1 Financial Circumstances Form

OMB Control No: 0970-0488

Expiration date: XX/XX/XXXX

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

Financial Circumstances Form

N.B. Sections II to VI should be completed only as necessary for the purposes of the application to which this form is attached and to the best of the applicant’s knowledge. When completing the Financial Circumstances Form, please consult Country Profile of the requested State to verify what information is required for a specific application.

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 items V.D. 2, 4, 6, 8, 10, 12, 14 and 16 and VI.D. 9 and 11 should only be provided in the Restricted Information on the Applicant page of this form.

1. REFERENCE INFORMATION

Requesting Central Authority Address Telephone number Fax number E-mail Reference number

Contact person in Requested State Address (if different) Telephone number (if different) Fax number (if different) E-mail (if different) Language(s)

3. The applicant, (family name(s) and given name(s)), born

(dd/mm/yyyy), is:  creditor,  representative of the person(s) for whom maintenance is sought or payable, or  debtor

3. This form is being submitted in relation to: (it is possible to tick more than one box)

   • Establishment of a decision (Art. 10(1) c) and d)) (Complete all sections)

   • Recognition or recognition and enforcement of a decision (Art. 10(1) a)) (Complete sections III and IV)

   • Enforcement of a decision made or recognised in the requested State (Art. 10(1) b)) (Complete sections III and IV)

   • Modification of a decision (Art. 10(1) e) and f) and (2) b) and c)) (Complete all sections)

   • Applying for legal assistance (Art. 17 a))

(Complete sections II, V and VI if the applicant is the person identified under II) (Complete sections III, V and VI if the applicant is the person identified under III)

3. Unless otherwise specified, the currency (ISO code) used to complete this form and, if applicable, the exchange rate (and date of exchange rate) if the amounts are converted into the currency of the requested State is: (dd/mm/yyyy)

PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection to collect financial information to include in an application under the 2007 Hague Child Support Convention. Public reporting burden for this collection of information is estimated to average 2 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].

2. GENERAL INFORMATION ABOUT THE CREDITOR OR THE PERSON(S) FOR WHOM MAINTENANCE IS SOUGHT OR PAYABLE (IF KNOWN)

1. Information about the creditor or the person(s) for whom maintenance is sought or payable

1. The creditor or the person for whom maintenance is sought is: Father  Mother  Caretaker other than parent  Foster care provider Both the child and the above person (marked) are considered as creditors The child her/himself is the only creditor Public body Other person (see the application)
2. Occupation, trade or profession
3. Estimated gross monthly earnings (specify currency)			4. Other monthly income (& source) (specify currency)
5. Present marital status Married  Single	Partner	Divorced		Separated

2. Information about creditor’s dependents

Family name(s) Given name(s)	Age	Relationship to creditor	Subject of this application?
			Yes  No
			Yes  No
			Yes  No
			Yes  No
			Yes  No

3. Information about current  spouse or  partner of creditor  other member of the household contributing to the expenses of the household

1. Family name(s), given name(s)	2. Employed? Yes  No  Unknown
3. Estimated gross monthly earnings (specify currency)	4. Other monthly income (& source) (specify currency)
5. The person identified above pays child support / maintenance  voluntarily or  judicial / administrative decision in the amount of per (specify currency and instalment period). As of (dd/mm/yyyy) the total amount paid is: ; and the total amount outstanding is: (specify currency).

3. GENERAL INFORMATION ABOUT THE DEBTOR (IF KNOWN)

1. Information about the debtor

1. The debtor is: Father  Mother Spouse  Partner	Caretaker other than parent Child		Foster care Other person
2. Occupation, trade or profession:
3. Name and address of the employer:
4. Estimated gross monthly earnings (specify currency)		5. Other monthly income (& source) (specify currency)
6. Present Marital Status Married  Single	Partner  Divorced		Separated

2. Information about debtor’s dependents

Family name(s) Given name(s)	Age	Relationship to debtor	Subject of this application?
1.			Yes  No
2.			Yes  No
3.			Yes  No
4.			Yes  No
5.			Yes  No

3. Information about current  spouse or  partner of debtor  other member of the household contributing to the expenses of the household

1. Family name(s), given name(s)	2. Employed? Yes  No  Unknown
3. Estimated gross monthly earnings (specify currency)	4. Other monthly income (& source) (specify currency)
5. The person identified above pays child support / maintenance  voluntarily or  judicial / administrative decision in the amount of per (specify currency and instalment period). As of (dd/mm/yyyy) the total amount paid is: ; and the total amount outstanding is: (specify currency).

4. ASSETS AND DEBTS OF THE DEBTOR (IF KNOWN)

Please specify currency used to complete the following tables:

1. Value of debtor’s assets

1. House – Market value: Ownership:  self  joint (specify):	2. (location and / or registration number)
3. Other real estate – Market value: Ownership:  self  joint (specify):	4. (location and / or registration number, description)
5. Motor vehicle(s) – Market value: Ownership:  self  joint (specify):	6. (location and / or registration number, model, year)
7. Caravans/boats – Market value: Ownership:  self  joint (specify):	8. (location and / or registration number, model, year)
9. Furniture and household effects – Market value: Ownership:  self  joint (specify):	10. (location and description)
11. Bank account(s)	12. (institution(s) and account number(s))
13. Life insurance and buy back value	14. (insurance company, policy number)
15. Other assets * – Value:	16. (institution(s) and account number(s))

2. Value of debtor’s debts

Credit provider	Amount	Payment rate	Encumbered property
1.
2.
3.
4.

