1 Request for Specific Measures – Response

OMB Control No: 0970-0488

Expiration date: NN/NN/NNNN

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Request for Specific Measures - Response

(Article 7(1))

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.
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)
 First Response /  Subsequent Response – Date of last Response: ____________ (dd/mm/yyyy)
3.

File identification
a. Requesting Central Authority file reference number:

_______________________

b. Family name(s) of the potential applicant: ____________________________________
or
b. Name of the public body:

____________________________________

and
c. Family name(s) of the person(s) for whom
maintenance would be sought or is payable:

______________________________
______________________________
______________________________

d. Family name(s) of debtor:

______________________________

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
recognition or for recognition and enforcement under the 2007 Hague Child Support Convention. Public reporting burden for this collection of information is estimated to
average 0.17 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].

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4.

The following measures have been taken

4.1.

Debtor or creditor located (Art. 6(2) b)):

The debtor, or

The person to whom maintenance is payable, or

The person for whom maintenance is payable, or

Both the person to whom maintenance is payable and the person for whom
maintenance is payable

Located in the requested State, please provide address, if possible: _______________
_________
_______________
____________
_______
________________
_____________________
_______________________
_____________________
_____________
Located / believed to be in another State, please specify: _______________________

_______________
____________
_______
__________
_______________
____________
_________________
_______________
____________
_____________
_________
Effective date of information: ___________________ (dd/mm/yyyy)

A determination of non-disclosure about the address has been made by the requested

Central Authority in accordance with Article 40.

4.2.

Financial information obtained (Art. 6(2) c)) (please attach relevant information)

Income of:
 the debtor, or
 the person to whom maintenance is payable, or
 the person for whom maintenance is payable, or
 both the person to whom maintenance is payable and the person for whom
maintenance is payable

Effective date of information: ___________________ (dd/mm/yyyy)

Assets of:
 the debtor, or
 the person to whom maintenance is payable, or
 the person for whom maintenance is payable, or
 both the person to whom maintenance is payable and the person for whom
maintenance is payable

Effective date of information: ___________________ (dd/mm/yyyy)

Location of the assets of:
 the debtor or
 the person to whom maintenance is payable or
 the person for whom maintenance is payable or
 both the person to whom maintenance is payable and the person for whom
maintenance is payable
Please specify the location of the assets, if possible: ___________________________
_______________________________________________________________________

Effective date of information: ___________________ (dd/mm/yyyy)
 A determination of non-disclosure about the location of the assets has been made
by the requested Central Authority in accordance with Article 40.

Other financial circumstances of:
 the debtor, or
 the person to whom maintenance is payable, or
 the person for whom maintenance is payable, or
 both the person to whom maintenance is payable and the person for whom
maintenance is payable

Effective date of information: ___________________ (dd/mm/yyyy)

4.3.

Documentary or other evidence obtained (Art. 6(2) g)) (please attach relevant
information)

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
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








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. Please specify: ____________________________________________
Decision of the requested State concerning a maintenance obligation
Including:
 Abstract of the Decision
 Statement of Enforceability of the Decision
 Statement of Proper Notice of Proceedings / Decision

4.4.

Assistance in establishing parentage where necessary for the recovery of maintenance
provided (Art. 6(2) h))

Genetic testing coordinated

Voluntary acknowledgment of parentage sought (please attach any signed
acknowledgement)

Legal determination of parentage sought (please attach any legal determination)

Request referred to the appropriate competent authority

Advice concerning the appropriate procedure(s) provided

Other, please specify: ____________________________________________________

4.5.



Proceedings to obtain any necessary provisional measures that are territorial in
nature and the purpose of which is to secure the outcome of a pending maintenance
application initiated or facilitated (Art. 6(2) i))
Please specify: __________________________________________________________

4.6.



Service of documents facilitated (Art. 6(2) j))
Please specify: __________________________________________________________

5.



Additional information concerning the measures taken: ______________________
______________________________________________________________________

6.



The requested Central Authority is unable to provide the specific requested
measure(s) for the following reasons: ______________________________________
______________________________________________________________________
______________________________________________________________________

7.



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

8.



The requested Central Authority has refused to process the request for specific
measures because it is not satisfied based on the information provided by the
requesting Central Authority that the requested measures are necessary to assist a
potential applicant in making an application under Article 10 or in determining
whether such an application should be initiated.

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

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