Form 1 Annex A: Abstract of a Decision

^{OMB Control No: 0970-0488}

Expiration date: XX/XX/XXXX

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

   1. Name:

   2. Address:

2.3	Telephone number:
2.4	Fax number:
2.5	E-mail:

3. The decision¹

   1. Type of authority:  judicial authority or  administrative authority²

   2. Name and place of authority:

   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. Name of the debtor:

PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to provide an abstract of a decision in an application 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 is a mandatory collection of information per 45 CFR 303.7. 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.

¹ For the definition of decision see Article 19(1).

² The Administrative Authority referred to in this Statement meets the requirements of Article 19(3).

5.

5.1

5.1.1

Terms of decision

Maintenance payable for one person or a group of persons (specify currency³ for each amount)

Name(s) and date(s) of birth of the person(s) entitled to support / maintenance, arrears and other payments

1. 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. Family name(s): Given name(s): Date of birth: (dd/mm/yyyy)

Terms of payment of support / maintenance

⁴ 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^):

2. Terms of payment of arrears

   • 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):

2. Terms of payment of retroactive maintenance

   • 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):

³ Currency should be specified using the ISO code.

⁴ 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.

2. 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):

2. Lump sum

The debtor shall pay the lump sum amount of on

• Due date (dd/mm/yyyy)

• Another frequency (specify):

2. Maintenance payments for more than one person on an individual basis (specify currency⁵ for each amount)

1. 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.

⁶ 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.

2. 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.

3. 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.

3. Maintenance payments directed to a public body (specify currency⁹ for each amount)

1. Name of the public body:

2. Family name(s) of the contact person:

3. Given name(s) of the contact person:

4. Address:

5. Telephone numbers:

6. Fax number:

7. 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.

¹⁰ 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. 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 _⁰_^.0_⁰_^% %

   • The maintenance should be indexed as follows:

6. Interest where maintenance payments are late

   • 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:

_⁰_^.0_⁰_^%  per  month  3 months  6 months  year

• The interest is:  simple or  compound

6. Effect of the decision

This decision shall remain in effect:

• 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:

6. Costs and expenses

   • 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 currency¹¹)

• 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

Date:

(dd/mm/yyyy)

Requesting Central Authority reference number:

(For Central Authority use only)

¹¹ Currency should be specified using the ISO code.