Form 1 Financial Circumstances Form

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

I. REFERENCE INFORMATION
1. Requesting 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)

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
4. 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)
5. 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)

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

II. GENERAL INFORMATION ABOUT THE CREDITOR OR THE PERSON(S) FOR WHOM MAINTENANCE
IS SOUGHT OR PAYABLE (IF KNOWN)
A. 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:
Caretaker other than parent
Foster care provider
Father
Mother
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
4. Other monthly income (& source)
3. Estimated gross monthly earnings
(specify currency)
(specify currency)
5. Present marital status
Married
Single

Partner

Divorced

Separated

B. Information about creditor’s dependents
Family name(s)
Given name(s)

Age

C. Information about current spouse or partner of creditor
household contributing to the expenses of the household
1. Family name(s), given name(s)
3. Estimated gross monthly earnings
(specify currency)

Subject of this
application?
Yes
No
No
Yes
No
Yes
No
Yes
No
Yes

Relationship to creditor

other member of the

2. Employed?
Yes
No
Unknown
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).
III. GENERAL INFORMATION ABOUT THE DEBTOR (IF KNOWN)
A. Information about the debtor
1. The debtor is:
Father
Mother
Caretaker other than parent
Spouse
Partner
Child
2. Occupation, trade or profession:
3. Name and address of the employer:
4. Estimated gross monthly earnings
(specify currency)
6. Present Marital Status
Married
Single

Partner

Foster care
Other person

5. Other monthly income (& source)
(specify currency)

Divorced

Separated

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

B. Information about debtor’s dependents
Family name(s)
Given name(s)

Age

Relationship to debtor

1.
2.
3.
4.
5.
C. Information about current spouse or partner of debtor
contributing to the expenses of the household
1. Family name(s), given name(s)
3. Estimated gross monthly earnings
(specify currency)

Subject of this
application?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No

other member of the household

2. Employed?
Yes
No
Unknown
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).
IV. ASSETS AND DEBTS OF THE DEBTOR (IF KNOWN)
Please specify currency used to complete the following tables: ____________
A. Value of debtor’s assets
1. House – Market value:
2. (location and / or registration number)
Ownership: self joint (specify):
__________________
4. (location and / or registration number,
3. Other real estate – Market value:
description)
Ownership: self joint (specify):
__________________
5. Motor vehicle(s) – Market value:
6. (location and / or registration number, model,
year)
Ownership: self joint (specify):
__________________
8. (location and / or registration number, model,
7. Caravans/boats – Market value:
year)
Ownership: self joint (specify):
__________________
9. Furniture and household effects – Market value: 10. (location and description)
Ownership: self joint (specify):
__________________
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))

*

Please list specifically each additional item.

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

B. Value of debtor’s debts
Credit provider

Amount

Payment rate

Encumbered property

1.
2.
3.
4.
V. FINANCIAL STATEMENT OF THE APPLICANT
Please specify currency used to complete the following tables: ____________
A. Applicant’s gross income
1.
Monthly
Annual

Applicant

Child(ren)
for whom
Applicant’s
maintenance
current
spouse/partner is sought or
payable

Other
persons for
whom
maintenance
is sought or
payable

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
B. Applicant’s income deductions
1.
Monthly
Annual

Applicant

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

*

Please list specifically each additional item.

Applicant’s
current
spouse/partner

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

C. Applicant’s expenses
1.
Monthly
Annual

Applicant

Child(ren)
Applicant’s
for whom
current
maintenance
spouse/partner 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
D. Value of applicant’s assets 1
1. House – Market value:
Ownership: self joint (specify):
__________________
3. Other real estate – Market value:
Ownership: self joint (specify):
__________________
5. Motor vehicle(s) – Market value:
Ownership: self joint (specify):
__________________
7. Caravans/boats – Market value:
Ownership: self joint (specify):
__________________
9. Furniture and household effects – Market value:
Ownership: self joint (specify):
__________________
11. Bank account(s)

2. (location and / or registration number)

4. (location and / or registration number,
description)
6. (location and / or registration number, model,
year)
8. (location and / or registration number, model,
year)
10. (location and description)

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.
*
Please list specifically each additional item.

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

E. Value of applicant’s debts 2
Credit provider

Amount

Payment
Rate

Encumbered property

1.
2.
3.
4.
VI. MEDICAL INSURANCE
A. Is debtor required by a maintenance decision to provide medical insurance for the child(ren)?
Yes No
B. Is debtor required by a maintenance decision to provide medical insurance for the creditor?
Yes No
C. Medical coverage for child(ren) for whom maintenance is sought and/or the creditor is
provided by:
D. Insurance coverage
Coverage provided by:
1. Creditor
2. Debtor

For child(ren)

For creditor

3. State Medicare
4. Creditor’s employer
5. Debtor’s employer
6. Other:
___________________________
7. Unknown
8. No coverage

9. Creditor’s Insurance
Company:
Policy number:
10. Debtor’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)
Authorised representative of the Central Authority

Date: ________________
(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.

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

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):
__________________
3. Other real estate – Market value:
Ownership: self joint (specify):
__________________
5. Motor vehicle(s) – Market value:
Ownership: self joint (specify):
__________________
7. Caravans/boats – Market value:
Ownership: self joint (specify):
__________________
9. Furniture and household effects – Market value:
Ownership: self joint (specify):
__________________
11. Bank account(s)

2. (location and / or registration No)

4. (location and / or registration No)

6. (location and / or registration No)

8. (location and / or registration No)

10. (location and description)

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:

11. Other Insurance Company:

Policy number:

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)
Authorised representative of the Central Authority

Date: ________________
(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 2 hours 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.
*

Please list specifically each additional item.