FinancialCircumstancesForm

N.B. Sections II to VI should becompleted onlyasnecessaryfor thepurposesof theapplication towhich thisformisattachedandtothebestoftheapplicant’sknowledge.WhencompletingtheFinancial CircumstancesForm,pleaseconsultCountryProfileoftherequestedStatetoverifywhatinformationis requiredforaspecificapplication.

CONFIDENTIALITY AND PERSONALDATA PROTECTIONNOTICE

PersonaldatagatheredortransmittedundertheConventionshallbeusedonlyforthepurposesfor whichitwasgatheredortransmitted.Anyauthorityprocessingsuchinformationshallensureits confidentiality, inaccordance with the lawof its State.

Anauthorityshallnotdiscloseorconfirminformationgatheredortransmittedinapplicationofthis Conventionifitdeterminesthattodosocouldjeopardisethehealth,safetyorlibertyofapersonin accordance with Article 40.

Adeterminationofnon-disclosurehasbeenmadebyaCentralAuthorityinaccordancewith Article40.Ifthisboxisticked,informationunderitemsV.D.2,4,6,8,10,12,14and16andVI.D. 9 and 11 shouldonlybeprovidedin the RestrictedInformation on theApplicantpageof this form.

I.REFERENCEINFORMATION

1.RequestingCentralAuthority

a.Address

b.Telephonenumber

c.Faxnumber

d.E-mail

e.Referencenumber

2.ContactpersoninRequestedState

a.Address(ifdifferent)

b.Telephonenumber(ifdifferent)

c.Faxnumber(ifdifferent)

d.E-mail(ifdifferent)

e.Language(s)

3.The applicant,(familyname(s)andgivenname(s)),born

(dd/mm/yyyy),is:□ creditor,□ representativeoftheperson(s)forwhommaintenanceissoughtorpayable,or□ debtor

4.Thisformisbeingsubmittedinrelationto:(itispossibletotickmorethanone box)

□Establishmentofadecision(Art.10(1)c)andd))

(Completeallsections)

□ Recognitionorrecognitionandenforcementofadecision(Art.10(1)a))

(CompletesectionsIIIandIV)

□ EnforcementofadecisionmadeorrecognisedintherequestedState(Art.10(1)b))

(CompletesectionsIIIandIV)

□ Modificationofadecision(Art.10(1)e)andf)and(2)b)andc))

(Completeallsections)

□ Applyingforlegalassistance(Art.17a))

(CompletesectionsII,VandVIiftheapplicantisthepersonidentifiedunderII)

(CompletesectionsIII,VandVIiftheapplicantisthepersonidentifiedunderIII)

5.Unlessotherwisespecified,thecurrency(ISOcode)usedtocompletethisformand,ifapplicable,theexchangerate(anddateofexchangerate)iftheamountsareconvertedintothecurrencyoftherequested Stateis: _(dd/mm/yyyy)

II.GENERAL INFORMATIONABOUTTHECREDITOROR THEPERSON(S)FOR WHOM MAINTENANCE IS SOUGHTOR PAYABLE(IF KNOWN)

A.Informationaboutthecreditorortheperson(s)forwhommaintenanceissoughtorpayable

1.Thecreditororthepersonforwhommaintenanceissoughtis:
□ Father□ Mother□ Caretakerotherthanparent□ Fostercareprovider
□ Boththechildandtheaboveperson(marked)areconsideredascreditors
□ Thechildher/himselfistheonlycreditor
□ Publicbody
□ Otherperson(seetheapplication)
2.Occupation,tradeorprofession
3.Estimatedgrossmonthlyearnings
(specifycurrency) / 4.Othermonthlyincome(&source)
(specifycurrency)
5.Presentmaritalstatus
□Married□Single□Partner□Divorced□Separated

B.Informationaboutcreditor’sdependents

Familyname(s)Givenname(s) / Age / Relationshiptocreditor / Subjectofthisapplication?
□Yes / □No
□Yes / □No
□Yes / □No
□Yes / □No
□Yes / □No

C.Informationaboutcurrent□spouseor□partnerofcreditor□othermemberofthehouseholdcontributingtotheexpensesofthehousehold

1.Familyname(s),givenname(s) / 2.Employed?
□Yes □No□Unknown
3.Estimatedgrossmonthlyearnings
(specifycurrency) / 4.Othermonthlyincome(&source)
(specifycurrency)
5.Thepersonidentifiedabovepayschildsupport/maintenance□ voluntarilyor□judicial/administrative decision in theamount of per (specifycurrencyandinstalmentperiod).As of (dd/mm/yyyy)thetotalamountpaidis:
;andthe total amount outstanding is:(specifycurrency).

