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CERTIFICATE CONCERNING DECISIONS IN MATTERS OF PARENTAL RESPONSIBILITY (Point (b) of Article 36(1) of Council Regulation (EU) 2019/1111 ) IMPORTANT To be issued, upon application by a party, with regard to a decision in matters of parental responsibility, 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* 5. CHILD(REN) COVERED BY THE DECISION* 5.1. Child 1* 5.1.1. Surname(s)* 5.1.2. Given name(s)* 5.1.3. Date of birth (dd/mm/yyyy)* 5.1.4. Place of birth (if available)

5.1.5. Identity number or social security number (if applicable and available) 5.2. Child 2 5.2.1. Surname(s) 5.2.2. Given name(s) 5.2.3. Date of birth (dd/mm/yyyy) 5.2.4. Place of birth (if available) 5.2.5. Identity number or social security number (if applicable and available) 5.3. Child 3 5.3.1. Surname(s) 5.3.2. Given name(s) 5.3.3. Date of birth (dd/mm/yyyy) 5.3.4. Place of birth (if available) 5.3.5. Identity number or social security number (if applicable and available) 6. RIGHTS OF CUSTODY 6.1. Rights of custody attributed according to the decision …… 6.2. Attributed to the following party(ies) 6.2.1. Party 1 6.2.1.1. Natural person 6.2.1.1.1. Surname(s) 6.2.1.1.2. Given name(s) 6.2.1.1.3. Date of birth (dd/mm/yyyy) 6.2.1.1.4. Place of birth (if available) 6.2.1.1.5. Identity number or social security number (if applicable and available) 6.2.1.1.6. Address (if available) 6.2.1.1.6.1. as stated in the decision … 6.2.1.1.6.2. any additional information (for example, concerning a different current address) … 6.2.1.2. Legal person, institution or other body 6.2.1.2.1. Full name 6.2.1.2.2. Identification number (if applicable and available)

6.2.1.2.3. Address (if available) 6.2.2. Party 2 6.2.2.1. Natural person 6.2.2.1.1. Surname(s) 6.2.2.1.2. Given name(s) 6.2.2.1.3. Date of birth (dd/mm/yyyy) 6.2.2.1.4. Place of birth (if available) 6.2.2.1.5. Identity number or social security number (if applicable and available) 6.2.2.1.6. Address (if available) 6.2.2.1.6.1. as stated in the decision … 6.2.2.1.6.2. any additional information (for example, concerning a different current address) … 6.2.2.2. Legal person, institution or other body 6.2.2.2.1. Full name 6.2.2.2.2. Identification number (if applicable and available) 6.2.2.2.3. Address (if available) 6.3. The decision entails the handover of the child(ren) 6.3.1. No 6.3.2. Yes 6.3.2.1. Details of the handover relevant for enforcement if not already indicated in point 6.1 (for example, to whom, which child(ren), periodical or single handover) …… 7. RIGHTS OF ACCESS 7.1. Rights of access granted by the decision …… 7.2. Granted to the following party(ies) 7.2.1. Party 1 7.2.1.1. Surname(s) 7.2.1.2. Given name(s) 7.2.1.3. Date of birth (dd/mm/yyyy) 7.2.1.4. Place of birth (if available)

7.2.1.5. Identity number or social security number (if applicable and available) 7.2.1.6. Address (if available) 7.2.1.6.1. as stated in the decision … 7.2.1.6.2. any additional information (for example, concerning a different current address) … 7.2.2. Party 2 7.2.2.1. Surname(s) 7.2.2.2. Given name(s) 7.2.2.3. Date of birth (dd/mm/yyyy) 7.2.2.4. Place of birth (where available) 7.2.2.5. Identity number or social security number (if applicable and available) 7.2.2.6. Address (if available) 7.2.2.6.1. as stated in the decision … 7.2.2.6.2. any additional information (for example, concerning a different current address) … 7.3. The decision entails the handover of the child(ren) 7.3.1. No 7.3.2. Yes 7.3.2.1. Details of the handover relevant for enforcement if not already indicated in point 7.1 (for example, to whom, which child(ren), periodical or single handover) …… 8. OTHER RIGHTS IN MATTERS OF PARENTAL RESPONSIBILITY 8.1. Right(s) attributed according to the decision …… 8.2. Attributed to the following party(ies) 8.2.1. Party 1 8.2.1.1. Natural person 8.2.1.1.1. Surname(s) 8.2.1.1.2. Given name(s) 8.2.1.1.3. Date of birth (dd/mm/yyyy)

