
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.
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
ANNEX


ANNEX I 
(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)

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. 

 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.  2.1. Name: …
 2.2. Address:

2.2.1. Street and number/PO box: …
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
 2.3. Telephone/Fax/E-mail: …
 3.  3.1.  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: …
3.1.4.2. Place and postal code: …
3.1.4.3. Country: …
 3.1.5. Has benefited from
 3.1.5.1. 

 Yes  No
 3.1.5.2. 

 Yes  No
 3.1.5.3. 

 Yes  No
 3.2.  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: …
3.2.4.2. Place and postal code: …
3.2.4.3. Country: …
 3.2.5. Has benefited from
 3.2.5.1. 

 Yes  No
 3.2.5.2. 

 Yes  No
 3.2.5.3. 

 Yes  No
 3.3.  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: …
3.3.4.2. Place and postal code: …
3.3.4.3. Country: …
 3.3.5. Has benefited from
 3.3.5.1. 

 Yes  No
 3.3.5.2. 

 Yes  No
 3.3.5.3. 

 Yes  No
 4.  4.1.  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: …
4.1.4.2. Place and postal code: …
4.1.4.3. Country: …
 4.1.5. Has benefited from
 4.1.5.1. 

 Yes  No
 4.1.5.2. 

 Yes  No
 4.1.5.3. 

 Yes  No
 4.2.  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: …
4.2.4.2. Place and postal code: …
4.2.4.3. Country: …
 4.2.5. Has benefited from
 4.2.5.1. 

 Yes  No
 4.2.5.2. 

 Yes  No
 4.2.5.3. 

 Yes  No
 4.3.  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: …
4.3.4.2. Place and postal code: …
4.3.4.3. Country: …
 4.3.5. Has benefited from
 4.3.5.1. 

 Yes  No
 4.3.5.2. 

 Yes  No
 4.3.5.3. 

 Yes  No
 5.  5.1. 
 Euro (EUR)  Lev (BGN)  Czech koruna (CZK)  Kuna (HRK)  Forint (HUF)  Zloty (PLN)  Leu (RON)  Krona (SEK)  Other (please specify ISO code): …
 5.2.  5.2.1.  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
 
 
 
 
 5.2.1.4.  Sum to be paid regularly
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.  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
 
 
 
 
 5.2.2.4.  Sum to be paid regularly
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.  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
 
 
 
 
 5.2.3.4.  Sum to be paid regularly
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. 
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 
(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)

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. 

 Decision  Court settlement

Date and reference number: …
 2.  2.1. Name: …
 2.2. Address:

2.2.1. Street and number/PO box: …
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
 2.3. Telephone/Fax/E-mail: …
 3.  3.1.  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: …
3.1.4.2. Place and postal code: …
3.1.4.3. Country: …
 3.1.5. Has benefited from
 3.1.5.1. 

 Yes  No
 3.1.5.2. 

 Yes  No
 3.1.5.3. 

 Yes  No
 3.2.  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: …
3.2.4.2. Place and postal code: …
3.2.4.3. Country: …
 3.2.5. Has benefited from
 3.2.5.1. 

 Yes  No
 3.2.5.2. 

 Yes  No
 3.2.5.3. 

 Yes  No
 3.3.  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: …
3.3.4.2. Place and postal code: …
3.3.4.3. Country: …
 3.3.5. Has benefited from
 3.3.5.1. 

 Yes  No
 3.3.5.2. 

 Yes  No
 3.3.5.3. 

 Yes  No
 4.  4.1.  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: …
4.1.4.2. Place and postal code: …
4.1.4.3. Country: …
 4.1.5. Has benefited from
 4.1.5.1. 

 Yes  No
 4.1.5.2. 

 Yes  No
 4.1.5.3. 

 Yes  No
 4.2.  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: …
4.2.4.2. Place and postal code: …
4.2.4.3. Country: …
 4.2.5. Has benefited from
 4.2.5.1. 

 Yes  No
 4.2.5.2. 

 Yes  No
 4.2.5.3. 

 Yes  No
 4.3.  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: …
4.3.4.2. Place and postal code: …
4.3.4.3. Country: …
 4.3.5. Has benefited from
 4.3.5.1. 

 Yes  No
 4.3.5.2. 

 Yes  No
 4.3.5.3. 