III.GENERAL INFORMATIONABOUTTHEDEBTOR (IF KNOWN)

A.Informationaboutthedebtor

1.Thedebtoris:
□Father□Mother□Caretakerotherthanparent□Fostercare
□Spouse□Partner□Child□Otherperson
2.Occupation,tradeorprofession:
3.Nameandaddressoftheemployer:
4.Estimatedgrossmonthlyearnings
(specifycurrency) / 5.Othermonthlyincome(&source)
(specifycurrency)
6.PresentMaritalStatus
□ Married□Single□Partner□Divorced□Separated

B.Informationaboutdebtor’sdependents

Familyname(s)Givenname(s) / Age / Relationshiptodebtor / Subjectofthisapplication?
1. / □Yes / □No
2. / □Yes / □No
3. / □Yes / □No
4. / □Yes / □No
5. / □Yes / □No

C.Informationaboutcurrent□spouseor□partnerofdebtor□othermemberofthehouseholdcontributingtotheexpensesofthehousehold

1.Familyname(s),givenname(s) / 2.Employed?
□Yes □No□Unknown
3.Estimatedgrossmonthlyearnings
(specifycurrency) / 4.Othermonthlyincome(&source)
(specifycurrency)
5.Thepersonidentifiedabovepayschildsupport/maintenance□voluntarilyor□judicial/administrative decision in theamount of per (specifycurrencyandinstalmentperiod).As of (dd/mm/yyyy)thetotalamountpaidis:
;andthe total amount outstanding is:(specifycurrency).

IV.ASSETS AND DEBTSOF THE DEBTOR(IF KNOWN)

Pleasespecifycurrencyusedtocompletethefollowingtables:

A.Valueofdebtor’sassets

1.House–Marketvalue:
Ownership:□self □joint(specify): / 2.(locationand/orregistrationnumber)
3.Otherrealestate–Marketvalue:
Ownership:□self □joint(specify): / 4.(locationand/orregistrationnumber,
description)
5.Motorvehicle(s)–Marketvalue:
Ownership:□self □joint(specify): / 6.(locationand/orregistrationnumber,model,year)
7.Caravans/boats–Marketvalue:
Ownership:□self □joint(specify): / 8.(locationand/orregistrationnumber,model,
year)
9.Furnitureandhouseholdeffects–Marketvalue:
Ownership:□self □joint(specify): / 10.(locationanddescription)
11.Bankaccount(s) / 12.(institution(s)andaccountnumber(s))
13.Lifeinsuranceandbuybackvalue / 14.(insurancecompany,policynumber)
15.Otherassets* –Value: / 16.(institution(s)andaccountnumber(s))

*Please list specifically eachadditionalitem.

Creditprovider / Amount / Paymentrate / Encumberedproperty
1.
2.
3.
4.

V.FINANCIAL STATEMENTOF THE APPLICANT

Pleasespecifycurrencyusedtocompletethefollowingtables:

A.Applicant’sgrossincome

1.
□Monthly
□Annual / Applicant / Applicant’scurrentspouse/partner / Child(ren)forwhommaintenanceissoughtorpayable / Otherpersonsforwhommaintenanceissoughtor
payable
2.Grosssalary(incl.paymentsinkind)
3.Incomefromnon-salariedoccupations
4.Pensions,disabilitypensions,alimonies,
allowances,annuities
5.Unemploymentbenefits
6.Incomefrom
securities/floatingcapital
7.Incomefromrealproperty
8.Publicassistance
9.Othersourcesofincome*
10.TOTAL

B.Applicant’sincomedeductions

1.
□Monthly
□ Annual / Applicant / Applicant’scurrentspouse/partner / Child(ren)forwhommaintenanceissoughtorpayable / Otherpersonsforwhom
maintenance
issoughtorpayable
2.National/Federaltax
3.State/Provincialtax
4.City/Localtax
5.Insurancepremiums
6.Mandatorypension
contributions
7.Union/professionaldues
8.Otherdeductions*
9.TOTAL

*Please list specifically eachadditionalitem.