8.2.1.1.4. Place of birth (if available) 8.2.1.1.5. Identity number or social security number (if applicable and available) 8.2.1.1.6. Address (if available) 8.2.1.1.6.1. as stated in the decision … 8.2.1.1.6.2. any additional information (for example, concerning a different current address) … 8.2.1.2. Legal person, institution or other body 8.2.1.2.1. Full name 8.2.1.2.2. Identification number (if applicable and available) 8.2.1.2.3. Address (if available) 8.2.2. Party 2 8.2.2.1. Natural person 8.2.2.1.1. Surname(s) 8.2.2.1.2. Given name(s) 8.2.2.1.3. Date of birth (dd/mm/yyyy) 8.2.2.1.4. Place of birth (if available) 8.2.2.1.5. Identity number or social security number (if applicable and available) 8.2.2.1.6. Address (if available) 8.2.2.1.6.1. as stated in the decision … 8.2.2.1.6.2. any additional information (for example, concerning a different current address) … 8.2.2.2. Legal person, institution or other body 8.2.2.2.1. Full name 8.2.2.2.2. Identification number (if applicable and available) 8.2.2.2.3. Address (if available) 8.3. The decision entails the handover of the child(ren) 8.3.1. No 8.3.2. Yes

8.3.2.1. Details of the handover relevant for enforcement if not already indicated in point 8.1 (for example, to whom, which child(ren), periodical or single handover) …… 9. THE DECISION ORDERS (A) PROVISIONAL, INCLUDING PROTECTIVE, MEASURE(S)* 9.1. No 9.2. Yes 9.2.1. Description of the measure(s) ordered …… 10. THE DECISION IS SUBJECT TO FURTHER APPEAL UNDER THE LAW OF THE MEMBER STATE OF ORIGIN* 10.1. No 10.2. Yes 11. THE DECISION IS ENFORCEABLE IN THE MEMBER STATE OF ORIGIN* 11.1. Concerning rights of custody as indicated in point 6 11.1.1. No 11.1.1.1. The decision does not contain an enforceable obligation (if applicable).

11.1.2. Yes, without any restrictions (please indicate the date (dd/mm/yyyy) on which the decision became enforceable): …/…/…… 11.1.3. Yes, but only against the party as indicated in point … (please fill in) 11.1.3.1. Please indicate the date (dd/mm/yyyy) on which the decision became enforceable against this party: …/…/…… 11.1.4. Yes, but limited to the following part(s) of the decision (please specify) … 11.1.4.1. Please indicate the date (dd/mm/yyyy) on which this (these) part(s) of the decision became enforceable: …/…/……

11.2. Concerning rights of access as indicated in point 7 11.2.1. No 11.2.1.1. The decision does not contain an enforceable obligation (if applicable).

11.2.2. Yes, without any restrictions (please indicate the date (dd/mm/yyyy) on which the decision became enforceable): …/…/…… 11.2.3. Yes, but only against the party as indicated in point … (please fill in) 11.2.3.1. Please indicate the date (dd/mm/yyyy) on which the decision became enforceable against this party: …/…/…… 11.2.4. Yes, but limited to the following part(s) of the decision (please specify) … 11.2.4.1. Please indicate the date (dd/mm/yyyy) on which this (these) part(s) of the decision became enforceable: …/…/…… 11.3. Concerning other rights in matters of parental responsibility as indicated in point 8 11.3.1. No 11.3.1.1. The decision does not contain an enforceable obligation (if applicable).

