Form 1 Annex A: Abstract of a Decision

OMB Control No: XXXX-XXXX
Expiration date: mm/dd/yyyy
Convention on the International Recovery of Child Support and Other Forms of Family Maintenance

Abstract of a Decision
(Article 25(3) b))

1.

Name of the State of origin of the decision:

___________________________________

(identify territorial unit if applicable)

___________________________________

2.

Competent authority issuing the Abstract

2.1

Name:

_____________________________________________

2.2

Address:

_____________________________________________
_____________________________________________
_____________________________________________

2.3

Telephone number:

________________________________

2.4

Fax number:

________________________________

2.5

E-mail:

________________________________

3.

The decision 1

3.1

Type of authority:  judicial authority or  administrative authority 2

3.2

Name and place of authority: _________________________________________________

3.3

(address if applicable)

_________________________________________________
_________________________________________________

3.4

Date of the decision:

______________________________ (dd/mm/yyyy)

3.5

Date of effect of the decision:

______________________________ (dd/mm/yyyy)

3.6

Reference number of the decision:

___________________________________________

3.7

Names of the parties to the decision: ___________________________________________
___________________________________________
___________________________________________

3.8

Decision results from:

 Divorce or legal separation proceedings
 Parentage establishment proceedings
 Maintenance proceedings
 Parental responsibility proceedings
 Other: ________________________________________

4.

1
2

Name of the debtor:

___________________________________________

For the definition of decision see Article 19(1).
The Administrative Authority referred to in this Statement meets the requirements of Article 19(3).

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

5.

Terms of decision

5.1

Maintenance payable for one person or a group of persons (specify currency 3 for each
amount)
Name(s) and date(s) of birth of the person(s) entitled to support / maintenance, arrears
and other payments
a.

b.

c.

5.1.1

_________________________________________________

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)

Beginning _______________ (dd/mm/yyyy) the debtor shall pay support /
maintenance in the amount of _______________ every:
 week
 two weeks  month
 3 months  6 months
 year
 other (specify): ________________________________________
This payment includes
 arrears
 retroactive maintenance
 interest
 health insurance
 school fees  other payments,
arrangements or conditions (specify  ): ____________________________________

As of _______________ (dd/mm/yyyy) the total amount of arrears is in the
amount of _______________. Beginning _______________ (dd/mm/yyyy) the
debtor shall pay arrears in the amount of _______________ every:
 week
 two weeks  month
 3 months  6 months
 year
 single payment
 other (specify): ____________________

Terms of payment of retroactive maintenance


3

Given name(s):

Terms of payment of arrears


5.1.3

_________________________________________________

Terms of payment of support / maintenance
4

5.1.2

Family name(s):

As of _______________ (dd/mm/yyyy) the total amount of retroactive
maintenance is in the amount of _______________. Beginning _______________
(dd/mm/yyyy) the debtor shall pay retroactive maintenance in the amount of
_______________ every:
 week
 two weeks  month
 3 months  6 months
 year
 single payment
 other (specify): ____________________

Currency should be specified using the ISO code.
Where different payments are provided for different periods please replicate this information for such periods with the
understanding that at the new beginning date the former amount is replaced by the new one.

Include extract of the decision if necessary.
4

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

5.1.4

5.1.5

Other payments as provided in the decision


Beginning _______________ (dd/mm/yyyy) the debtor shall pay interest in the
amount of _______________ every:
 week
 two weeks  month
 3 months  6 months
 year
 other (specify): ________________________________________



Beginning _______________ (dd/mm/yyyy) the debtor shall pay health insurance
in the amount of _______________ every:
 week
 two weeks  month
 3 months  6 months
 year
 other (specify): ________________________________________



Beginning _______________ (dd/mm/yyyy) the debtor shall pay school fees in the
amount of _______________ every:
 week
 two weeks  month
 3 months  6 months
 year
 other (specify): ________________________________________



Beginning _______________ (dd/mm/yyyy) the debtor shall make other
payments, arrangements or conditions (specify*):___________________________
________________________ to be paid in the amount of _______________ every:
 week
 two weeks  month
 3 months  6 months
 year
 other (specify): ________________________________________

Lump sum
The debtor shall pay the lump sum amount of _______________ on
 Due date _______________ (dd/mm/yyyy)
 Another frequency (specify): ________________________________________

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

5.2

Maintenance payments for more than one person on an individual basis (specify
currency 5 for each amount)
a.