 Yes  No
 5.  5.1. 
 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.  5.2.1.  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
 
 
 
 
 5.2.1.4.  Sum to be paid regularly
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.  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
 
 
 
 
 5.2.2.4.  Sum to be paid regularly
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.  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
 
 
 
 
 5.2.3.4.  Sum to be paid regularly
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. 
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 
(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)

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.  2.1. Instrument formally drawn up or registered on: … (dd/mm/yyyy)
Agreement concluded or authenticated on: … (dd/mm/yyyy)
 2.2. Competent authority:

2.2.1. Name: …
2.2.2. Address:

2.2.2.1. Street and number/PO box: …
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
2.2.3. Telephone/Fax/E-mail: …
 3.  3.1.  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: …
3.1.4.2. Place and postal code: …
3.1.4.3. Country: …
 3.2.  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: …
3.2.4.2. Place and postal code: …
3.2.4.3. Country: …
 3.3.  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: …
3.3.4.2. Place and postal code: …
3.3.4.3. Country: …
 4.  4.1.  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: …
4.1.4.2. Place and postal code: …
4.1.4.3. Country: …
 4.2.  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: …
4.2.4.2. Place and postal code: …
4.2.4.3. Country: …
 4.3.  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: …
4.3.4.2. Place and postal code: …
4.3.4.3. Country: …
 5.  5.1. 
 Euro (EUR)  Lev (BGN)  Czech koruna (CZK)  Kuna (HRK)  Forint (HUF)  Zloty (PLN)  Leu (RON)  Krona (SEK)  Other (please specify ISO code): …
 5.2.  5.2.1.  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
 
 
 
 
 5.2.1.4.  Sum to be paid regularly
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.  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
 
 
 
 
 5.2.2.4.  Sum to be paid regularly
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.  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
 
 
 
 
 5.2.3.4.  Sum to be paid regularly
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. 
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 
(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)

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.  2.1.  Instrument formally drawn up or registered on: … (dd/mm/yyyy)
Agreement concluded or authenticated on: … (dd/mm/yyyy)
 2.2. Competent authority:

2.2.1. Name: …
2.2.2. Address:

2.2.2.1. Street and number/PO box: …
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
2.2.3. Telephone/Fax/E-mail: …
 3.  3.1.  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: …
3.1.4.2. Place and postal code: …
3.1.4.3. Country: …
 3.2.  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: …
3.2.4.2. Place and postal code: …
3.2.4.3. Country: …
 3.3.  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: …
3.3.4.2. Place and postal code: …
3.3.4.3. Country: …
 4.  4.1.  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: …
4.1.4.2. Place and postal code: …
4.1.4.3. Country: …
 4.2.  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: …
4.2.4.2. Place and postal code: …
4.2.4.3. Country: …
 4.3.  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: …
4.3.4.2. Place and postal code: …
4.3.4.3. Country: …
 5.  5.1. 
 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.  5.2.1.  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
 
 
 
 
 5.2.1.4.  Sum to be paid regularly
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.  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
 
 
 
 
 5.2.2.4.  Sum to be paid regularly
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.  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
 
 
 
 
 5.2.3.4.  Sum to be paid regularly
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. 
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 
(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)
 PART A  1.  1.1. Name: …
 1.2. Address:

1.2.1. Street and number/PO box: …
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
 1.3. 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): …
1.7.2. Telephone: …
1.7.3. E-mail: …
 2.  2.1. Name: …
 2.2. Address:

2.2.1. Street and number/PO box: …
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
 3.  3.1. 

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.)
3.1.3.  facilitate the obtaining of documentary or other evidence
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
3.1.6.  facilitate service of a document
 3.2. 
…

…

…

…

…
 3.3.  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: …
 3.3.1.3. Last known address: …
 3.3.1.4. Identity number or social security number: …
 3.3.1.5. Any other information which may be useful:
…
…
 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: …
 3.3.2.3. Last known address: …
 3.3.2.4. Identity number or social security number: …
 3.3.2.5. Any other information which may be useful:
…
…
 3.4.  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

 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  4.  5.  5.1. Surname and given name(s): …
 5.2. Telephone: …
 5.3. Fax …
 5.4. E-mail: …
 6. 
…

…

…

…
 7.  7.1.  7.1.1. Debtor’s/creditor’s address:

 No  Yes (please specify):
…
…
 7.1.2. Debtor’s/creditor’s revenue:

 No  Yes (please specify):
…
…
 7.1.3. Debtor’s/creditor’s assets:

 No  Yes (please specify):
…
…
 7.2.  7.2.1. Debtor’s/creditor’s address:

 No  Yes (please specify):
…
…
…
 7.2.2. Existence of debtor’s income:

 No  Yes
 7.2.3. Existence of debtor’s assets:

 No  Yes

(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. 
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 
(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)

PART A 1. 
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.  2.1. Name: …
 2.2. Address:

