ANNEX I

Application for a European order for payment Form A Article 7(1) of Regulation (EC) No 1896/2006 of the European Parliament and of the Council creating a European order for payment procedure Please ensure that you read the guidelines on the last page – they will help you to understand this form! Please note in particular that this form must be completed in the language or one of the languages accepted by the court to be seised. The form is available in all official languages of the European Union; this may help you fill in the form in the required language. 1. Court Case number (to be completed by the court) Court Received by the court (day/month/year) Address Signature and/or stamp Postal code City Country 2. Parties and their representatives Codes: 01 Claimant 03 Claimant's representative * 05 Claimant's legally authorised representative ** 02 Defendant 04 Defendant's representative * 06 Defendant's legally authorised representative ** Code Corporate name of company or organisation Identification code (if applicable) Surname First Name Address Postal code City Country Phone *** Fax *** email *** Occupation *** Other details *** Code Corporate name of company or organisation Identification code (if applicable) Surname First Name Address Postal code City Country Phone *** Fax *** email *** Occupation *** Other details *** Code Corporate name of company or organisation Identification code (if applicable) Surname First Name Address Postal code City Country Phone *** Fax *** email *** Occupation *** Other details ***

Code Corporate name of company or organisation Identification code (if applicable) Surname First Name Address Postal code City Country Phone *** Fax *** email *** Occupation *** Other details *** * e.g. lawyer ** e.g. parent, guardian, managing director *** optional 3. Grounds for the court's jurisdiction Codes: 01 Domicile of the defendant or co-defendant 02 Place of performance of the obligation in question 03 Place of the harmful event 04 Where a dispute arises out of the operations of a branch, agency or other establishment, the place in which the branch, agency or other establishment is situated 05 Domicile of the trust 06 Where a dispute arises concerning the payment of remuneration claimed in respect of the salvage of a cargo or freight, the place of the court under the authority of which the cargo or freight is or could have been arrested 07 Domicile of the policyholder, the insured or the beneficiary in insurance matters 08 Domicile of the consumer 09 Place where the employee carries out his work 10 Place where the business which engaged the employee is situated 11 Place where the immovable property is situated 12 Choice of court agreed by the parties 13 Domicile of the maintenance creditor 14 Other (please specify) Code Specification only for code 14 4. Cross-border nature of the case Codes: 01 02 03 04 05 Belgium Bulgaria Czech Republic Germany Estonia 06 07 08 09 10 Greece Spain France Croatia Ireland 11 12 13 14 15 Italy Cyprus Latvia Lithuania Luxembourg 16 17 18 19 20 Hungary Malta The Netherlands Austria Poland 21 22 23 24 25 Portugal Romania Slovenia Slovakia Finland 26 27 28 Sweden United Kingdom other (please specify) Domicile or habitual residence of claimant Domicile or habitual residence of defendant Country of the court 5. Bank details (optional) 5.1. Payment of court fees by the claimant Codes: 01 By bank transfer 02 By credit card 03 Collection by court from claimant's bank account 04 Legal aid 05 Other (please specify) If you choose code 02 or 03, please fill in the bank details in Appendix 1 Code If you choose code 05, please specify 5.2. Payment by defendant of amount awarded Account holder Bank name (BIC) or other relevant bank code Account number International bank account number (IBAN)

EUR Euro BGN Bulgarian Lev CZK Czech Koruna GBP Pound sterling HUF Hungarian Forint HRK Croatian kuna PLN Polish Zloty RON Romanian Leu SEK Swedish Krona Other (according to international banking code) 6. Principal Currency: Total value of principal, excluding interest and costs: The claim relates to (Code 1) 01 Sales contract 02 Rental agreement — movable property 03 Rental agreement — immovable property 04 Rental agreement — commercial lease 05 Contract of service — electricity, gas, water, phone 06 Contract of service — medical services 07 Contract of service — transport 08 Contract of service — legal, tax, technical advice 09 Contract of service — hotel, restaurant 10 Contract of service — repair 11 Contract of service — brokerage 12 Contract of service — other (please specify) 13 Building contract 14 Insurance contract 15 Loan 16 Guarantee or other collateral(s) 17 Claims arising from non-contractual obligations if they are subject to an agreement between the parties or an admission of debt (e.g. damages, unjust enrichment) 18 Claims arising from joint ownership of property 19 Damages — contract 20 Subscription agreement (newspaper, magazine) 21 Membership fee 22 Employment agreement 23 Out-of-court settlement 24 Maintenance agreement 25 Other (please specify) Circumstances invoked (Code 2) 30 Non-payment 31 Insufficient payment 32 Late payment 33 Non-delivery of goods or services 34 Delivery of defective goods or poor services 35 Goods or services not in conformity with the order 36 Other (please specify) Other details (Code 3) 40 Place of purchase 41 Place of delivery 42 Date of purchase 43 Date of delivery 44 Type of goods or services concerned 45 Address of immovable property 46 In case of loan, purpose: Consumer credit 47 In case of loan, purpose: Mortgage credit 48 Other detail (please specify) ID 1 Code 1 Code 2 Code 3 Explanatory statement Date* (or period) Amount ID 2 Code 1 Code 2 Code 3 Explanatory statement Date* (or period) Amount ID 3 Code 1 Code 2 Code 3 Explanatory statement Date* (or period) Amount ID 4 Code 1 Code 2 Code 3 Explanatory statement Date* (or period) Amount * Date format: day/month/year The claim has been assigned to the claimant by (if applicable) Corporate name of company or organisation Identification code (if applicable) Surname First Name Address Postal code City Country Additional specifications for claims relating to consumer contracts (if applicable) The claim concerns matters relating to consumer contracts If yes, the defendant is the consumer If yes, the defendant is domiciled within the meaning of Article 59 of Council Regulation (EC) No 44/2001 in the Member State where the court is seised yes no yes no yes no

