Annex D - Application for modification of a decision
| Published date | 21 March 2018 |
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
3.1Maintenance is sought or payable for the applicant named above
Maintenance basis:
parentage in loco parentis or equivalent relationship
marriageanalogous 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
3.3Maintenance 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: ________________________________________________
3.4Maintenance 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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