Form 1 Application for Establishment 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

Application for Establishment of a Decision
(including where necessary the establishment of parentage)
( Article 10(1) c)  Article 10(1) d))
CONFIDENTIALITY AND PERSONAL DATA PROTECTION NOTICE

Personal data gathered or transmitted under the Convention shall be used only for the purposes for
which it was gathered or transmitted. Any authority processing such information shall ensure its
confidentiality, in accordance with the law of its State.
An authority shall not disclose or confirm information gathered or transmitted in application of this
Convention if it determines that to do so could jeopardise the health, safety or liberty of a person in
accordance with Article 40.

A determination of non-disclosure has been made by a Central Authority in accordance
with Article 40. If this box is ticked, information under sections 2 d, e, f and g and 5 should only be
provided in the Restricted Information on the Applicant page of this form.
1.

Requesting Central Authority file reference number: _____________________________

2.

Particulars of the applicant
a.

Family name(s):

_________________________________________________

b.

Given name(s):

_________________________________________________

c.

Date of birth:

_____________________________________ (dd/mm/yyyy)

d.

Address:

_________________________________________________
_________________________________________________

e.

Telephone numbers:

_________________________________________________
_________________________________________________

f.

Fax number:

_________________________________________________

g.

E-mail:

_________________________________________________

3.

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

3.1



Maintenance is sought or payable for the applicant named above


Parentage is established or presumed

Maintenance basis:
 parentage
 in loco parentis or equivalent relationship
 marriage
 analogous relationship to marriage
 affinity (please identify): _________________________________
 grandparent
 sibling
 grandchild
 other: ________________________________________________

Convention on the International Recovery of Child Support and Other Forms of Family Maintenance

3.2



Maintenance is sought or payable for the following child(ren)

a.

Family name(s):

_____________________________________

Given name(s):

_____________________________________

Date of birth:

_____________________________________ (dd/mm/yyyy)



b.

Maintenance basis:
 parentage
Family name(s):

 in loco parentis or equivalent relationship
_____________________________________

Given name(s):

_____________________________________

Date of birth:

_____________________________________ (dd/mm/yyyy)



c.

Parentage is established or presumed

Parentage is established or presumed

Maintenance basis:
 parentage
Family name(s):

 in loco parentis or equivalent relationship
_____________________________________

Given name(s):

_____________________________________

Date of birth:

_____________________________________ (dd/mm/yyyy)



Parentage is established or presumed

Maintenance basis:
 parentage
3.3



 in loco parentis or equivalent relationship

Maintenance is sought or payable for the following person
Family name(s):

_____________________________________

Given name(s):

_____________________________________

Date of birth:

_____________________________________ (dd/mm/yyyy)

Maintenance basis:
 marriage
 analogous relationship to marriage
 affinity (please identify): _________________________________
 grandparent
 sibling
 grandchild
 other: ________________________________________________
3.4



4.

Particulars (if known) of the debtor (respondent)

Maintenance is sought or payable for additional children or persons, additional
particulars are attached

a.

Family name(s):

____________________________________

b.

Given name(s):

____________________________________

c.

Date of birth:

____________________________________ (dd/mm/yyyy)

d.

Personal identification number:
_______________________
(include name of country or territorial unit that issued the number)

e.

Residential address:

____________________________________
____________________________________

f.

Postal address:

____________________________________
____________________________________

Convention on the International Recovery of Child Support and Other Forms of Family Maintenance

g.

Any other information that may assist with the location of the debtor
________________________________________________________
________________________________________________________

5.

Payments
a.

Details for electronic transfer of payments (if applicable)
Name of the bank:
NBIC:

b.

1

________________________________
________________________________

SWIFT-address:

________________________________

IBAN: 2

________________________________

Account number:

________________________________

Name of account holder:

________________________________

Reference: 3

________________________________

Details for payments by cheques (if applicable)
Cheque payable to:

________________________________

Cheque to be sent to:

________________________________

(address)

________________________________
________________________________
3

Reference:

________________________________

6.

This application is for the establishment of a decision in the requested State where:
there is no existing decision (Article 10(1) c))
a.

b.

recognition and enforcement of a decision is not possible or is refused
because of the lack of a basis for recognition and enforcement under
Article 20 or on the grounds specified in Article 22 b) or e)
(Article 10(1) d))

7.

