ANNEX I
OMB Control No: 0970-0488
Expiration date: XX/XX/XXXX
Transmittal form under Article 12(2)
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.
1. Requesting Central Authority |
2. Contact person in requesting 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) |
Requested Central Authority:
Address
Particulars of the applicant
Family name(s):
Given name(s):
Date of birth: (dd/mm/yyyy) or
a. Name of the public body :
PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this form is to transmit applications under the 2007 Hague Child Support Convention. Public reporting burden for this collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. This collection of information is required to process child support cases under the 2007 Hague Child Support Convention. 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].
Particulars of the person(s) for whom maintenance is sought or payable
i. Family name(s): Given name(s):
Date of birth: (dd/mm/yyyy)
Family name(s): Given name(s):
Date of birth: (dd/mm/yyyy)
Family name(s): Given name(s):
Date of birth: (dd/mm/yyyy)
Particulars of the debtor1
Family name(s):
Given name(s):
Date of birth: (dd/mm/yyyy)
This transmittal form concerns and is accompanied by an application under:
The following documents are appended to the application:
For the purpose of an application under Article 10(1) a), and: In accordance with Article 25:
1 According to Art. 3 of the Convention “‘debtor’ means an individual who owes or who is alleged to owe maintenance”.
In accordance with Article 30(3):
For the purpose of an application under Article 10(1) b), c), d), e), f) and (2) a), b) or c), the following number of supporting documents (excluding the transmittal form and the application itself) in accordance with Article 11(3):
Name : (in block letters) Date: Authorised representative of the Central Authority (dd/mm/yyyy)
Final Act
Final Act
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
File Title | Annex 1 - Transmittal form under Article 12 (2) |
Subject | OMB 0970-0488 |
Author | plevin |
File Modified | 0000-00-00 |
File Created | 2023-08-25 |