Annex E - Financial circumstances
| Published date | 21 March 2018 |
N.B. Sections II to VI should becompleted onlyasnecessaryfor thepurposesof theapplication towhich thisformisattachedandtothebestoftheapplicant’sknowledge.WhencompletingtheFinancial CircumstancesForm,pleaseconsultCountryProfileoftherequestedStatetoverifywhatinformationis requiredforaspecificapplication.
CONFIDENTIALITY AND PERSONALDATA PROTECTIONNOTICE
PersonaldatagatheredortransmittedundertheConventionshallbeusedonlyforthepurposesfor whichitwasgatheredortransmitted.Anyauthorityprocessingsuchinformationshallensureits confidentiality, inaccordance with the lawof its State.
Anauthorityshallnotdiscloseorconfirminformationgatheredortransmittedinapplicationofthis Conventionifitdeterminesthattodosocouldjeopardisethehealth,safetyorlibertyofapersonin accordance with Article 40.
Adeterminationofnon-disclosurehasbeenmadebyaCentralAuthorityinaccordancewith Article40.Ifthisboxisticked,informationunderitemsV.D.2,4,6,8,10,12,14and16andVI.D. 9 and 11 shouldonlybeprovidedin the RestrictedInformation on theApplicantpageof this form.
- REFERENCEINFORMATION
- RequestingCentralAuthority
- Address
- Telephonenumber
- Faxnumber
- Referencenumber
- ContactpersoninRequestedState
- Address(ifdifferent)
- Telephonenumber(ifdifferent)
- Faxnumber(ifdifferent)
- E-mail(ifdifferent)
- Language(s)
- The applicant,(familyname(s)andgivenname(s)),born
(dd/mm/yyyy),is:□ creditor,□ representativeoftheperson(s)forwhommaintenanceis soughtorpayable,or□ debtor
- Thisformisbeingsubmittedinrelationto:(itispossibletotickmorethanone box)
□ Establishmentofadecision(Art.10(1)c)andd))
(Completeallsections)
□ Recognitionorrecognitionandenforcementofadecision(Art.10(1)a))
(CompletesectionsIII andIV)
□ EnforcementofadecisionmadeorrecognisedintherequestedState(Art.10(1)b))
(CompletesectionsIIIandIV)
□ Modificationofadecision(Art.10(1)e)andf)and(2)b)andc))
(Completeallsections)
□ Applyingforlegalassistance(Art.17a))
(CompletesectionsII,VandVIiftheapplicantisthepersonidentifiedunderII)
(CompletesectionsIII,VandVIiftheapplicantisthepersonidentifiedunderIII)
- Unlessotherwisespecified,thecurrency(ISOcode)usedtocompletethisformand,ifapplicable, theexchangerate(anddateofexchangerate)iftheamountsareconvertedintothecurrencyofthe requested Stateis:_(dd/mm/yyyy)
- GENERAL INFORMATIONABOUTTHECREDITOROR THEPERSON(S)FOR WHOM MAINTENANCE IS SOUGHTOR PAYABLE(IF KNOWN)
- Informationaboutthecreditorortheperson(s)forwhommaintenanceissoughtorpayable
1.Thecreditororthepersonforwhommaintenanceissoughtis: □ Father□ Mother□ Caretakerotherthanparent□ Fostercareprovider □ Boththechildandtheaboveperson(marked)areconsideredascreditors □ Thechildher/himselfistheonlycreditor □ Publicbody □ Otherperson(seetheapplication) | |
2.Occupation,tradeorprofession | |
3.Estimatedgrossmonthlyearnings (specifycurrency) | 4.Othermonthlyincome(&source) (specifycurrency) |
5.Presentmaritalstatus □Married□Single□Partner□Divorced□Separated | |
- Informationaboutcreditor’sdependents
Familyname(s) Givenname(s) | Age | Relationshiptocreditor | Subjectofthis application? | |
□Yes | □No | |||
□Yes | □No | |||
□Yes | □No | |||
□Yes | □No | |||
□Yes | □No | |||
- Informationaboutcurrent□spouseor□partnerofcreditor□othermemberofthe householdcontributingtotheexpensesofthehousehold
1.Familyname(s),givenname(s) | 2.Employed? □Yes□No□Unknown |
3.Estimatedgrossmonthlyearnings (specifycurrency) | 4.Othermonthlyincome(&source) (specifycurrency) |
5.Thepersonidentifiedabovepayschildsupport/maintenance□ voluntarilyor□judicial/ administrative decision in theamount ofper(specify currencyandinstalmentperiod).As of(dd/mm/yyyy)thetotalamountpaidis: ;andthe total amount outstanding is:(specifycurrency). | |
- GENERAL INFORMATIONABOUTTHEDEBTOR (IF KNOWN)
- Informationaboutthedebtor
1.Thedebtoris: □Father□Mother□Caretakerotherthanparent□Fostercare □Spouse□Partner□Child□Otherperson | |
2.Occupation,tradeorprofession: | |
3.Nameandaddressoftheemployer: | |
4.Estimatedgrossmonthlyearnings (specifycurrency) | 5.Othermonthlyincome(&source) (specifycurrency) |
6.PresentMaritalStatus □ Married□Single□Partner□Divorced□Separated | |
- Informationaboutdebtor’sdependents
Familyname(s) Givenname(s) | Age | Relationshiptodebtor | Subjectofthis application? | |
1. | □Yes | □No | ||
2. | □Yes | □No | ||
3. | □Yes | □No | ||
4. | □Yes | □No | ||
5. | □Yes | □No | ||
- Informationaboutcurrent□spouseor□partnerofdebtor□othermemberof...
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