Annex D - Application for modification of a decision

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: [1] _____________________________________ (dd/mm/yyyy)

d. Address: _________________________________________________

_________________________________________________

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: ________________________________________________

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 in loco parentis or equivalent relationship

b. Family name(s): _____________________________________

Given name(s): _____________________________________

Date of birth: ________________________________ (dd/mm/yyyy)

Maintenance basis:

parentage in loco parentis or equivalent relationship

c. Family name(s): _____________________________________

Given name(s): _____________________________________

Date of birth: ________________________________ (dd/mm/yyyy)

Maintenance basis:

parentage in loco parentis or equivalent relationship

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:

marriage analogous relationship to marriage

affinity (please identify): _________________________________

grandparent sibling grandchild

other: ________________________________________________

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

4.1 Particulars (if known) of the debtor

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: ____________________________________

____________________________________

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: ____________________________________________

____________________________________________

e. Fax number: ____________________________________________

f. E-mail: ____________________________________________

4.3 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:[2] ________________________________

SWIFT-address: ________________________________

IBAN:[3] ________________________________

Account number: ________________________________

Name of account holder: ________________________________

Reference:[4] ________________________________

b. Details for payments by cheques (if applicable)

Cheque payable to: ________________________________

Cheque to be sent to: ________________________________

(address) ________________________________

________________________________

Reference:³ ________________________________

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:

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: ____________________________________________

8. 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): _______________________

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