Support / maintenance sought by the applicant 4 (specify currency 5 for each amount)




1

Support / maintenance
Please specify the amount:
_________________________________________
Frequency of payments
 week
 two weeks  month
 3 months  6 months
 year
 other (specify): ___________________________
Retroactive support / maintenance
Please specify date from which retroactive maintenance is sought:
_____________ (dd/mm/yyyy)
Please specify the amount:
_________________________________________
Frequency of payments
 week
 two weeks  month
 3 months  6 months
 year
 single payment
 other (specify): ___________________

National Bank Identification Code.
International Bank Account Number.
3
Where needed to affect payment.
4
Complete this section only if required by the requested State.
5
Currency should be specified using the ISO code.
2

Convention on the International Recovery of Child Support and Other Forms of Family Maintenance



Other payments, arrangements or conditions
Please specify: _______________________________________________
Please specify the amount:
__________________________________
Frequency of payments
 week
 two weeks  month
 3 months  6 months
 year
 other (specify): _______________________________

8.

The following document(s) are attached in support of this application:
 Birth certificate or equivalent
 Acknowledgement of parentage by the debtor
 Formal statement providing evidence relating to parentage
 Decision of competent authority concerning parentage
 Genetic test results
 Adoption certificate
 Certificate of marriage or similar relationship and date of divorce /
separation
 Formal statement providing evidence relating to common residence of the
parties
 Agreement between the parties relating to maintenance
 Evidence of attendance at secondary or post-secondary educational
institution
 Evidence of disability
 Financial Circumstances Form
 Statement of arrears or payment history
 Other evidence in accordance with the law of the requested State
 Decision of the requested State refusing recognition and enforcement

9.



10.

Other information: ________________________________________________

Please initiate enforcement measures once the decision is established

_________________________________________________________________
11.

Attestations



This application was completed by the applicant and reviewed by the requesting Central
Authority



This application complies with the requirement of the Convention (Article 12(2)). The
information contained in this application and the attached documents correspond to and
are in conformity with the information and documents provided by the applicant to the
requesting Central Authority. The application is forwarded by the Central Authority on
behalf of and with the consent of the applicant.

Name: _______________________________ (in block letters)
Authorised representative of the Central Authority

Date: ________________
(dd/mm/yyyy)

Convention on the International Recovery of Child Support and Other Forms of Family Maintenance

Restricted Information on the Applicant
Application for Establishment of a Decision
(including where necessary the establishment of parentage)
( Article 10(1) c)  Article 10(1) d))
N.B. The requesting Central Authority has determined that information under sections 2 d, e, f
and g and 5 on this page shall not be disclosed or confirmed for the protection of the health,
safety or liberty of a person. Such a determination shall according to Article 40(2) be taken into
account by the requested Central Authority.
1.

Requesting Central Authority file reference number: _____________________________

2.

Particulars of the applicant
a.
Family name(s):
b.
Given name(s):
c.
Date of birth:
d.
Address:
e.
f.
g.

_________________________________________________
_________________________________________________
_____________________________________ (dd/mm/yyyy)
_________________________________________________
_________________________________________________
Telephone numbers: _________________________________________________
_________________________________________________
Fax number:
_________________________________________________
E-mail:
_________________________________________________

5.

Payments
a.
Details for electronic transfer of payments (if applicable)
________________________________
Name of the bank:
NBIC:
________________________________
SWIFT-address:
________________________________
IBAN:
________________________________
Account number:
________________________________
Name of account holder:
________________________________
Reference:
________________________________
b.
Details for payments by cheques (if applicable)
Cheque payable to:
________________________________
Cheque to be sent to:
________________________________
(address)
________________________________
________________________________
Reference:
________________________________



This application was completed by the applicant and reviewed by the requesting Central
Authority



This application complies with the requirement of the Convention (Article 12(2)). The
information contained in this application and the attached documents correspond to and
are in conformity with the information and documents provided by the applicant to the
requesting Central Authority. The application is forwarded by the Central Authority on
behalf of and with the consent of the applicant

Name: _______________________________ (in block letters)
Authorised representative of the Central Authority

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 0.5 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.