Form 1 Annex 1 Transimittal

OMB Control No: XXXX-XXXX
Expiration date: mm/dd/yyyy

ANNEX I

Transmittal form under Article 12(2)
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 data 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. Requesting Central Authority

2. Contact person in requesting 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)

3.

Requested Central Authority: _______________________________________________
Address

_______________________________________________
_______________________________________________

4.

Particulars of the applicant
a.

Family name(s):

____________________________________________________

b.

Given name(s):

____________________________________________________

c.

Date of birth:

_________________________________________ (dd/mm/yyyy)

or
a.

Name of the public body :

________________________________________
________________________________________

______________________________________________________________________________________________
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5.

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

a.

The person is the same as the applicant named in point 4

b.

i.

Family name(s): _______________________________________________

ii.

iii.

6.

7.

_______________________________________________

Date of birth:

___________________________________ (dd/mm/yyyy)

Family name(s): _______________________________________________
Given name(s):

_______________________________________________

Date of birth:

___________________________________ (dd/mm/yyyy)

Family name(s): _______________________________________________
Given name(s):

_______________________________________________

Date of birth:

___________________________________ (dd/mm/yyyy)

Particulars of the debtor 1
a.

b.

Family name(s):

____________________________________________________

c.

Given name(s):

____________________________________________________

d.

Date of birth:

________________________________________ (dd/mm/yyyy)

The person is the same as the applicant named in point 4

This transmittal form concerns and is accompanied by an application under:

8.

Given name(s):

Article 10(1) a)
Article 10(1) b)
Article 10(1) c)
Article 10(1) d)
Article 10(1) e)
Article 10(1) f)
Article 10(2) a)
Article 10(2) b)
Article 10(2) c)

The following documents are appended to the application:
a.

For the purpose of an application under Article 10(1) a), and:
In accordance with Article 25:
… Complete text of the decision (Art. 25(1) a))
… Abstract or extract of the decision drawn up by the competent authority of the
State of origin (Art. 25(3) b)) (if applicable)

1

According to Art. 3 of the Convention “‘debtor’ means an individual who owes or who is alleged to owe maintenance”.

______________________________________________________________________________________________
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Document stating that the decision is enforceable in the State of origin and, in
the case of a decision by an administrative authority, a document stating that
the requirements of Article 19(3) are met unless that State has specified in
accordance with Article 57 that decisions of its administrative authorities
always meet those requirements (Art. 25(1) b)) or if Article 25(3) c) is
applicable
If the respondent did not appear and was not represented in the proceedings
in the State of origin, a document or documents attesting, as appropriate,
either that the respondent had proper notice of the proceedings and an
opportunity to be heard, or that the respondent had proper notice of the
decision and the opportunity to challenge or appeal it on fact and law
(Art. 25(1) c))
Where necessary, a document showing the amount of any arrears and the date
such amount was calculated (Art. 25(1) d))
Where necessary, a document providing the information necessary to make
appropriate calculations in case of a decision providing for automatic
adjustment by indexation (Art. 25(1) e))
Where necessary, documentation showing the extent to which the applicant
received free legal assistance in the State of origin (Art. 25(1) f))

In accordance with Article 30(3):

Complete text of the maintenance arrangement (Art. 30(3) a))
A document stating that the particular maintenance arrangement is
enforceable as a decision in the State of origin (Art. 30(3) b))

Any other documents accompanying the application (e.g., if required, a
document for the purpose of Art. 36(4)):
____________________________________________________________________
____________________________________________________________________

b.

Name :

For the purpose of an application under Article 10(1) b), c), d), e), f) and (2) a), b) or
c), the following number of supporting documents (excluding the transmittal form
and the application itself) in accordance with Article 11(3):

Article 10(1) b)

_____

Article 10(1) c)

_____

Article 10(1) d)

_____

Article 10(1) e)

_____

Article 10(1) f)

_____

Article 10(2) a)

_____

Article 10(2) b)

_____

Article 10(2) c)

_____

_______________________________ (in block letters) Date: ________________

Authorised representative of the Central Authority

(dd/mm/yyyy)

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13)
Public reporting burden for this collection of information is estimated to average 1 hour per response, including the time for
reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information.
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a
currently valid OMB control number.

______________________________________________________________________________________________

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