (please specify relationship): ... |
|  | Other (please specify): ... |



Parentage (please specify relationship): ...



Marriage



Analogous relationship to marriage



Alliance (please specify relationship): ...



Other (please specify): ...

9.3.2.   Person B

9.3.2.1.   Surname and given name(s): ...

9.3.2.2.   Date (dd/mm/yyyy) and place of birth: ...

9.3.2.3.   Identity number or social security number (81): ...

9.3.2.4.   Nationality (82): ...

9.3.2.5.   Occupation (83): ...

9.3.2.6.   Civil status (84): ...

9.3.2.7.   Maintenance is on the basis of the following relationship:

|  | Parentage (please specify relationship): ... |
| --- | --- |
|  | Marriage |
|  | Analogous relationship to marriage |
|  | Alliance (please specify relationship): ... |
|  | Other (please specify): ... |



Parentage (please specify relationship): ...



Marriage



Analogous relationship to marriage



Alliance (please specify relationship): ...



Other (please specify): ...

9.3.3.   Person C

9.3.3.1.   Surname and given name(s): ...

9.3.3.2.   Date (dd/mm/yyyy) and place of birth: ...

9.3.3.3.   Identity number or social security number (85): ...

9.3.3.4.   Nationality (86): ...

9.3.3.5.   Occupation (87): ...

9.3.3.6.   Civil status (88): ...

9.3.3.7.   Maintenance is on the basis of the following relationship:

|  | Parentage (please specify relationship): ... |
| --- | --- |
|  | Marriage |
|  | Analogous relationship to marriage |
|  | Alliance (please specify relationship): ... |
|  | Other (please specify): ... |



Parentage (please specify relationship): ...



Marriage



Analogous relationship to marriage



Alliance (please specify relationship): ...



Other (please specify): ...

10.   DEBTOR

10.1.    The person is the same as the applicant named in point 6

10.2.    The person is the same as the defendant named in point 7

|  | The applicant |  | The defendant |
| --- | --- | --- | --- |



The applicant



The defendant

is the representative (89) defending the interests of the following person:

| 10.3.1. | Surname and given name(s): ... |
| --- | --- |

10.3.1.

Surname and given name(s): ...

| 10.3.2. | Date (dd/mm/yyyy) and place of birth: ... |
| --- | --- |

10.3.2.

Date (dd/mm/yyyy) and place of birth: ...

| 10.3.3. | Identity number or social security number (90): ... |
| --- | --- |

10.3.3.

Identity number or social security number (90): ...

| 10.3.4. | Nationality (91): ... |
| --- | --- |

10.3.4.

Nationality (91): ...

| 10.3.5. | Occupation (92): ... |
| --- | --- |

10.3.5.

Occupation (92): ...

| 10.3.6. | Civil status (93): ... |
| --- | --- |

10.3.6.

Civil status (93): ...

| 10.3.7. | Maintenance is on the basis of the following relationship:






   | Parentage (please specify relationship): ... |
| --- | --- | --- |
|  | Marriage |
|  | Analogous relationship to marriage |
|  | Alliance (please specify relationship): ... |
|  | Other (please specify): ... |

10.3.7.

Maintenance is on the basis of the following relationship:



Parentage (please specify relationship): ...



Marriage



Analogous relationship to marriage



Alliance (please specify relationship): ...



Other (please specify): ...

11.   INFORMATION ON THE FINANCIAL SITUATION OF THE PERSONS CONCERNED BY THE APPLICATION (ONLY GIVE INFORMATION WHICH IS RELEVANT FOR THE PURPOSE OF OBTAINING OR MODIFYING A DECISION)

11.1.   Currency

 Euro (EUR)  Lev (BGN)  Czech koruna (CZK)  Pound sterling (GBP)  Kuna (HRK)  Forint (HUF)  Zloty (PLN)  Leu (RON)  Krona (SEK)  Other (please specify ISO code): ...