5. FINANCIAL STATEMENT OF THE APPLICANT

Please specify currency used to complete the following tables:

1. Applicant’s gross income

1. Monthly Annual	Applicant	Applicant’s current spouse/partner	Child(ren) for whom maintenance is sought or payable	Other persons for whom maintenance is sought or payable
2. Gross salary (incl. payments in kind)
3. Income from non-salaried occupations
4. Pensions, disability pensions, alimonies, allowances, annuities
5. Unemployment benefits
6. Income from securities/floating capital
7. Income from real property
8. Public assistance
9. Other sources of income *
10. TOTAL

2. Applicant’s income deductions

1. Monthly Annual	Applicant	Applicant’s current spouse/partner	Child(ren) for whom maintenance is sought or payable	Other persons for whom maintenance is sought or payable
2. National/Federal tax
3. State/Provincial tax
4. City/Local tax
5. Insurance premiums
6. Mandatory pension contributions
7. Union/professional dues
8. Other deductions *
9. TOTAL

3. Applicant’s expenses

1. Monthly Annual	Applicant	Applicant’s current spouse/partner	Child(ren) for whom maintenance is sought or payable	Other persons for whom maintenance is sought or payable
2. Rent or mortgage
3. Household costs
4. Food and house supplies
5. Clothing
6. Medical/dental/optical fees
7. Maintenance paid
8. Insurance (other than under Part V.B)
9. Transportation expenses
10. Child care
11. Education for children
12. Extracurricular activities for children
13. Yearly savings
14. Debt-repayment
15. Other expenses *
16. TOTAL

4. Value of applicant’s assets¹

1. House – Market value: Ownership:  self  joint (specify):	2. (location and / or registration number)
3. Other real estate – Market value: Ownership:  self  joint (specify):	4. (location and / or registration number, description)
5. Motor vehicle(s) – Market value: Ownership:  self  joint (specify):	6. (location and / or registration number, model, year)
7. Caravans/boats – Market value: Ownership:  self  joint (specify):	8. (location and / or registration number, model, year)
9. Furniture and household effects – Market value: Ownership:  self  joint (specify):	10. (location and description)
11. Bank account(s)	12. (institution(s) and account number(s))
13. Life insurance and buy back value	14. (insurance company, policy number)
15. Other assets * – Value:	16. (institutions and account numbers)

¹ Do not complete this table if the person identified under III is the applicant as this information would be the same as the one found under Section IV.A.

5. Value of applicant’s debts²

Credit provider	Amount	Payment Rate	Encumbered property
1.
2.
3.
4.

6. MEDICAL INSURANCE

1. Is debtor required by a maintenance decision to provide medical insurance for the child(ren)?

• Yes  No

2. Is debtor required by a maintenance decision to provide medical insurance for the creditor?

• Yes  No

3. Medical coverage for child(ren) for whom maintenance is sought and/or the creditor is provided by:

4. Insurance coverage

Coverage provided by:	For child(ren)	For creditor	9. Creditor’s Insurance Company: Policy number:
1. Creditor		
2. Debtor		
3. State Medicare			10. Debtor’s Insurance Company: Policy number:
4. Creditor’s employer		
5. Debtor’s employer		
6. Other:			11. Other Insurance Company: Policy number:
7. Unknown		
8. No coverage		

• This Financial Circumstances Form was completed by the applicant and reviewed by the requesting Central Authority.

• The information contained in this Financial Circumstances Form corresponds to and is in conformity with the information and documents provided by the applicant to the requesting Central Authority. The Financial Circumstances Form 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)

² Do not complete this table if the person identified under III is the applicant as this information would be the same as the one found under Section IV.B.

Restricted Information on the Applicant

Financial Circumstances Form

N.B. The requesting Central Authority has determined that information under items V.D. 2, 4, 6, 8, 10, 12, 14 and 16 and VI.D. 9 and 11 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:

V.D. Value of applicant’s assets

1. House – Market value: Ownership:  self  joint (specify):	2. (location and / or registration No)
3. Other real estate – Market value: Ownership:  self  joint (specify):	4. (location and / or registration No)
5. Motor vehicle(s) – Market value: Ownership:  self  joint (specify):	6. (location and / or registration No)
7. Caravans/boats – Market value: Ownership:  self  joint (specify):	8. (location and / or registration No)
9. Furniture and household effects – Market value: Ownership:  self  joint (specify):	10. (location and description)
11. Bank account(s)	12. (institution(s) and account number(s))
13. Life insurance and buy back value	14. (insurance company, policy number)
15. Other assets * – Value:	16. (institution(s) and account number(s))

VI.D. Insurance coverage

9. Creditor’s Insurance Company: Policy number:

11. Other Insurance Company: Policy number:

• This Financial Circumstances Form was completed by the applicant and reviewed by the requesting Central Authority

• The information contained in this Financial Circumstances Form corresponds to and is in conformity with the information and documents provided by the applicant to the requesting Central Authority. The Financial Circumstances Form 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)

^* Please list specifically each additional item.