ANNEX I

EUROPEAN SMALL CLAIMS PROCEDURE FORM A CLAIM FORM (Article 4(1) of Regulation (EC) No 861/2007 of the European Parliament and of the Council establishing a European Small Claims Procedure) Case number (*): Received by the court/tribunal on: / / (*) (*) To be filled in by the court/tribunal. IMPORTANT INFORMATION PLEASE READ THE GUIDELINES AT THE BEGINNING OF EACH SECTION — THEY WILL HELP YOU TO FILL IN THIS FORM Assistance in filling in the form You may benefit from assistance in filling in this form. To find out how to obtain such assistance, you may refer to the information provided by the Member States and published on the website of the European Judicial Atlas in civil and commercial matters, available at the European e-Justice Portal https://e-justice.europa.eu/content_small_claims-354-en.do Please note that this assistance does not include legal aid, for which appropriate application must be made under national law; nor does it include a legal assessment of your case. Language Fill in this form in the language of the court/tribunal to which you are sending your application. Please note that the form is available in all official languages of the institutions of the European Union on the European e-Justice Portal https://e-justice.europa.eu/content_small_claims_forms-177-en.do This may help you in filling in the form in the required language. Supporting documents Please note that the claim form should be accompanied, where appropriate, by any relevant supporting documents. However, this does not prevent you from submitting, where appropriate, further evidence during the procedure. A copy of the claim form and, where appropriate, of the supporting documents, will be served on the defendant. The defendant will have an opportunity to submit a response. 1. Court/tribunal In this field you should identify the court/tribunal before which you are making your claim. When deciding which court/tribunal to choose, you need to consider the grounds for the court’s/tribunal’s jurisdiction. A non-exhaustive list of possible grounds of jurisdiction is included in section 4. You may wish to use the dedicated search facility, available on the European e-Justice Portal to find the details (address, telephone number etc.) of the court with jurisdiction: https://e-justice.europa.eu/content_small_claims-354-en.do 1. Before which court/tribunal are you making your claim? 1.1. Name: 1.2. Street and number/PO box: 1.3. City and postal code: 1.4. Country:

2. Claimant This field must identify you as the claimant and your representative, if any. Please note that it is not mandatory to be represented by a lawyer or another legal professional. It may not be sufficient in some countries to give only a P.O. Box as the address and you should therefore include the street name and number with a postcode. Failure to do so may result in the document not being served. If you have a personal identification number given by the authorities of a Member State it would be helpful to provide it. If you don’t have such number, it would be helpful to provide the number of your passport or identification document, if you have them. If you act on behalf of a legal person or any entity having legal capacity, it would be helpful to provide a relevant registration number. ‘Other details’ may contain further information that helps to identify you, for example, your date of birth, occupation or position in the company. Where there is more than one claimant, please use additional sheets. 2. The claimant’s details 2.1. Surname, first name/name of company or organisation: 2.2. Personal identification number or passport number/registration number (*): 2.3. Street and number/PO box: 2.4. City and postal code: 2.5. Country: 2.6. Telephone (*): 2.7. Email (*): 2.8. Claimant’s representative, if any, and contact details (*): 2.9. Other details (*): 3. Defendant In this field you should identify the defendant and, if known, his representative. Please note that it is not mandatory for the defendant to be represented by a lawyer or another legal professional. It may not be sufficient in some countries to give only a PO box as the address and therefore you should include the street name and number with a postcode. Failure to do so may result in the document not being served. If you know a personal identification number given to a defendant by authorities of a Member State it would be helpful to provide it. Alternatively or additionally it would be helpful to provide a number of the defendant’s passport or identification document, if you have them. If the defendant is a legal person or any entity having legal capacity, it would be helpful to provide a relevant registration number for the defendant if you know it. ‘Other details’ may contain further information that helps to identify the person, for example the date of birth, occupation or position in the company. If there is more than one defendant, please use additional sheets. 3. The defendant’s details 3.1. Surname, first name/name of company or organisation: 3.2. Personal identification number or passport number/registration number 3.3. Street and number/PO box: (*) Optional.

3.4. City and postal code: 3.5. Country: 3.6. Telephone (*): 3.7. Email (*): 3.8. Defendant’s representative, if known, and contact details (*): 3.9. Other details (*): 4. Jurisdiction Your application must be lodged with the court/tribunal that has jurisdiction to deal with it. The court/tribunal must have jurisdiction in accordance with the rules of Regulation (EU) No 1215/2012 of the European Parliament and of the Council (1). This section includes a non-exhaustive list of possible grounds for jurisdiction. Information on the rules of jurisdiction can be found on the website of the European Judicial Atlas at https://e-justice.europa.eu/content_brussels_i_regulation_recast-350-en.do You can also look at http://ec.europa.eu/civiljustice/glossary/glossary_en.htm for an explanation of some of the legal terms employed. 4. On what ground do you consider the court/tribunal to have jurisdiction? 4.1. Domicile of the defendant 4.2. Domicile of the consumer 4.3. Domicile of the policyholder, the insured or the beneficiary in insurance matters 4.4. Place of performance of the obligation in question 4.5. Place of the harmful event 4.6. Place where the immovable property is situated 4.7. Choice of court/tribunal agreed by the parties 4.8. Other (please specify) 5. Cross-border nature of the case In order to make use of the European Small Claims Procedure, your case must be of a cross-border nature. A case is of a cross-border nature if at least one of the parties is domiciled or habitually resident in a Member State other than the Member State of the court/tribunal. (*) Optional. (1) Regulation (EU) No 1215/2012 of the European Parliament and of the Council of 12 December 2012 on jurisdiction and the recognition and enforcement of judgments in civil and commercial matters (OJ L 351, 20.12.2012, p. 1).

