Form 1 Annex 2 Acknowledgement

ANNEX II

OMB Control No: 0970-0488 Expiration date: XX/XX/XXXX

Acknowledgement form under Article 12(3)

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 data 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.

1. Requested Central Authority	2. Contact person in requested State
a. Address	a. Address (if different)
b. Telephone number	b. Telephone number (if different)
c. Fax number	c. Fax number (if different)
d. E-mail	d. E-mail (if different)
e. Reference number	e. Language(s)

3. Requesting Central Authority Contact person

Address

3. The requested Central Authority acknowledges receipt on (dd/mm/yyyy) of the transmittal form from the requesting Central Authority (reference number ; dated (dd/mm/yyyy)) concerning the following application under:

   • Article 10(1) a)

   • Article 10(1) b)

   • Article 10(1) c)

   • Article 10(1) d)

   • Article 10(1) e)

   • Article 10(1) f)

   • Article 10(2) a)

   • Article 10(2) b)

   • Article 10(2) c)

PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to acknowledge receipt of an application under the 2007 Hague Child Support Convention. Public reporting burden for this collection of information is estimated to average 0.5 hours per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. This is a mandatory collection of information per 45 CFR 303.7. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information subject to the requirements of the Paperwork Reduction Act of 1995, unless it displays a currently valid OMB control number. If you have any comments on this collection of information, please contact the ACF Reports Clearance Officer by email at [email protected].

Family name(s) of applicant:

Family name(s) of the person(s) for whom

maintenance is sought or payable:

Family name(s) of debtor:

3. Initial steps taken by the requested Central Authority:

   • The file is complete and is under consideration

     • See attached status of application report

     • Status of application report will follow

   • Please provide the following additional information and / or documentation:

• The requested Central Authority refuses to process this application as it is manifest that the requirements of the Convention are not fulfilled (Art. 12(8)). The reasons:

  • are set out in an attached document

  • will be set out in a document to follow

The requested Central Authority requests that the requesting Central Authority inform it of any change in the status of the application.

Name: (in block letters) Date: Authorised representative of the Central Authority (dd/mm/yyyy)

Final Act