11.2.   The person(s) for whom maintenance is sought or owed and the person primarily responsible for that person (those persons)

11.2.1.   Gross income

|  Monthly
   Annual | Person primarily responsible for the person(s) for whom maintenance is sought or owed | Spouse or current partner of the person primarily responsible for the person(s) for whom maintenance is sought or owed | Person for whom maintenance is sought or owed
  (Person A) | Person for whom maintenance is sought or owed
  (Person B) | Person for whom maintenance is sought or owed
  (Person C) |
| --- | --- | --- | --- | --- | --- |
| Salary (including payments in kind), pensions, disability pensions, maintenance payments, allowances, annuities, unemployment benefits | | | | | |
| Income from non-salaried occupations | | | | | |
| Income from securities/floating capital/real property | | | | | |
| Other sources of income | | | | | |
| TOTAL | | | | | |

 Monthly

 Annual

Person primarily responsible for the person(s) for whom maintenance is sought or owed

Spouse or current partner of the person primarily responsible for the person(s) for whom maintenance is sought or owed

Person for whom maintenance is sought or owed

(Person A)

Person for whom maintenance is sought or owed

(Person B)

Person for whom maintenance is sought or owed

(Person C)

Salary (including payments in kind), pensions, disability pensions, maintenance payments, allowances, annuities, unemployment benefits

Income from non-salaried occupations

Income from securities/floating capital/real property

Other sources of income

TOTAL

11.2.2.   Expenses and charges

|  Monthly
   Annual | Person primarily responsible for the person(s) for whom maintenance is sought or owed | Spouse or current partner of the person primarily responsible for the person(s) for whom maintenance is sought or owed | Person for whom maintenance is sought or owed
  (Person A) | Person for whom maintenance is sought or owed
  (Person B) | Person for whom maintenance is sought or owed
  (Person C) |
| --- | --- | --- | --- | --- | --- |
| Taxes | | | | | |
| Insurance premiums, mandatory social security and professional contributions | | | | | |
| Rent/cost of co-ownership, mortgage payments | | | | | |
| Food and clothing | | | | | |
| Medical expenses | | | | | |
| Maintenance paid to a third party by virtue of a legal obligation and/or expenditure for other dependent persons not covered by the application | | | | | |
| Education costs of children | | | | | |
| Loan repayments, other debts | | | | | |
| Other expenditure | | | | | |
| TOTAL | | | | | |

 Monthly

 Annual

Person primarily responsible for the person(s) for whom maintenance is sought or owed

Spouse or current partner of the person primarily responsible for the person(s) for whom maintenance is sought or owed

Person for whom maintenance is sought or owed

(Person A)

Person for whom maintenance is sought or owed

(Person B)

Person for whom maintenance is sought or owed

(Person C)

Taxes

Insurance premiums, mandatory social security and professional contributions

Rent/cost of co-ownership, mortgage payments

Food and clothing

Medical expenses

Maintenance paid to a third party by virtue of a legal obligation and/or expenditure for other dependent persons not covered by the application

Education costs of children

Loan repayments, other debts

Other expenditure

TOTAL

11.2.3.   Other assets

...

...

...

11.3.   The debtor

11.3.1.   Gross income

|  Monthly
   Annual | Debtor | Current spouse or partner of the debtor |
| --- | --- | --- |
| Salary (including payments in kind), pensions, disability pensions, maintenance payments, allowances, annuities, unemployment benefits | | |
| Income from non-salaried occupations | | |
| Income from securities/floating capital/real property | | |
| Other sources of income | | |
| TOTAL | | |

 Monthly

 Annual

Debtor

Current spouse or partner of the debtor

Salary (including payments in kind), pensions, disability pensions, maintenance payments, allowances, annuities, unemployment benefits

Income from non-salaried occupations

Income from securities/floating capital/real property

Other sources of income

TOTAL

11.3.2.   Expenses and charges

|  Monthly
   Annual | Debtor | Current spouse or partner of the debtor |
| --- | --- | --- |
| Taxes | | |
| Insurance premiums, mandatory social security and professional contributions | | |
| Rent/cost of co-ownership, mortgage payments | | |
| Food and clothing | | |
| Medical expenses | | |
| Maintenance paid to a third party by virtue of a legal obligation and/or expenditure for other dependent persons not covered by the application | | |
| Education costs of children | | |
| Loan repayments, other debts | | |
| Other expenditure | | |
| TOTAL | | |

 Monthly

 Annual

Debtor

Current spouse or partner of the debtor

Taxes

Insurance premiums, mandatory social security and professional contributions

Rent/cost of co-ownership, mortgage payments

Food and clothing

Medical expenses

Maintenance paid to a third party by virtue of a legal obligation and/or expenditure for other dependent persons not covered by the application

Education costs of children

Loan repayments, other debts

Other expenditure

TOTAL

11.3.3.   Other assets

...