5. Cross-border nature of the case 5.1. Country of domicile or habitual residence of claimant: 5.2. Country of domicile or habitual residence of defendant: 5.3. Member State of the court/tribunal: 6. Bank details (optional) In field 6.1 you may inform the court/tribunal by which means you intend to pay the application fee. Please note that not all methods are necessarily available at the court/tribunal to which you are sending your application. You should verify which methods of payment will be accepted by the court/tribunal. You can do this by checking the information given by the Member State concerned and published on the website of the European Judicial atlas in civil and commercial matters, available on the European e-Justice Portal https://e-justice.europa.eu/content_small_claims-354-en.do or by contacting the court/tribunal concerned. By the same means you can discover more information about the amount of the court fee that you will need to pay. If you choose to pay by credit card or to allow the court/tribunal to collect the fee from your bank account, you should give the necessary credit card or bank account details in the Appendix to this form. The Appendix will be for the information of the court/tribunal only and will not be forwarded to the defendant. In field 6.2 you are given the possibility of indicating by which means you wish to receive payment from the defendant, for example if the defendant wishes to pay immediately even before the judgment is given. If you wish to be paid by bank transfer, please give the necessary bank details. 6. Bank details (*) 6.1. How will you pay the application fee? 6.1.1. By bank transfer 6.1.2. By credit card (please fill in the Appendix) 6.1.3. Direct debit from your bank account (please fill in the Appendix) 6.1.4. Other (please specify): 6.2. To which account do you wish the defendant to pay any amount claimed or awarded? 6.2.1. Account holder: 6.2.2. Bank name, BIC or other relevant bank code: 6.2.3. Account number/IBAN: 7. Claim Scope: Please note that the European Small Claims Procedure has a limited scope. No claims of a value higher than EUR 5 000 or which are listed in Article 2 of Regulation (EC) No 861/2007 of the European Parliament and of the Council establishing a European Small Claims Procedure can be dealt with under this procedure. If your claim does not relate to an action within the scope of that Regulation in accordance with Article 2, proceedings will continue before the courts/tribunals with jurisdiction in accordance with the rules of ordinary civil procedure. If you do not wish to continue proceedings in that event, you should withdraw your application. (*) Optional.

Monetary or other claim: You should indicate whether you are claiming money and/or something else (non-monetary claim), for example, delivery of goods, and then fill in respectively either 7.1 and/or 7.2. If your claim is not for money, please fill in section 7.2 and indicate the estimated value of your claim there. In the case of a non-monetary claim, you should indicate whether you have a secondary claim for compensation if it is not possible to satisfy the original claim. If you wish to claim the costs of the proceedings (e.g. translation costs, lawyers’ fees, costs relating to the service of documents etc.), then you should indicate this in 7.3. Please note that rules regarding the costs which courts/tribunals can award vary between different Member States. Details of categories of costs in the Member States can be found on the European e-Justice Portal https://e-justice.europa.eu/content_costs_of_proceedings-37-en.do If you wish to claim any contractual interest, for example on a loan, you should indicate the rate and from what date it runs. The court/tribunal may award statutory interest on your claim, if you are successful. If you wish to claim interest, please indicate this and the date from which the interest should run. If necessary, please use additional pages to describe your claim e.g. if you claim several payments and the interest is claimed from different date on each of the payments. 7. About your claim 7.1. Claim for money 7.1.1. Amount of principal (excluding interest and costs): 7.1.2. Currency Euro (EUR) Bulgarian lev (BGN) Croatian kuna (HRK) Czech koruna (CZK) Hungarian forint (HUF) Pound Sterling (GBP) Polish zloty (PLN) Romanian leu (RON) Swedish kronor (SEK) Other (please specify): 7.2. Other claim: 7.2.1. Please specify what you are claiming: 7.2.2. Estimated value of the claim: Currency: Euro (EUR) Bulgarian lev (BGN) Croatian kuna (HRK) Czech koruna (CZK) Hungarian forint (HUF) Pound Sterling (GBP) Polish zloty (PLN) Romanian leu (RON) Swedish kronor (SEK) Other (please specify):