7. Interest Codes (please combine number with letter): 01 Statutory A per year 02 Contractual B per half year 03 Capitalisation of interest C per quarter 04 Interest rate on a loan ** D per month 05 Amount calculated by the claimant E Other *** 06 Other *** ID * Code Interest rate (%) % over base rate (ECB) on (amount) Starting from to ID * Code Interest rate (%) % over base rate (ECB) on (amount) Starting from to ID * Code Interest rate (%) % over base rate (ECB) on (amount) Starting from to ID * Code Interest rate (%) % over base rate (ECB) on (amount) Starting from to ID * Please specify in case of Code 6 and/or E * Fill in corresponding claim ID ** Taken out by the claimant for at least the amount of the principal *** Please specify 8. Contractual penalties (if applicable) Amount Please specify 9. Costs (if applicable) Codes: 01 Court fees 02 Other (please specify) Code Specification only for code 02 Currency Amount Code Specification only for code 02 Currency Amount Code Specification only for code 02 Currency Amount Code Specification only for code 02 Currency Amount 10. Evidence available in support of the claim Codes: 01 Written evidence 02 Oral evidence 03 Expert evidence 04 Inspection of an object or site 05 Other (please specify) ID * Code Description of evidence Date (day/month/year) ID * Code Description of evidence Date (day/month/year) ID * Code Description of evidence Date (day/month/year) ID * Code Description of evidence Date (day/month/year) * Fill in corresponding claim ID

11. Additional statements and further information (if necessary) I hereby request the court to order the defendant(s) to pay to the claimant(s) the sum of the above principal plus interest, contractual penalties and costs. I declare that to the best of my knowledge and belief the information provided is true. I acknowledge that any deliberate false statement could lead to appropriate penalties under the law of the Member State of origin. Done at Date (day/month/year) Signature and/or stamp

Appendix 1 to the application for a European order for payment Bank details for the purposes of payment of court fees by the claimant Codes: 02 By credit card 03 Collection by court from claimant's bank account Code Account holder Bank name (BIC) or other relevant bank code / Credit card company Account number / Credit card number International bank account number (IBAN) / Expiry date and security number of credit card

Appendix 2 to the application for a European order for payment Further procedure in a case of lodging of a statement of opposition Codes: 01 If the defendant lodges a statement of opposition, I request that the proceedings discontinue. 02 If the defendant lodges a statement of opposition, I request that the proceedings continue in accordance with the rules of the European Small Claims Procedure, if applicable. 03 If the defendant lodges a statement of opposition, I request that the proceedings continue in accordance with any appropriate national civil procedure. Case number (to be completed if this Appendix is sent to the court separately from the application form): Corporate name of company or organisation Surname First name Code If despite of my choice above, my claim does not fall in the scope of the European small claims Procedure (Code 02), I request that the proceedings discontinue continue in accordance with any appropriate national civil procedure Done at Date (day/month/year) Signature and/or stamp

