Form 1 Annex 2 Acknowledgement

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

ANNEX II

Acknowledgement form under Article 12(3)
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. 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)

3. Requesting Central Authority

_________________________________________________

Contact person

_________________________________________________

Address

_________________________________________________
_________________________________________________

4. The requested Central Authority acknowledges receipt on ___________ (dd/mm/yyyy) of the transmittal
form from the requesting Central Authority (reference number ____________; dated ______________
(dd/mm/yyyy)) concerning the following application under:

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)

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Family name(s) of applicant:

___________________________________

Family name(s) of the person(s) for whom
maintenance is sought or payable:

___________________________________
___________________________________
___________________________________

Family name(s) of debtor:

___________________________________

5. Initial steps taken by the requested Central Authority:

The file is complete and is under consideration

See attached status of application report

Status of application report will follow

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

The requested Central Authority refuses to process this application as it is manifest that the
requirements of the Convention are not fulfilled (Art. 12(8)). The reasons:

are set out in an attached document

will be set out in a document to follow

The requested Central Authority requests that the requesting Central Authority inform it of any change in
the status of the application.

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 0.5 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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