...

...

12.   INFORMATION REGARDING PAYMENT, IF THE APPLICATION IS MADE BY THE CREDITOR

12.1.   Payment by electronic means

12.1.1.   Name of bank: ...

12.1.2.   BIC or other relevant bank code: ...

12.1.3.   Account holder: ...

12.1.4.   International Bank Account Number (IBAN): ...

12.2.   Payment by cheque

12.2.1.   Cheque payable to: ...

12.2.2.   Cheque to be sent to

12.2.2.1.   Surname and given name(s): ...

12.2.2.2.   Address:

| 12.2.2.2.1. | Street and number/PO box: ... |
| --- | --- |

12.2.2.2.1.

Street and number/PO box: ...

| 12.2.2.2.2. | Place and postal code: ... |
| --- | --- |

12.2.2.2.2.

Place and postal code: ...

| 12.2.2.2.3. | Country: ... |
| --- | --- |

12.2.2.2.3.

Country: ...

13.   ADDITIONAL INFORMATION (WHERE APPLICABLE):

...

...

...

Done at: ... on ... (dd/mm/yyyy)

Applicant’s signature: ...

and/or, where appropriate:

Name and signature of the person/authority authorised in the requesting Member State to complete the form on the applicant’s behalf:

...

---

(1)  OJ L 7, 10.1.2009, p. 1.

1

(2)  If the parties are not the claimant or defendant in the decision/court settlement, indicate either of the parties as claimant or defendant.

2

(3)  If the decision/court settlement concerns more than three claimants or three defendants, attach an additional sheet.

3

(4)  If the parties are not the claimant or defendant in the decision/court settlement, indicate either of the parties as claimant or defendant.

4

(5)  If the decision/court settlement concerns more than three claimants or three defendants, attach an additional sheet.

5

(6)  If the decision/court settlement concerns more than three maintenance claims, attach an additional sheet.

6

(7)  OJ L 7, 10.1.2009, p. 1.

7

(8)  If the parties are not the claimant or defendant in the decision/court settlement, indicate either of the parties as claimant or defendant.

8

(9)  If the decision/court settlement concerns more than three claimants or three defendants, attach an additional sheet.

9

(10)  For Denmark, the administrative authorities listed in the agreement between the European Community and the Kingdom of Denmark on jurisdiction and the recognition and enforcement of judgments in civil and commercial matters (OJ L 251, 21.9.2013, p. 1).

10

(11)  For Denmark, the administrative authorities listed in the agreement between the European Community and the Kingdom of Denmark on jurisdiction and the recognition and enforcement of judgments in civil and commercial matters (OJ L 251, 21.9.2013, p. 1).

11

(12)  For Denmark, the administrative authorities listed in the agreement between the European Community and the Kingdom of Denmark on jurisdiction and the recognition and enforcement of judgments in civil and commercial matters (OJ L 251, 21.9.2013, p. 1).

12

(13)  If the parties are not the claimant or defendant in the decision/court settlement, indicate either of the parties as claimant or defendant.

13

(14)  If the decision/court settlement concerns more than three claimants or three defendants, attach an additional sheet.

14

(15)  For Denmark, the administrative authorities listed in the agreement between the European Community and the Kingdom of Denmark on jurisdiction and the recognition and enforcement of judgments in civil and commercial matters (OJ L 251, 21.9.2013, p. 1).

15

(16)  For Denmark, the administrative authorities listed in the agreement between the European Community and the Kingdom of Denmark on jurisdiction and the recognition and enforcement of judgments in civil and commercial matters (OJ L 251, 21.9.2013, p. 1).