GUIDELINES FOR FILLING IN THE APPLICATION FORM Important information This form must be filled in in the language or one of the languages accepted by the court to be seised. Please note that the form is available in all official languages of the European Union; this may help you fill in the form in the required language. If the defendant lodges an opposition to your claim, proceedings will continue before the competent courts in accordance with the rules of ordinary civil procedure. If you do not wish to continue proceedings in that event, you should also fill in Appendix 2 to this form. This appendix should reach the court before the European order for payment is issued. If the application concerns a claim against a consumer relating to a consumer contract, it must be lodged with the competent court of the Member State in which the consumer is domiciled. In other cases, the application must be lodged with the court having jurisdiction in accordance with the rules of Council Regulation (EC) No 44/2001 (*). Information on the rules of jurisdiction can be found at the European e-Justice Portal https://e-justice.europa.eu/content_jurisdiction-85-en.do Please make sure you duly sign and date the form on the last page. Guidelines At the start of each section you will find specific codes that should be inserted, as appropriate, in the relevant boxes. 1. Court When deciding which court to choose, you need to consider the grounds for the court’s jurisdiction. 2. Parties and their representatives This field must identify the parties and their representatives (e.g. lawyer of, guardian of), if any, in accordance with the codes indicated on the form. The box [Identification code] should refer, where applicable, to the special number which solicitors have in certain Member States for the purposes of electronic communication with the court (see Art. 7(6), second subparagraph, of Regulation (EC) No 1896/2006), to the registration number for companies or organisations or to any applicable identification number for natural persons. The box [Other details] may contain any other information that helps to identify the person (e.g. date of birth, position of the named person in the company or organisation concerned). If there are more than four parties and/or representatives, please use field [11]. 3. Grounds for the court's jurisdiction See ‘Important information’ above. 4. Cross-border nature of the case For you to be allowed to use this European order for payment procedure, at least two of the boxes in this field must refer to different States. 5. Bank details (optional) In field [5.1], you may inform the court by what means you intend to pay the court fees. Please note that not all methods of payment in this field are necessarily available at the court to which you are making this application. You should verify which method of payment will be accepted by the court. You can do this by contacting the court concerned or by consulting the website of the European Judicial Network in civil and commercial matters (http://ec.europa.eu/civiljustice/). If you choose to pay by credit card or to allow the court to collect the fees from your bank account, you should give the necessary credit card/bank account details in Appendix 1 to this form. In field [5.2], you may indicate by what means you wish to receive payment from the defendant. If you wish to be paid by bank transfer, please give the necessary bank details. 6. Principal This field must contain a description of the principal and the circumstances forming the basis of the claim in accordance with the codes indicated on the form. You need to use an identification number (‘ID’) for each claim, numbering them from 1 through 4. Each claim must be specified on the line of the box following the ID number, by filling in the relevant numbers of codes 1, 2 and 3. If you need more space, please use field [11]. The box [Date (or period)] refers, for instance, to the date of the contract or harmful event or to the period of the rent. 7. Interest If interest is sought, this should be specified for each claim in accordance with the codes indicated on the form. The code must contain both the relevant number (first row of the codes) and the letter (second row of the codes). For instance, if the interest rate has been agreed by contract and covers annual periods, the code is 02A. If it is for the court to decide the amount of interest the last box [to] should be left blank, and code 06E should be used. Code 01 refers to an interest rate laid down by statute. Code 02 refers to an interest rate agreed by the parties. If you use Code 03 (capitalisation of interest), the amount indicated should be the basis for the remainder of the term to be covered. Capitalisation of interest refers to the situation where the accrued interest is added to the principal and is taken into account for the purpose of calculating further interest. Please note that in commercial transactions as referred to in Directive 2000/35/EC of the European Parliament and of the Council (**), the statutory interest rate is the sum of the interest rate applied by the European Central Bank to its most recent main refinancing operation carried out before the first calendar day of the half-year in question (‘the reference rate’), plus at least seven percentage points. For a Member State which is not participating in the third stage of economic and monetary union, the reference rate referred to above is the equivalent rate set at national level (e.g. by the national central bank). In both cases the reference rate in force on the first calendar day of the half-year in question will apply for the following six months (see Article 3(1)(d) of Directive 2000/35/EC). The ‘base rate (ECB)’ refers to the interest rate applied by the European Central Bank to its main refinancing operations. 8. Contractual penalties (if applicable) 9. Costs (if applicable) If reimbursement of costs is sought, these must be described using the codes indicated on the form. The box [specification] must be used only for code 02, i.e. when reimbursement of costs other than court fees is demanded. These other costs could include, for instance, fees of a claimant’s representative or prelitigation costs. If you request reimbursement of the court fees but you do not know the exact amount, you must fill in the box [Code] (01) but you may leave the box [Amount] blank and it will be filled in by the court. Costs should be stated in the same currency as the principal. 10. Evidence available in support of the claim This field must specify the evidence available in support of each claim using the codes indicated on the form. The box [Description of evidence] will contain, for instance, the title, name, date, and/or reference number of the document concerned, the amount mentioned on the document concerned, and/or the name of the witness or expert.