Form 1 Application for Modification 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

Application for Modification of a Decision
( Article 10(1) e)  Article10(1) f)  Article 10(2) b)  Article 10(2) c))
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 sections 2 d, e, f and g and 5 should only be
provided in the Restricted Information on the Applicant page of this form.
1.

Requesting Central Authority file reference number: _____________________________

2.

Particulars of the applicant
The applicant is:

The person for whom maintenance is sought or payable

The representative of the person for whom maintenance is sought or payable

The debtor

The representative of the debtor
a.

Family name(s):

_________________________________________________

b.

Given name(s):

_________________________________________________

c.

Date of birth:

d.

Address:

1

_____________________________________ (dd/mm/yyyy)
_________________________________________________
_________________________________________________

e.

Telephone numbers:

_________________________________________________
_________________________________________________

f.

Fax number:

_________________________________________________

g.

E-mail:

_________________________________________________

3.

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

3.1



Maintenance is sought or payable for the applicant named above
Maintenance basis:
 parentage
 in loco parentis or equivalent relationship
 marriage
 analogous relationship to marriage
 affinity (please identify): _________________________________
 grandparent
 sibling
 grandchild
 other: ________________________________________________

1

It is not necessary to provide a date of birth in the case of a representative.

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

3.2



Maintenance is sought or payable for the following child(ren)

a.

Family name(s):

_____________________________________

Given name(s):

_____________________________________

Date of birth:

_____________________________________ (dd/mm/yyyy)

Maintenance basis:
 parentage
Family name(s):

 in loco parentis or equivalent relationship
_____________________________________

Given name(s):

_____________________________________

Date of birth:

_____________________________________ (dd/mm/yyyy)

Maintenance basis:
 parentage
Family name(s):

 in loco parentis or equivalent relationship
_____________________________________

Given name(s):

_____________________________________

Date of birth:

_____________________________________ (dd/mm/yyyy)

Maintenance basis:
 parentage

 in loco parentis or equivalent relationship

b.

c.

3.3



Maintenance is sought or payable for the following person
Family name(s):

_____________________________________

Given name(s):

_____________________________________

Date of birth:

_____________________________________ (dd/mm/yyyy)

Maintenance basis:
 analogous relationship to marriage
 marriage
 affinity (please identify): _________________________________
 grandparent
 sibling
 grandchild
 other: ________________________________________________
3.4



4.1

Particulars (if known) of the debtor

Maintenance is sought or payable for additional children or persons, additional
particulars are attached



The person is the same as the applicant named above

a.

Family name(s):

____________________________________

b.

Given name(s):

____________________________________

c.

Date of birth:

____________________________________ (dd/mm/yyyy)

d.

Residential address:

____________________________________
____________________________________

e.

Postal address:

____________________________________
____________________________________

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

4.2

If the debtor is the applicant, particulars (if known and applicable) of the representative
of the person(s) for whom maintenance is sought or payable
a.

Family name(s):

_________________________________________________

b.

Given name(s):

_________________________________________________

c.

Address:

_________________________________________________
_________________________________________________

d.

Telephone numbers:

_________________________________________________
_________________________________________________

4.3

e.

Fax number:

_________________________________________________

f.

E-mail:

_________________________________________________

Information that may assist with the location of the respondent
a.

Personal identification number:
____________________________________
(including name of country or territorial unit that issued the number)

b.

Any other information that may assist with the location of the respondent
_____________________________________________________________________

5.

Payments
a.

Details for electronic transfer of payments (if applicable)
Name of the bank:
NBIC:

b.

2

________________________________
________________________________

SWIFT-address:

________________________________

IBAN: 3

________________________________

Account number:

________________________________

Name of account holder:

________________________________

Reference: 4

________________________________

Details for payments by cheques (if applicable)
Cheque payable to:

________________________________

Cheque to be sent to:

________________________________

(address)

________________________________
________________________________
3

Reference:

2

National Bank Identification Code.
International Bank Account Number.
4
Where needed to affect payment.
3

________________________________

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

6.

The decision

6.1

Type of authority:  judicial authority or  administrative authority

6.2

Name and place of authority: _________________________________________________

6.3

(address if applicable)

_________________________________________________
_________________________________________________

6.4

Date of the decision:

______________________________ (dd/mm/yyyy)

6.5

Date of effect of the decision:

______________________________ (dd/mm/yyyy)

6.6

Reference number of the decision:

___________________________________________

6.7

Names of the parties:

___________________________________________
___________________________________________
___________________________________________
___________________________________________

7.