1.
□Monthly
□Annual / Applicant / Applicant’scurrentspouse/partner / Child(ren)forwhommaintenanceissoughtorpayable / Otherpersonsforwhom
maintenance
issoughtorpayable
2.Rentormortgage
3.Householdcosts
4.Foodandhousesupplies
5.Clothing
6.Medical/dental/opticalfees
7.Maintenancepaid
8.Insurance(otherthanunder
PartV.B)
9.Transportationexpenses
10.Childcare
11.Educationforchildren
12.Extracurricularactivitiesforchildren
13.Yearlysavings
14.Debt-repayment
15.Otherexpenses*
16.TOTAL

D.Valueofapplicant’sassets1

1.House–Marketvalue:
Ownership:□self □joint(specify): / 2.(locationand/orregistrationnumber)
3.Otherrealestate–Marketvalue:
Ownership:□self □joint(specify): / 4.(locationand/orregistrationnumber,description)
5.Motorvehicle(s)–Marketvalue:
Ownership:□self □joint(specify): / 6.(locationand/orregistrationnumber,model,
year)
7.Caravans/boats–Marketvalue:
Ownership:□self □joint(specify): / 8.(locationand/orregistrationnumber,model,
year)
9.Furnitureandhouseholdeffects–Marketvalue:
Ownership:□self □joint(specify): / 10.(locationanddescription)
11.Bankaccount(s) / 12.(institution(s)andaccountnumber(s))
13.Lifeinsuranceandbuybackvalue / 14.(insurancecompany,policynumber)
15.Otherassets* –Value: / 16.(institutionsandaccountnumbers)

1Do not completethistableif theperson identifiedunder III is theapplicantas thisinformationwould be thesameas theone found underSectionIV.A.

*Please list specifically eachadditionalitem.

E.Valueofapplicant’sdebts2

Creditprovider / Amount / PaymentRate / Encumberedproperty
1.
2.
3.
4.

VI.MEDICALINSURANCE

A.Isdebtorrequiredbyamaintenancedecisiontoprovidemedicalinsuranceforthechild(ren)?

□Yes□No

B.Isdebtorrequiredbyamaintenancedecisiontoprovidemedicalinsuranceforthecreditor?

□Yes□ No

C.Medicalcoverageforchild(ren)forwhommaintenanceissoughtand/orthecreditorisprovidedby:

D.Insurancecoverage

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 / ? / ?

ThisFinancialCircumstancesFormwascompletedbytheapplicantandreviewedbytherequestingCentralAuthority.

TheinformationcontainedinthisFinancialCircumstancesFormcorrespondstoandisin conformitywiththeinformationanddocumentsprovidedbytheapplicanttotherequesting CentralAuthority.TheFinancialCircumstancesFormisforwardedbytheCentralAuthority onbehalfofandwiththeconsentoftheapplicant.

Name:(inblockletters)Date: Authorised representative oftheCentralAuthority (dd/mm/yyyy)

2Do not completethistableif theperson identifiedunder III is theapplicantas thisinformationwould be thesameas theone found underSectionIV.B.

RestrictedInformationontheApplicant

FinancialCircumstancesForm

N.B.TherequestingCentralAuthorityhasdeterminedthatinformationunderitemsV.D.2,4,6,8,10, 12,14 and16andVI.D.9and 11onthis pageshallnotbedisclosedorconfirmed fortheprotectionofthehealth,safetyorlibertyofaperson.SuchadeterminationshallaccordingtoArticle40(2)betakenintoaccountbytherequestedCentralAuthority.

1.RequestingCentralAuthorityfilereferencenumber:

V.D.Valueofapplicant’sassets

1.House–Marketvalue:
Ownership:?self ?joint(specify): / 2.(locationand/orregistrationNo)
3.Otherrealestate–Marketvalue:
Ownership:?self ?joint(specify): / 4.(locationand/orregistrationNo)
5.Motorvehicle(s)–Marketvalue:
Ownership:?self ?joint(specify): / 6.(locationand/orregistrationNo)
7.Caravans/boats–Marketvalue:
Ownership:?self ?joint(specify): / 8.(locationand/orregistrationNo)
9.Furnitureandhouseholdeffects–Marketvalue:
Ownership:?self ?joint(specify): / 10.(locationanddescription)
11.Bankaccount(s) / 12.(institution(s)andaccountnumber(s))
13.Lifeinsuranceandbuybackvalue / 14.(insurancecompany,policynumber)
15.Otherassets*–Value: / 16.(institution(s)andaccountnumber(s))

VI.D.Insurancecoverage

9.Creditor’sInsuranceCompany:Policynumber:

11.OtherInsuranceCompany:Policynumber:

ThisFinancialCircumstancesFormwascompletedbytheapplicantandreviewedbytherequestingCentralAuthority

TheinformationcontainedinthisFinancialCircumstancesFormcorrespondstoandisin conformitywiththeinformationanddocumentsprovidedbytheapplicanttotherequesting CentralAuthority.TheFinancialCircumstancesFormisforwardedbytheCentralAuthority onbehalfofandwiththeconsentoftheapplicant

Name:(inblockletters)Date: Authorised representative oftheCentralAuthority (dd/mm/yyyy)

*Please list specifically eachadditionalitem.