1 Statement of Proper Notice

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

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

Statement of Proper Notice¹

(Article 25(1) c))

1. Name of the State of origin of the decision:

(identify territorial unit if applicable)

2. Competent authority issuing the Statement

   1. Name:

   2. Address:

2.3	Telephone number:
2.4	Fax number:
2.5	E-mail:

3. The decision²

   1. Type of authority:  judicial authority or  administrative authority³

   2. Name and place of authority:

   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. Name of the respondent:

PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to provide a statement of proper notice in 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].

¹ A Statement of Proper Notice should be provided if the Respondent did not appear and was not represented in the proceedings in the State of origin.

² For the definition of decision see Article 19(1).

³ The Administrative Authority referred to in this Statement meets the requirements of Article 19(3).

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

5. Proper notice to the respondent

• The respondent had proper notice of the proceedings and an opportunity to be heard ( Certificate of Service attached if applicable^)

• The respondent had proper notice of the decision and an opportunity to challenge or appeal it on fact and law ( Certificate of Service attached if applicable^)

Name: (in block letters) Date:

Name of the official from the competent authority of the State of origin (dd/mm/yyyy)

• This Statement of Proper Notice 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) Date:

Authorised representative of the Central Authority (dd/mm/yyyy)

Requesting Central Authority reference number:

(For Central Authority use only)

• For example, a certificate issued under domestic law or, where appropriate, a certificate issued under an international instrument.