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CERTIFICATE CONCERNING DECISIONS IN MATRIMONIAL MATTERS (Point (a) of Article 36(1) of Council Regulation (EU) 2019/1111 ) IMPORTANT To be issued, upon application by a party, with regard to a decision granting divorce, legal separation or marriage annulment, by the court of a Member State of origin as communicated to the Commission pursuant to Article 103 of the Regulation.

1. MEMBER STATE OF ORIGIN* Belgium (BE) Bulgaria (BG) Czechia (CZ) Germany (DE) Estonia (EE) Ireland (IE) Greece (EL) Spain (ES) France (FR) Croatia (HR) Italy (IT) Cyprus (CY) Latvia (LV) Lithuania (LT) Luxembourg (LU) Hungary (HU) Malta (MT) Netherlands (NL) Austria (AT) Poland (PL) Portugal (PT) Romania (RO) Slovenia (SI) Slovakia (SK) Finland (FI) Sweden (SE) United Kingdom (UK) 2. COURT ISSUING THE CERTIFICATE* 2.1. Name* 2.2. Address* 2.3. Tel./fax/e-mail* 3. COURT WHICH GAVE THE DECISION (if different) 3.1. Name 3.2. Address 4. DECISION* 4.1. Date (dd/mm/yyyy)* 4.2. Reference number* 4.3. Type of decision* 4.3.1. Divorce 4.3.2. Marriage annulment 4.3.3. Legal separation 5. MARRIAGE* 5.1. Spouses* 5.1.1.

5.1.1.1. Surname(s)* 5.1.1.2. Given name(s)* 5.1.1.3. Date of birth (dd/mm/yyyy)*

5.1.1.4. Place of birth 5.1.1.5. Identity number or social security number (if applicable and available) 5.1.1.6. Address (if available) 5.1.1.6.1. as stated in the decision … 5.1.1.6.2. any additional information (for example, concerning a different current address) … 5.1.2.

5.1.2.1. Surname(s)* 5.1.2.2. Given name(s)* 5.1.2.3. Date of birth (dd/mm/yyyy)* 5.1.2.4. Place of birth 5.1.2.5. Identity number or social security number (if applicable and available 5.1.2.6. Address (if available) 5.1.2.6.1. as stated in the decision … 5.1.2.6.2. any additional information (for example, concerning a different current address) … 5.2. Date, country and place of marriage* 5.2.1. Date (dd/mm/yyyy)* 5.2.2. Country* 5.2.3. Place (if available) 6. THE DECISION WAS GIVEN IN DEFAULT OF APPEARANCE* 6.1. No 6.2. Yes 6.2.1. Party in default of appearance as indicated in point … (please fill in) 6.2.2. That party was served with the document which instituted the proceedings or with an equivalent document.

6.2.2.1. No 6.2.2.2. Not known to the court 6.2.2.3. Yes 6.2.2.3.1. Date of service (dd/mm/yyyy) 7. THE DECISION IS SUBJECT TO FURTHER APPEAL UNDER THE LAW OF THE MEMBER STATE OF ORIGIN*

7.1. No 7.2. Yes 8. DATE OF LEGAL EFFECT IN THE MEMBER STATE WHERE THE DECISION WAS GIVEN (dd/mm/yyyy)* 9. NAME(S) OF PARTY(IES) WHO BENEFITED FROM LEGAL AID IN ACCORDANCE WITH ARTICLE 74(1) OF THE REGULATION 9.1. Party(ies) 9.1.1. as indicated in point 5.1.1 9.1.2. as indicated in point 5.1.2 10. COSTS AND EXPENSES OF THE PROCEEDINGS 10.1. The decision also covers matters of parental responsibility, and the information on costs relating to the proceedings under this Regulation is provided solely in the certificate concerning decisions in matters of parental responsibility.

10.2. The decision provides that … (surname(s)) … (given name(s)) must pay to … (surname(s)) … (given name(s)) the sum of … Euro (EUR) Bulgarian lev (BGN) Croatian kuna (HRK) Czech koruna (CZK) Hungarian forint (HUF) Polish zloty (PLN) Pound sterling (GBP) Romanian leu (RON) Swedish krona (SEK) Other (please specify (ISO code)): 10.3. Any additional information which might be relevant (for example, fixed amount or percentage; interests awarded; shared costs; where more than one party has been ordered to bear the costs, whether the whole amount may be collected from any one of them): …

Done at …, date (dd/mm/yyyy) Signature and/or stamp