Family name(s):

_________________________________________________

Given name(s):

_________________________________________________

Date of birth:

_____________________________________ (dd/mm/yyyy)

6

Beginning _______________ (dd/mm/yyyy) the debtor shall pay support /
maintenance in the amount of _______________ every:
 week
 two weeks  month
 3 months  6 months
 year
 other (specify): _______________________________________
This payment includes
 arrears
 retroactive maintenance
 interest
 health insurance
 school fees  other payments,
arrangements or conditions (specify  ): ____________________________________



Beginning _______________ (dd/mm/yyyy) the debtor shall pay arrears in the
amount of _______________ every:
 week
 two weeks  month
 3 months  6 months
 year
 single payment
 other (specify): ____________________



Beginning _______________ (dd/mm/yyyy) the debtor shall pay retroactive
maintenance in the amount of _______________ every:
 week
 two weeks  month
 3 months  6 months
 year
 single payment
 other (specify): ____________________



Beginning _______________ (dd/mm/yyyy) the debtor shall pay interest in the
amount of _______________ every:
 week
 two weeks  month
 3 months  6 months
 year
 other (specify): ________________________________________



Beginning _______________ (dd/mm/yyyy) the debtor shall pay health insurance
in the amount of _______________ every:
 week
 two weeks  month
 3 months  6 months
 year
 other (specify): ________________________________________



Beginning _______________ (dd/mm/yyyy) the debtor shall pay school fees in the
amount of _______________ every:
 week
 two weeks  month
 3 months  6 months
 year
 other (specify): ________________________________________



Beginning _______________ (dd/mm/yyyy) the debtor shall make other
*
payments, arrangements or conditions (specify ):___________________________
________________________ to be paid in the amount of _______________ every:
 week
 two weeks  month
 3 months  6 months
 year
 other (specify): ________________________________________

Lump sum
The debtor shall pay the lump sum amount of _______________ on
 Due date _______________ (dd/mm/yyyy)
 Another frequency (specify): ________________________________________

5

Currency should be specified using the ISO code.
Where different payments are provided for different periods please replicate this information for such periods with the
understanding that at the new beginning date the former amount is replaced by the new one.

Include extract of the decision if necessary.
6

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

b.

Family name(s):

_________________________________________________

Given name(s):

_________________________________________________

Date of birth:

_____________________________________ (dd/mm/yyyy)

7

Beginning _______________ (dd/mm/yyyy) the debtor shall pay support /
maintenance in the amount of _______________ every:
 week
 two weeks  month
 3 months  6 months
 year
 other (specify): ________________________________________
This payment includes
 arrears
 retroactive maintenance
 interest
 health insurance
 school fees  other payments,
arrangements or conditions (specify  ): ____________________________________



Beginning _______________ (dd/mm/yyyy) the debtor shall pay arrears in the
amount of _______________ every:
 week
 two weeks  month
 3 months  6 months
 year
 single payment
 other (specify): ____________________



Beginning _______________ (dd/mm/yyyy) the debtor shall pay retroactive
maintenance in the amount of _______________ every:
 week
 two weeks  month
 3 months  6 months
 year
 single payment
 other (specify): ____________________



Beginning _______________ (dd/mm/yyyy) the debtor shall pay interest in the
amount of _______________ every:
 week
 two weeks  month
 3 months  6 months
 year
 other (specify): ________________________________________



Beginning _______________ (dd/mm/yyyy) the debtor shall pay health insurance
in the amount of _______________ every:
 week
 two weeks  month
 3 months  6 months
 year
 other (specify): ________________________________________



Beginning _______________ (dd/mm/yyyy) the debtor shall pay school fees in the
amount of _______________ every:
 week
 two weeks  month
 3 months  6 months
 year
 other (specify): ________________________________________



Beginning _______________ (dd/mm/yyyy) the debtor shall make other
payments, arrangements or conditions (specify*):___________________________
________________________ to be paid in the amount of _______________ every:
 week
 two weeks  month
 3 months  6 months
 year
 other: _______________________________________________

Lump sum
The debtor shall pay the lump sum amount of _______________ on
 Due date _______________ (dd/mm/yyyy)
 Another frequency (specify): ________________________________________

7

Where different payments are provided for different periods please replicate this information for such periods with the
understanding that at the new beginning date the former amount is replaced by the new one.

Include extract of the decision if necessary.

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

c.

Family name(s):

_________________________________________________

Given name(s):

_________________________________________________

Date of birth:

_____________________________________ (dd/mm/yyyy)

8

Beginning _______________ (dd/mm/yyyy) the debtor shall pay support /
maintenance in the amount of _______________ every:
 week
 two weeks  month
 3 months  6 months
 year
 other (specify): ________________________________________
This payment includes
 arrears
 retroactive maintenance
 interest
 health insurance
 school fees  other payments,
arrangements or conditions (specify  ): ____________________________________



Beginning _______________ (dd/mm/yyyy) the debtor shall pay arrears in the
amount of _______________ every:
 week
 two weeks  month
 3 months  6 months
 year
 single payment
 other (specify): ____________________



Beginning _______________ (dd/mm/yyyy) the debtor shall pay retroactive
maintenance in the amount of _______________ every:
 week
 two weeks  month
 3 months  6 months
 year
 single payment
 other (specify): ____________________



Beginning _______________ (dd/mm/yyyy) the debtor shall pay interest in the
amount of _______________ every:
 week
 two weeks  month
 3 months  6 months
 year
 other (specify): ________________________________________



Beginning _______________ (dd/mm/yyyy) the debtor shall pay health insurance
in the amount of _______________ every:
 week
 two weeks  month
 3 months  6 months
 year
 other (specify): ________________________________________



