Form 1 Statement of Enforceability of a Decision

OMB Control No: XXXX-XXXX
Expiration date: mm/dd/yyyy
Convention on the International Recovery of Child Support and Other Forms of Family Maintenance

Statement of Enforceability of a Decision
(Article 25(1) b))

1.

Name of the State of origin of the decision:

____________________________________

(identify territorial unit if applicable)

____________________________________

2.

Competent authority issuing the Statement

2.1

Name:

_____________________________________________

2.2

Address:

_____________________________________________
_____________________________________________
_____________________________________________

2.3

Telephone number:

________________________________

2.4

Fax number:

________________________________

2.5

E-mail:

________________________________

3.

The decision 1

3.1

Type of authority:  judicial authority or  administrative authority 2

3.2

Name and place of authority: _________________________________________________

3.3

(address if applicable)

_________________________________________________
_________________________________________________

3.4

Date of the decision:

______________________________ (dd/mm/yyyy)

3.5

Date of effect of the decision:

______________________________ (dd/mm/yyyy)

3.6

Reference number of the decision:

___________________________________________

3.7

Names of the parties to the decision: ___________________________________________
___________________________________________
___________________________________________

4.



The decision is enforceable in the State of origin.

Date: ________________
Name: _______________________________ (in block letters)
(dd/mm/yyyy)
Name of the official from the competent authority of the State of origin


This Statement of Enforceability of a Decision was completed by the official from the
competent authority of the State of origin whose name appears above and is transmitted
by the requesting Central Authority.

Name: _______________________________ (in block letters)
Authorised representative of the Central Authority
Requesting Central Authority reference number:
(For Central Authority use only)

Date: ________________
(dd/mm/yyyy)
______________________________

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13)
Public reporting burden for this collection of information is estimated to average 0.17 hour per response, including the time for
reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information.
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a
currently valid OMB control number.
1
2

For the definition of decision see Article 19(1).
The Administrative Authority referred to in this Statement meets the requirements of Article 19(3).