The following changes have occurred since the decision was made or last modified:










8.

Change in the income of the creditor or its financial situation
Change in the income of the debtor or its financial situation
Change in the income or financial situation of the person who has care of the
child
Change in circumstances of the person for whom maintenance is sought
Change in child care arrangements
Change in cost of living
Change of currency exchange rate
Decision was made by consent, and the amount ordered to be paid is no longer
appropriate or adequate
Other. Please specify: ____________________________________________

The following modifications are sought by the applicant:









Increasing the amount of maintenance
Please specify the new amount and currency: _________________________
Decreasing the amount of maintenance
Please specify the new amount and currency: _________________________
Modifying the frequency of payments, please specify:
 week
 two weeks  month
 3 months  6 months
 year
 other (specify): ___________________________________
Modifying the method of payment
Please specify: ___________________________________________________
Modifying the nature of payments
Please specify: ___________________________________________________
Reducing or cancelling arrears
Please specify reasons: ____________________________________________
Terminating the maintenance obligation
Please specify reasons: ____________________________________________
Please specify termination date: _________________________ (dd/mm/yyyy)
Other. Please specify: _____________________________________________

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

9.

The following documents are attached to establish the basis for modification of the
maintenance decision and to assist in establishing, where necessary, the amount of the
maintenance:







Complete text of the decision from the State of origin
Evidence establishing a change in income or other change in circumstances
Written agreement between the parties related to modification of the
maintenance
Financial Circumstances Form
Written submissions in support of application
Other evidence in accordance with the law of the requested State

10.

 Please initiate enforcement measures once the decision is established

11.

Other information: ______________________________________________________
_______________________________________________________________________

12.

If the applicant is the debtor in the case of an application under Article 10(2) c), please
tick the applicable boxes:



The creditor is not habitually resident in the State of origin.
The creditor is habitually resident in the State of origin, but the following
provision of Article 18 applies or may apply:





The parties agreed in writing to the jurisdiction of the requested State in
accordance with Article 18(2) a) ( agreement attached); 5
The creditor may submit to the jurisdiction of the requested State in
accordance with Article 18(2) b);
The competent authority in the State of origin cannot, or refuses to,
exercise jurisdiction in accordance with Article 18(2) c) ( decision
attached); or,
The decision made in the State of origin cannot be recognized or declared
enforceable in the Contracting State where proceedings for a new or
modified decision are contemplated in accordance with Article 18(2) d)
( decision attached).

13.

Attestations



This application was completed by the applicant and reviewed by the requesting Central
Authority



This application complies with the requirement of the Convention (Article 12(2)). The
information contained in this application and the attached documents correspond to and
are in conformity with the information and documents provided by the applicant to the
requesting Central Authority. The application 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

5

Date: ________________
(dd/mm/yyyy)

The first condition of Article 18(2) does not apply in disputes relating to maintenance obligations in respect of children.

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

Restricted Information on the Applicant
Application for Modification of a Decision
( Article 10(1) e)  Article10(1) f)  Article 10(2) b)  Article 10(2) c))
N.B. The requesting Central Authority has determined that information under sections 2 d, e, f
and g and 5 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: _____________________________

2.

Particulars of the applicant
a.
Family name(s):
b.
Given name(s):
c.
Date of birth:
d.
Address:
e.
f.
g.

_________________________________________________
_________________________________________________
_____________________________________ (dd/mm/yyyy)
_________________________________________________
_________________________________________________
Telephone numbers: _________________________________________________
_________________________________________________
Fax number:
_________________________________________________
E-mail:
_________________________________________________

5.

Payments
a.
Details for electronic transfer of payments (if applicable)
________________________________
Name of the bank:
NBIC:
________________________________
SWIFT-address:
________________________________
IBAN:
________________________________
Account number:
________________________________
Name of account holder:
________________________________
Reference:
________________________________
b.
Details for payments by cheques (if applicable)
Cheque payable to:
________________________________
Cheque to be sent to:
________________________________
(address)
________________________________
________________________________
Reference:
________________________________



This application was completed by the applicant and reviewed by the requesting Central
Authority



This application complies with the requirement of the Convention (Article 12(2)). The
information contained in this application and the attached documents correspond to and
are in conformity with the information and documents provided by the applicant to the
requesting Central Authority. The application 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 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.