Beginning _______________ (dd/mm/yyyy) the debtor shall pay school fees in the
amount of _______________ every:
 week
 two weeks  month
 3 months  6 months
 year
 other (specify): ________________________________________



Beginning _______________ (dd/mm/yyyy) the debtor shall make other
*
payments, arrangements or conditions (specify ):___________________________
________________________ to be paid in the amount of _______________ every:
 week
 two weeks  month
 3 months  6 months
 year
 other (specify): ________________________________________

Lump sum
The debtor shall pay the lump sum amount of _______________ on
 Due date _______________ (dd/mm/yyyy)
 Another frequency (specify): ________________________________________

8

Where different payments are provided for different periods please replicate this information for such periods with the
understanding that at the new beginning date the former amount is replaced by the new one.

Include extract of the decision if necessary.

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

5.3

Maintenance payments directed to a public body (specify currency 9 for each amount)
a.

Name of the public body:

b.

Family name(s) of the contact person: ____________________________________

c.

Given name(s) of the contact person: ____________________________________

d.

Address:

_________________________________________________

e.

Telephone numbers:

_________________________________________________

f.

Fax number:

_________________________________________________

g.

E-mail:

_________________________________________________

 10

Beginning _______________ (dd/mm/yyyy) the debtor shall pay support /
maintenance in the amount of _______________ every:
 week
 two weeks  month
 3 months  6 months
 year
 other (specify): _______________________________________
This payment includes
 arrears
 retroactive maintenance
 interest
 health insurance
 school fees  other payments,
arrangements or conditions (specify  ): ____________________________________
Beginning _______________ (dd/mm/yyyy) the debtor shall pay arrears in the
amount of _______________ every:
 week
 two weeks  month
 3 months  6 months
 year
 single payment
 other (specify): ____________________



____________________________________



Beginning _______________ (dd/mm/yyyy) the debtor shall pay retroactive
maintenance in the amount of _______________ every:
 week
 two weeks  month
 3 months  6 months
 year
 single payment
 other (specify): ____________________



Beginning _______________ (dd/mm/yyyy) the debtor shall pay interest in the
amount of _______________ every:
 week
 two weeks  month
 3 months  6 months
 year
 other (specify): ________________________________________



Beginning _______________ (dd/mm/yyyy) the debtor shall pay health insurance
in the amount of _______________ every:
 week
 two weeks  month
 3 months  6 months
 year
 other (specify): ________________________________________



Beginning _______________ (dd/mm/yyyy) the debtor shall pay school fees in the
amount of _______________ every:
 week
 two weeks  month
 3 months  6 months
 year
 other (specify): ________________________________________



Beginning _______________ (dd/mm/yyyy) the debtor shall make other
*
payments, arrangements or conditions (specify ):___________________________
________________________ to be paid in the amount of _______________ every:
 week
 two weeks  month
 3 months  6 months
 year
 other (specify): ________________________________________

Lump sum
The debtor shall pay the lump sum amount of _______________ on
 Due date _______________ (dd/mm/yyyy)
 Another frequency (specify): ________________________________________

9

Currency should be specified using the ISO code.
Where different payments are provided for different periods please replicate this information for such periods with the
understanding that at the new beginning date the former amount is replaced by the new one.

Include extract of the decision if necessary.
10

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

6.

Indexation of maintenance





The decision is silent about indexation
The maintenance is indexed by operation of law.
The maintenance should be indexed every year by ______ %
The maintenance should be indexed as follows:
_______________________

___________________________________________________________________________
7.

Interest where maintenance payments are late





8.

The decision is silent about interest where maintenance payments are late
The interest on late payments is by operation of law.
Unpaid amounts generate interest where payments are late at the following rate:
__________________  per  month  3 months  6 months  year
The interest is:  simple or  compound

Effect of the decision
This decision shall remain in effect:







9.

Costs and expenses







Until the child(ren) has (have) reached the age of: _____
Until the child(ren) is (are) self-supporting
Until the child(ren) has (have) completed education (specify):

Secondary school

High school

Other: __________

College

University
__________
Until the creditor is self-supporting
Unless and until it is changed or discontinued by further decision or by operation
of law
Other: ______________________________________________________________

The decision is silent about costs and expenses
The debtor is ordered to pay costs and expenses
The creditor is ordered to pay costs and expenses
Costs and expenses amount to:
___________________ (specify currency 11 )

This Abstract accurately reflects the content of the decision, described under item 3
above, in relation to maintenance for the persons listed under items 5.1. and 5.2. a, b and
c above.

Name: _______________________________ (in block letters)
Date:
Name of the official from the competent authority of the State of origin


________________
(dd/mm/yyyy)

This Abstract was completed by the official from the competent authority of the State of
origin whose name appears above and is transmitted by the requesting Central
Authority.

Name: _______________________________ (in block letters)
Authorised representative of the Central Authority
Requesting Central Authority reference number:
(For Central Authority use only)

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 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.
11

Currency should be specified using the ISO code.