1 Status of Application Report Article 12

^{OMB Control No: 0970-0488}

Expiration date: XX/XX/XXXX

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

Status of Application Report – Article 12¹

(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.

Requested Central Authority Address Telephone number Fax number E-mail Reference number	Contact person in Requested State Address (if different) Telephone number (if different) Fax number (if different) E-mail (if different) Language(s)
First Report /  Subsequent Report – Date of last Report: (dd/mm/yyyy)

3. File identification

   1. Requesting Central Authority file reference number:

   2. Family name(s) of applicant:

   3. Family name(s) of the person(s) for whom

maintenance is sought or payable:

4. Family name(s) of debtor:

3. Status of the application for modification of a decision for maintenance in the Requested State

   1.  On (dd/mm/yyyy) the application has been sent to the competent authority responsible for modification (name)

(address)

(reference number)

PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to provide information on the status of an application under the 2007 Hague Child Support Convention. Public reporting burden for this collection of information is estimated to average 0.33 hours 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 The Status of Application Report can be used for the purpose of Article 12(3), (4) and (5). If the Report is being used to provide updates, only include additional information that was not included in the previous reports.

2.  On or by (dd/mm/yyyy) the competent authority is due to issue a decision

3.  On (dd/mm/yyyy) the competent authority issued a decision modifying a decision for maintenance ( decision attached for information purposes only;  service or notice of the decision has been effected on the applicant ( certificate of service^ attached if applicable);

   • service or notice of the decision will be effected on the applicant;

   • statement of enforceability attached;  statement of proper notice attached)

4.  On (dd/mm/yyyy) the competent authority has decided against modifying a decision for maintenance ( decision attached for information purposes only;  service or notice of the decision has been effected on the applicant ( certificate of service^* attached if applicable);  service or notice of the decision will be effected on the applicant)

5.  On (dd/mm/yyyy) the respondent has lodged a challenge or an appeal against the decision modifying the decision for maintenance

6.  On (dd/mm/yyyy) the decision to modify a decision for maintenance is final

7.  Application is still pending before the Central Authority

3.  The following steps have been taken (past):

   1.   Debtor /  creditor located

   2.   Debtor /  creditor contacted for settlement

   3.  Voluntary payment secured (no enforcement measures were necessary) ( documentation attached if applicable)

   4.  Information concerning the financial circumstances of the

      • debtor /  creditor gathered

   5.  Assets of the debtor located

   6.  Enforcement and other measures initiated

      • Provisional measures

      • Wage withholding

      • Garnishment from bank account or other sources

      • Deductions from social security payments

      • Lien on or forced sale of property

      • Tax refund withholding

      • Withholding or attachment of pension benefits

      • Credit bureau reporting

      • Denial, suspension or revocation of licenses or passport

      • Mediation, conciliation or similar processes

      • Seizure of lottery or gambling winnings

      • Prohibition from leaving the requested State

      • Incarceration

      • Other:

   7.  Payments were secured (enforcement measures were necessary)

   8.  Record of payments made by the debtor as of

(dd/mm/yyyy) attached

9.  Other:

• For example, a certificate issued under domestic law or, where appropriate, a certificate issued under an international instrument.

3.  The following steps are being taken (present):

   1.  Locating the  debtor /  creditor

   2.  Contacting the  debtor /  creditor for settlement

   3.  Securing voluntary payment (no enforcement measures are necessary)

   4.  Gathering of information concerning the financial circumstances of the

      • debtor /  creditor

   5.  Locating the assets of the debtor

   6.  Initiating enforcement measures

   7.  Securing payments (enforcement measures are necessary)

   8.  Other:

3.  The following steps will be taken (future):

   1.   Debtor /  creditor to be located

   2.   Debtor /  creditor to be contacted for settlement

   3.  Voluntary payment to be sought (no enforcement measures will be necessary)

   4.  Information to be gathered concerning the financial circumstances of the

      • debtor /  creditor

   5.  Assets of the debtor to be located

   6.  Enforcement measures to be initiated

   7.  Payments to be sought (enforcement measures will be necessary)

   8.  Other:

3.  Please provide the following additional information and / or documentation:

3.  The requested Central Authority has refused to process the application for the following reason(s):

   1.  Requesting Central Authority did not produce the additional documents or information within the period provided under Article 12(9)

   2.  Requirements of the Convention manifestly not fulfilled ( reasons attached)

3.  The competent authority has refused to modify the decision for the following reason(s):

   1.  Application contrary to Article 18

   2.  Other requirements of the Convention not fulfilled

   3.   Debtor /  creditor not located in the requested State

   4.  Other:

Name: (in block letters) Date:

Authorised representative of the Central Authority (dd/mm/yyyy)