Form 1 Annex 1 Transimittal

ANNEX I

OMB Control No: 0970-0488

Expiration date: XX/XX/XXXX

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.

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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

3. Particulars of the applicant

   1. Family name(s):

   2. Given name(s):

   3. Date of birth: (dd/mm/yyyy) or

a. Name of the public body :

PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this form is to transmit applications under the 2007 Hague Child Support Convention. 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. This collection of information is required to process child support cases under the 2007 Hague Child Support Convention. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information subject to the requirements of the Paperwork Reduction Act of 1995, unless it displays a currently valid OMB control number. If you have any comments on this collection of information, please contact the ACF Reports Clearance Officer by email at infocollection@acf.hhs.gov.

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

1. 

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

2. i. Family name(s): Given name(s):

Date of birth: (dd/mm/yyyy)

2. Family name(s): Given name(s):

Date of birth: (dd/mm/yyyy)

2. Family name(s): Given name(s):

Date of birth: (dd/mm/yyyy)

3. Particulars of the debtor¹

   1. 

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

   2. Family name(s):

   3. Given name(s):

   4. Date of birth: (dd/mm/yyyy)

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

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Article 10(1) a)

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Article 10(1) b)

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Article 10(1) c)

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Article 10(1) d)

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Article 10(1) e)

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Article 10(1) f)

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Article 10(2) a)

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Article 10(2) b)

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Article 10(2) c)

3. The following documents are appended to the application:

1. 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”.



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)):

2. 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):

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













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)

Name : (in block letters) Date: Authorised representative of the Central Authority (dd/mm/yyyy)

Final Act

Final Act