7.3. Are you claiming the costs of proceedings? 7.3.1. Yes 7.3.2. No 7.3.3. If yes, please specify which costs and indicate the amount claimed or incurred so far: 7.4. Are you claiming interest? Yes No If yes, is the interest: Contractual? If so, go to 7.4.1 Statutory? If so, go to 7.4.2 7.4.1. If contractual 1) the rate is: % % above the base rate of the ECB other: 2) the interest should run from: / / (date) to: / / (date) to the date of the judgment to the date of payment of principal 7.4.2. If statutory the interest should run from: / / (date) to: / / (date) to the date of the judgment to the date of payment of principal 7.5. Are you claiming interest on costs? Yes No If yes, the interest should run from: / / (date) (event) to: / / (date) to the date of payment of costs

8. Details of claim In 8.1 you should describe briefly the substance of your claim. In 8.2 you should describe any relevant supporting evidence. This could, for example, be written evidence (e.g. contracts, receipts, etc.) or oral or written statements from witnesses. For each piece of evidence, please indicate which aspect of your claim it is intended to support. If space is insufficient, you can add additional sheets. 8. Details of claim 8.1. Please give reasons for your claim, for example what happened, where and when. 8.2. Please describe the evidence you wish to put forward to support your claim and state which points of the claim it supports. Where appropriate, you should add relevant supporting documents. 8.2.1. Written evidence please specify below 8.2.2. Witnesses please specify below 8.2.3. Other please specify below 9. Oral hearing Please note that the European Small Claims Procedure is a written procedure. However the court may decide to have an oral hearing if it considers that it is not possible to give the judgment on the basis of written evidence. You can request, in this form or at a later stage, that an oral hearing be held. The court may refuse your request if it considers, in the light of the circumstances of the case, that an oral hearing is not necessary for the fair conduct of the proceedings. The oral hearing should be carried out through appropriate distance communication means, like videoconference or teleconference, provided that they are available to the court. If the person to be heard is domiciled in a Member State other than that of the court seised, a hearing by distance communication technology shall be arranged by making use of the procedures provided for in Council Regulation (EC) No 1206/2001 (1) (https://e-justice.europa.eu/content_taking_of_evidence-76-en.do). However the court may decide that the persons summoned for the hearing must be physically present. You can indicate your preferences to the court, bearing in mind, that if you requested to be physically present at the hearing, the recovery of any costs incurred with regard to this presence is subject to the rules of Article 16 of Regulation (EC) No 861/2007 establishing a European Small Claims Procedure. This Article stipulates that the court shall not award to the successful party costs that were unnecessarily incurred or are disproportionate to the claim. 9.1. Do you want an oral hearing to be held? Yes No If yes, please indicate reasons (*): 9.2. If the court decides to hold an oral hearing, do you want to be physically present? Yes No Please indicate reasons (*): (*) Optional. (1) Council Regulation (EC) No 1206/2001 of 28 May 2001 on cooperation between the courts of the Member States in the taking of evidence in civil or commercial matters (OJ L 174, 27.6.2001, p. 1).

10. Service of documents and communication with the court Procedural documents, like your application, the response from the defendant, any counterclaim and the judgment may be served upon the parties by post or by electronic means, if such means are technically available to the court and admissible in accordance with the procedural law of the Member State in which the procedure is conducted. If the documents are to be served in a Member State other than the one in which the procedure is conducted, the procedural rules of the Member State where service is effected have to be observed as well. Electronic means could be used also for other written communications (e.g. a request to attend a court hearing). Electronic means can be used only if the addressee expressly consents in advance to their use or if he/she is legally obliged to accept electronic service and/or other written communication from the court in accordance with the procedural rules of the Member State in which the addressee is domiciled. To see if electronic means of service and/or communication are available and admissible in the relevant Member States check the information on the European e-justice portal at https://e-justice.europa.eu/content_small_claims-354-en.do?clang=en 10.1. Do you agree to the use of electronic means of communication for the service of the response by the defendant, any counterclaim and the judgment? Yes No 10.2. Do you agree to the use of electronic means of communication to receive written communications other than the documents mentioned in point 10.1? Yes No 11. Certificate A judgment given in a Member State in the European Small Claims Procedure can be recognised and enforced in another Member State. If you intend to ask for recognition and enforcement in a Member State other than that of the court/tribunal, you can request in this form that the court/tribunal, after having made a decision in your favour, issue a certificate concerning that judgment. 11.1. Certificate I ask the court/tribunal to issue a certificate concerning the judgment Yes No Upon your request the court may provide you with the certificate in another language, by making use of the dynamic forms available through the European e-Justice Portal. This may be helpful in enforcement of the judgment in another Member State. Please note, that the court is not obliged to provide any translation or transliteration of a text entered in the free-text fields of the certificate. 11.2. I ask the court/tribunal to issue a certificate in another language than the language of the court proceedings, in particular: BG ES CS DE ET EL EN FR HR IT LV LT HU MT NL PL PT RO SK SL FI SV 12. Date and signature Please make sure that you write your name clearly and sign and date your application at the end.

12. Date and signature I hereby request that the court/tribunal give a judgment against the defendant on the basis of my claim. I declare that the information provided is true to the best of my knowledge and is given in good faith. Done at: Date: / / Name and signature: