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APPLICATION FORM TO OBTAIN OR HAVE MODIFIED A DECISION IN MATTERS RELATING TO MAINTENANCE OBLIGATIONS (Articles 56 and 57 of Council Regulation (EC) No 4/2009 of 18 December 2008 on jurisdiction, applicable law, recognition and enforcement of decisions and cooperation in matters relating to maintenance obligations ()) PART A To be completed by the requesting Central Authority 1. APPLICATION  Application to obtain a decision (Article 56(1)(c))  Application to obtain a decision (Article 56(1)(d))  Application for the modification of a decision (Article 56(1)(e))  Application for the modification of a decision (Article 56(1)(f))  Application for the modification of a decision (Article 56(2)(b))  Application for the modification of a decision (Article 56(2)(c)) 2. REQUESTING CENTRAL AUTHORITY 2.1. Name: …

2.2. Address: 2.2.1. Street and number/PO box: … 2.2.2. Place and postal code: … 2.2.3. Member State  Belgium  Bulgaria  Czech Republic  Germany  Estonia  Ireland  Greece  Spain  France  Croatia  Italy  Cyprus  Latvia  Lithuania  Luxembourg  Hungary  Malta  Netherlands  Austria  Poland  Portugal  Romania  Slovenia  Slovakia  Finland  Sweden  United Kingdom 2.3. Telephone: … 2.4. Fax … 2.5. E-mail: … 2.6. Reference number of the application: … Application to be handled with the application(s) bearing the following reference number(s): … 2.7. Person responsible for following up the application: 2.7.1. Surname and given name(s): … 2.7.2. Telephone: … 2.7.3. E-mail: … 3. REQUESTED CENTRAL AUTHORITY 3.1. Name: … 3.2. Address: 3.2.1. Street and number/PO box: … 3.2.2. Place and postal code: … 3.2.3. Member State  Belgium  Bulgaria  Czech Republic  Germany  Estonia  Ireland  Greece  Spain  France  Croatia  Italy  Cyprus  Latvia  Lithuania  Luxembourg  Hungary  Malta  Netherlands  Austria  Poland  Portugal  Romania  Slovenia  Slovakia  Finland  Sweden  United Kingdom 4. DOCUMENTS ATTACHED () TO THE APPLICATION, AS APPROPRIATE

 Decision of the requested Member State refusing recognition or a declaration of enforceability  Copy of the decision to be modified  Extract from the decision to be modified  Document(s) proving a change in income or any other change in circumstances  Birth certificate(s) or equivalent  Debtor’s acknowledgement of parentage  Document(s) proving biological parentage  Decision by a competent authority in relation to parentage  Results of genetic tests  Adoption certificate  Certificate of marriage or similar relationship  Document(s) proving the date of divorce/separation  Document(s) proving that the parties live together  Certificate(s) regarding schooling  Document(s) relevant to the financial situation  Other (please specify): … … … … Total number of documents attached to the application form: … Done at: … on … (dd/mm/yyyy) Name and signature of the authorised official of the requesting Central Authority: … PART B To be completed by the applicant or, as appropriate, by the person/authority authorised in the requesting Member State to complete the form on the applicant’s behalf 5. APPLICATION

5.1.  Application to obtain a decision 5.1.1.  Parentage has not been established 5.1.2.  No decision exists 5.1.3.  Recognition and a declaration of enforceability of an existing decision are not possible 5.1.4.  Amount requested: … … …

5.2.  Application for modification of a decision 5.2.1.  The decision was given in the requested Member State 5.2.2.  The decision was given in a State other than the requested Member State 5.2.3. Date (dd/mm/yyyy) and reference number of the decision: … 5.2.4. Name of the court of origin: … 5.2.5. Changes in circumstances which have occurred:  Change in income:  of the person(s) for whom maintenance is sought or owed  of the person primarily responsible for the person(s) for whom maintenance is sought or owed  of the debtor  Change in expenses and charges:  of the person(s) for whom maintenance is sought or owed  of the person primarily responsible for the person(s) for whom maintenance is sought or owed  of the debtor  Change in the situation of the child/children  Change in civil status:  of the person(s) for whom maintenance is sought or owed  of the person primarily responsible for the person(s) for whom maintenance is sought or owed  of the debtor  Other (please specify): … … … 5.2.6. Modification(s) requested:  Increase in the amount of maintenance:  The amount of maintenance should be increased by (please specify): …  The new amount of maintenance should be (please specify): Currency  Euro (EUR)  Lev (BGN)  Czech koruna (CZK)  Pound sterling (GBP)  Kuna (HRK)  Forint (HUF)  Zloty (PLN)  Leu (RON)  Krona (SEK)  Other (please specify ISO code): …  Reduction in the amount of maintenance:  The amount of maintenance should be reduced by (please specify): …  The new amount of maintenance should be (please specify): Currency  Euro (EUR)  Lev (BGN)  Czech koruna (CZK)  Pound sterling (GBP)  Kuna (HRK)  Forint (HUF)  Zloty (PLN)  Leu (RON)  Krona (SEK)  Other (please specify ISO code): …  Modification of the frequency of payments (please specify): …  Modification of the arrangements for payment (please specify): …  Modification of the nature of payments (please specify): …  Termination of the maintenance obligation (please specify): …  Other (please specify): … …

6. APPLICANT 6.1. Surname and given name(s): … 6.2. Address:  The address given below is the applicant’s personal address.  The applicant is in a situation of family violence (). The address given below is an address care of: … (surname and given name(s)) 6.2.1. Street and number/PO box: … 6.2.2. Place and postal code: … 6.2.3. Member State  Belgium  Bulgaria  Czech Republic  Germany  Estonia  Ireland  Greece  Spain  France  Croatia  Italy  Cyprus  Latvia  Lithuania  Luxembourg  Hungary  Malta  Netherlands  Austria  Poland  Portugal  Romania  Slovenia  Slovakia  Finland  Sweden  United Kingdom 6.3. Telephone/E-mail: … 6.4. Date (dd/mm/yyyy) and place of birth: … 6.5. Identity number or social security number (): … 6.6. Nationality: … 6.7. Occupation: … 6.8. Civil status: … 6.9. If applicable, surname, given name(s) and contact details of the applicant’s representative (lawyer, etc. …): … … 7. DEFENDANT 7.1. Surname and given name(s): …

7.2. Address (): 7.2.1. Street and number/PO box: … 7.2.2. Place and postal code: … 7.2.3. Member State  Belgium  Bulgaria  Czech Republic  Germany  Estonia  Ireland  Greece  Spain  France  Croatia  Italy  Cyprus  Latvia  Lithuania  Luxembourg  Hungary  Malta  Netherlands  Austria  Poland  Portugal  Romania  Slovenia  Slovakia  Finland  Sweden  United Kingdom 7.3. Date (dd/mm/yyyy) and place of birth (): … 7.4. Identity number or social security number (): … 7.5. Nationality (): … 7.6. Occupation (): … 7.7. Civil status (): … 8. ANY OTHER INFORMATION THAT MAY HELP LOCATE THE DEFENDANT: … … … 9. PERSON(S) FOR WHOM MAINTENANCE IS SOUGHT OR OWED () 9.1.  The person is the same as the applicant named in point 6 9.2.  The person is the same as the defendant named in point 7

9.3. is the representative () defending the interests of the following person(s): 9.3.1. Person A 9.3.1.1. Surname and given name(s): … 9.3.1.2. Date (dd/mm/yyyy) and place of birth: … 9.3.1.3. Identity number or social security number (): … 9.3.1.4. Nationality (): … 9.3.1.5. Occupation (): … 9.3.1.6. Civil status (): … 9.3.1.7. Maintenance is on the basis of the following relationship:  Parentage (please specify relationship): …  Marriage  Analogous relationship to marriage  Alliance (please specify relationship): …  Other (please specify): … 9.3.2. Person B 9.3.2.1. Surname and given name(s): … 9.3.2.2. Date (dd/mm/yyyy) and place of birth: … 9.3.2.3. Identity number or social security number (): … 9.3.2.4. Nationality (): … 9.3.2.5. Occupation (): … 9.3.2.6. Civil status (): … 9.3.2.7. Maintenance is on the basis of the following relationship:  Parentage (please specify relationship): …  Marriage  Analogous relationship to marriage  Alliance (please specify relationship): …  Other (please specify): … 9.3.3. Person C 9.3.3.1. Surname and given name(s): … 9.3.3.2. Date (dd/mm/yyyy) and place of birth: … 9.3.3.3. Identity number or social security number (): … 9.3.3.4. Nationality (): … 9.3.3.5. Occupation (): … 9.3.3.6. Civil status (): … 9.3.3.7. Maintenance is on the basis of the following relationship:  Parentage (please specify relationship): …  Marriage  Analogous relationship to marriage  Alliance (please specify relationship): …  Other (please specify): …

10. DEBTOR 10.1.  The person is the same as the applicant named in point 6 10.2.  The person is the same as the defendant named in point 7 10.3. is the representative () defending the interests of the following person: 10.3.1. Surname and given name(s): … 10.3.2. Date (dd/mm/yyyy) and place of birth: … 10.3.3. Identity number or social security number (): … 10.3.4. Nationality (): … 10.3.5. Occupation (): … 10.3.6. Civil status (): … 10.3.7. Maintenance is on the basis of the following relationship:  Parentage (please specify relationship): …  Marriage  Analogous relationship to marriage  Alliance (please specify relationship): …  Other (please specify): … 11. INFORMATION ON THE FINANCIAL SITUATION OF THE PERSONS CONCERNED BY THE APPLICATION (ONLY GIVE INFORMATION WHICH IS RELEVANT FOR THE PURPOSE OF OBTAINING OR MODIFYING A DECISION) 11.1. Currency  Euro (EUR)  Lev (BGN)  Czech koruna (CZK)  Pound sterling (GBP)  Kuna (HRK)  Forint (HUF)  Zloty (PLN)  Leu (RON)  Krona (SEK)  Other (please specify ISO code): … 11.2. The person(s) for whom maintenance is sought or owed and the person primarily responsible for that person (those persons) 11.2.1. Gross income

11.2.2. Expenses and charges 11.2.3. Other assets … … … 11.3. The debtor 11.3.1. Gross income 11.3.2. Expenses and charges 11.3.3. Other assets … … … 12. INFORMATION REGARDING PAYMENT, IF THE APPLICATION IS MADE BY THE CREDITOR 12.1. Payment by electronic means 12.1.1. Name of bank: … 12.1.2. BIC or other relevant bank code: … 12.1.3. Account holder: … 12.1.4. International Bank Account Number (IBAN): … 12.2. Payment by cheque 12.2.1. Cheque payable to: … 12.2.2. Cheque to be sent to 12.2.2.1. Surname and given name(s): … 12.2.2.2. Address: 12.2.2.2.1. Street and number/PO box: … 12.2.2.2.2. Place and postal code: … 12.2.2.2.3. Country: … 13. ADDITIONAL INFORMATION (WHERE APPLICABLE): … … … Done at: … on … (dd/mm/yyyy) Applicant’s signature: … and/or, where appropriate: Name and signature of the person/authority authorised in the requesting Member State to complete the form on the applicant’s behalf: …