1 Application for Establishment of a Decision

OMB Control No: 0970-0488

Expiration date: XX/XX/XXXX

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

   1. Family name(s):

   2. Given name(s):

   3. Date of birth: (dd/mm/yyyy)

   4. Address:

5. Telephone numbers:

6. Fax number:

7. E-mail:

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

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:

PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to submit an application for the establishment of a decision 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].

4.

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

1. Family name(s): Given name(s):

Date of birth: (dd/mm/yyyy)

• Parentage is established or presumed Maintenance basis:

• parentage  in loco parentis or equivalent relationship

1. Family name(s): Given name(s):

Date of birth: (dd/mm/yyyy)

• Parentage is established or presumed Maintenance basis:

• parentage  in loco parentis or equivalent relationship

1. Family name(s): Given name(s):

Date of birth: (dd/mm/yyyy)

• Parentage is established or presumed Maintenance basis:

• parentage  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:

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

Particulars (if known) of the debtor (respondent)

1. Family name(s):

2. Given name(s):

3. Date of birth: (dd/mm/yyyy)

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

5. Residential address:

6. Postal address:

7. Any other information that may assist with the location of the debtor

5. Payments

   1. Details for electronic transfer of payments (if applicable)

Name of the bank: NBIC: ¹

SWIFT-address:

IBAN:²

Account number: Name of account holder: Reference:³

2. Details for payments by cheques (if applicable)

Cheque payable to: Cheque to be sent to: (address)

Reference:³

5. This application is for the establishment of a decision in the requested State where:

   1.  there is no existing decision (Article 10(1) c))

   2.  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))

5. Support / maintenance sought by the applicant⁴ (specify currency⁵ for each amount)

• 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):

¹ National Bank Identification Code.

² 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.

• 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):

5. 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

5.  Please initiate enforcement measures once the decision is established

6. Other information:

5. 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) Date: Authorised representative of the Central Authority (dd/mm/yyyy)

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

   1. Family name(s):

   2. Given name(s):

   3. Date of birth: (dd/mm/yyyy)

   4. Address:

5. Telephone numbers:

6. Fax number:

7. E-mail:

5. Payments

   1. Details for electronic transfer of payments (if applicable)

Name of the bank: NBIC:

SWIFT-address:

IBAN:

Account number: Name of account holder: Reference:

2. 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) Date: Authorised representative of the Central Authority (dd/mm/yyyy)