16

(17)  For Denmark, the administrative authorities listed in the agreement between the European Community and the Kingdom of Denmark on jurisdiction and the recognition and enforcement of judgments in civil and commercial matters (OJ L 251, 21.9.2013, p. 1).

17

(18)  If the decision/court settlement concerns more than three maintenance claims, attach an additional sheet.

18

(19)  OJ L 7, 10.1.2009, p. 1.

19

(20)  If the authentic instrument concerns more than three creditors or three debtors, attach an additional sheet.

20

(21)  If the authentic instrument concerns more than three creditors or three debtors, attach an additional sheet.

21

(22)  If the authentic instrument concerns more than three maintenance claims, attach an additional sheet.

22

(23)  OJ L 7, 10.1.2009, p. 1.

23

(24)  If the authentic instrument concerns more than three creditors or three debtors, attach an additional sheet.

24

(25)  If the authentic instrument concerns more than three creditors or three debtors, attach an additional sheet.

25

(26)  If the authentic instrument concerns more than three maintenance claims, attach an additional sheet.

26

(27)  OJ L 7, 10.1.2009, p. 1.

27

(28)  If available.

28

(29)  If available.

29

(30)  For example, the name of a previous employer, names and addresses of family members, details of a vehicle or property which the person in question might own.

30

(31)  If available.

31

(32)  If available.

32

(33)  For example, the name of a previous employer, names and addresses of family members, details of a vehicle or property which the person in question might own.

33

(34)  OJ L 7, 10.1.2009, p. 1.

34

(35)  Tick the relevant boxes and number the documents in the order in which they are attached.

35

(36)  Tick the relevant boxes and number the documents in the order in which they are attached.

36

(37)  If available.

37

(38)  The national law of the requested Member State may, however, require the applicant to provide his/her personal address for the purposes of the proceedings (see Article 57(3) of Regulation (EC) No 4/2009].

38

(39)  If relevant.

39

(40)  If available.

40

(41)  If available.

41

(42)  If available.

42

(43)  If available.

43

(44)  If available.

44

(45)  If available.

45

(46)  If more than three persons, attach an additional sheet.

46

(47)  For example, the person with parental responsibility or the guardian of a protected adult.

47

(48)  If available and/or relevant.

48

(49)  If available and/or relevant.

49

(50)  If available and/or relevant.

50

(51)  If available and/or relevant.

51

(52)  If available and/or relevant.

52

(53)  If available and/or relevant.

53

(54)  If available and/or relevant.

54

(55)  If available and/or relevant.

55

(56)  If available and/or relevant.

56

(57)  If available and/or relevant.

57

(58)  If available and/or relevant.

58

(59)  If available and/or relevant.

59

(60)  For example, the person with parental responsibility or the guardian of a protected adult.

60

(61)  If available.

61

(62)  If available.

62

(63)  If available.

63

(64)  If available.

64

(65)  OJ L 7, 10.1.2009, p. 1.

65

(66)  Tick the relevant boxes and number the documents in the order in which they are attached.

66

(67)  The national law of the requested Member State may, however, require the applicant to provide his/her personal address for the purposes of the proceedings (see Article 57(3) of Regulation (EC) No 4/2009).

67

(68)  If available.

68

(69)  If available.

69

(70)  If available.

70

(71)  If available.

71

(72)  If available.

72

(73)  If available.

73

(74)  If available.

74

(75)  If more than three persons, attach an additional sheet.

75

(76)  For example the person with parental responsibility or the guardian of a protected adult.

76

(77)  If available and/or relevant.

77

(78)  If available and/or relevant.

78

(79)  If available and/or relevant.

79

(80)  If available and/or relevant.

80

(81)  If available and/or relevant.

81

(82)  If available and/or relevant.

82

(83)  If available and/or relevant.

83

(84)  If available and/or relevant.

84

(85)  If available and/or relevant.

85

(86)  If available and/or relevant.

86

(87)  If available and/or relevant.

87

(88)  If available and/or relevant.

88

(89)  For example the person with parental responsibility or the guardian of a protected adult.

89

(90)  If available.

90

(91)  If available.

91

(92)  If available.

92

(93)  If available.

93

---