11.3.2. Yes, without any restrictions (please indicate the date (dd/mm/yyyy) on which the decision became enforceable): …/…/…… 11.3.3. Yes, but only against the party as indicated in point … (please fill in) 11.3.3.1. Please indicate the date (dd/mm/yyyy) on which the decision became enforceable against this party: …/…/……

11.3.4. Yes, but limited to the following part(s) of the decision (please specify) … 11.3.4.1. Please indicate the date (dd/mm/yyyy) on which this (these) part(s) of the decision became enforceable: …/…/…… 12. AS OF THE DATE OF ISSUANCE OF THIS CERTIFICATE, THE DECISION HAS BEEN SERVED UPON THE PARTY(IES) AGAINST WHOM ENFORCEMENT IS SOUGHT* 12.1. Upon the party as indicated in point … (please fill in) 12.1.1. No 12.1.2. Not known to the court 12.1.3. Yes 12.1.3.1. Date of service (dd/mm/yyyy) 12.1.3.2. The decision was served in the following language(s): BG ES CS DE ET EL EN FR GA HR IT LV LT HU MT NL PL PT RO SK SL FI SV 12.2. Upon the party as indicated in point … (please fill in) 12.2.1. No 12.2.2. Not known to the court 12.2.3. Yes 12.2.3.1. Date of service (dd/mm/yyyy) 12.2.3.2. The decision was served in the following language(s): BG ES CS DE ET EL EN FR GA HR IT LV LT HU MT NL PL PT RO SK SL FI SV 13. THE DECISION WAS GIVEN IN DEFAULT OF APPEARANCE* 13.1. No 13.2. Yes 13.2.1. Party(ies) in default of appearance as indicated in point … (please fill in) 13.2.2. That party was served with the document which instituted the proceedings or with an equivalent document.

13.2.2.1. No 13.2.2.2. Not known to the court 13.2.2.3. Yes 13.2.2.3.1. Date of service (dd/mm/yyyy) 14. THE CHILD(REN) AS INDICATED IN POINT 5 WAS (WERE) CAPABLE OF FORMING HIS OR HER (THEIR) OWN VIEWS* 14.1. Child as indicated in point 5.1 14.1.1. Yes (then please fill in point 15) 14.1.2. No 14.2. Child as indicated in point 5.2 14.2.1. Yes (then please fill in point 15) 14.2.2. No 14.3. Child as indicated in point 5.3 14.3.1. Yes (then please fill in point 15) 14.3.2. No 15. THE CHILD(REN) CAPABLE OF FORMING HIS OR HER (THEIR) OWN VIEWS AS INDICATED IN POINT 14 WAS (WERE) GIVEN A GENUINE AND EFFECTIVE OPPORTUNITY TO EXPRESS HIS OR HER (THEIR) VIEWS IN ACCORDANCE WITH ARTICLE 21 OF THE REGULATION 15.1. Child as indicated in point 5.1 15.1.1. Yes 15.1.2. No, for the following reasons: … 15.2. Child as indicated in point 5.2 15.2.1. Yes 15.2.2. No, for the following reasons: … 15.3. Child as indicated in point 5.3 15.3.1. Yes 15.3.2. No, for the following reasons: … 16. NAME(S) OF PARTY(IES) WHO BENEFITED FROM LEGAL AID IN ACCORDANCE WITH ARTICLE 74(1) OF THE REGULATION 16.1. Party(ies) 16.1.1. as indicated in point … (please fill in)

16.1.2. as indicated in point … (please fill in) 17. COSTS AND EXPENSES OF THE PROCEEDINGS 17.1. The decision also covers matrimonial matters, and the information on costs relating to the proceedings under this Regulation is provided solely in this certificate.

17.2. 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)): 17.3. 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