2.2.1. Street and number/PO box: …
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
 2.3. 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): …
2.7.2. Telephone: …
2.7.3. E-mail: …
 3.  3.1. Name: …
 3.2. Address:

3.2.1. Street and number/PO box: …
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
 4. 
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. 
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 6.  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
6.1.2.  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 
6.1.3.  The national law of the requested Member State
6.1.4.  Other (please specify): …
…
…
 6.2.  Application for enforcement of a decision given or recognised in the requested Member State
 7.  7.1. Date and reference number: …
 7.2. Name of the court of origin: …
 8.  8.1.  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: …
 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. 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
8.1.9.2. 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
 8.1.10. If applicable, surname, given name(s) and contact details of the applicant’s representative (lawyer, etc. …): …
…
 8.2.  8.2.1. Name: …
 8.2.2. Address:

8.2.2.1. Street and number/PO box: …
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
 8.2.3. Telephone/Fax/E-mail: …
 8.2.4. Name of the person representing the body in the proceedings:
…
 8.2.5. Person responsible for following up the application:

8.2.5.1. Surname and given name(s): …
8.2.5.2. Telephone: …
8.2.5.3. Fax …
8.2.5.4. E-mail: …
 9.  9.1. Surname and given name(s): …
 9.2. Date (dd/mm/yyyy) and place of birth: …
 9.3. Identity number or social security number: …
 9.4. Nationality: …
 9.5. Occupation: …
 9.6. Civil status: …
 9.7. Address:
 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. 
…

…

…
 11.  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
 11.3. 
 The applicant  The defendant
is the representative defending the interests of the following person(s):
 11.3.1.  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: …
 11.3.1.4. Nationality: …
 11.3.1.5. Occupation: …
 11.3.1.6. Civil status: …
 11.3.2.  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: …
 11.3.2.4. Nationality: …
 11.3.2.5. Occupation: …
 11.3.2.6. Civil status: …
 11.3.3.  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: …
 11.3.3.4. Nationality: …
 11.3.3.5. Occupation: …
 11.3.3.6. Civil status: …
 12.  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
 12.3. 
 The applicant  The defendant
is the representative defending the interests of the following person:

12.3.1. Surname and given name(s): …
12.3.2. Date (dd/mm/yyyy) and place of birth: …
12.3.3. Identity number or social security number: …
12.3.4. Nationality: …
12.3.5. Occupation: …
12.3.6. Civil status: …
 13.  13.1.  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.  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: …
13.2.2.2.2. Place and postal code: …
13.2.2.2.3. Country: …
 14. 
…

…

…

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 
(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)

PART A 1. 
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.  2.1. Name: …
 2.2. Address:

2.2.1. Street and number/PO box: …
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
 2.3. 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): …
2.7.2. Telephone: …
2.7.3. E-mail: …
 3.  3.1. Name: …
 3.2. Address:

3.2.1. Street and number/PO box: …
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
 4. 
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 5.  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 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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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):
 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):
 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.  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. 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: …
 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.  7.1. Surname and given name(s): …
 7.2. Address:

7.2.1. Street and number/PO box: …
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
 7.3. Date (dd/mm/yyyy) and place of birth: …
 7.4. Identity number or social security number: …
 7.5. Nationality: …
 7.6. Occupation: …
 7.7. Civil status: …
 8. 
…

…

…
 9.  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
 9.3. 
 The applicant  The defendant
is the representative defending the interests of the following person(s):
 9.3.1.  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: …
 9.3.1.4. Nationality: …
 9.3.1.5. Occupation: …
 9.3.1.6. Civil status: …
 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): …
 9.3.2.  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: …
 9.3.2.4. Nationality: …
 9.3.2.5. Occupation: …
 9.3.2.6. Civil status: …
 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): …
 9.3.3.  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: …
 9.3.3.4. Nationality: …
 9.3.3.5. Occupation: …
 9.3.3.6. Civil status: …
 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): …
 10.  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
 10.3. 
 The applicant  The defendant
is the representative defending the interests of the following person:

10.3.1. Surname and given name(s): …
10.3.2. Date (dd/mm/yyyy) and place of birth: …
10.3.3. Identity number or social security number: …
10.3.4. Nationality: …
10.3.5. Occupation: …
10.3.6. Civil status: …
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.  11.1. 
 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.  11.2.1. 

 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. 

 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. 
…

…

…
 11.3.  11.3.1. 

 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. 

 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. 
…

…

…
 12.  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: …
12.2.2.2.2. Place and postal code: …
12.2.2.2.3. Country: …
 13. 
…

…

…

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:

…

