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Please indicate the position of the affected person in the proceedings: □ person against whom the confiscation order is directed □ person that owns the property that is covered by the confiscation order (ii) In the case of legal person(s) Name: … Legal form: … Shortened name, commonly used name or trading name, if applicable: … Registered seat: … Registration number: … Address: … Name of the representative: … Please indicate the position of the affected person in the proceedings: □ person against whom the confiscation order is directed □ person that owns the property that is covered by the confiscation order 2. If different from the address above, please give the location where the confiscation order is to be executed: … 3. Third parties whose rights in relation to the property that is covered by the confiscation order are directly prejudiced by the order (identity and grounds): … … 4. Provide any other information that will assist with the execution of the confiscation order: … SECTION D: Information on property to which the order relates

1. The court has decided that the property: □ is the proceeds of a criminal offence, or its equivalent, whether the full amount of the value or only part of the value of such proceeds □ constitutes the instrumentalities of a criminal offence, or the value of such instrumentalities □ is subject to confiscation through the application in the issuing State of any of the powers of confiscation provided for in Directive 2014/42/EU (including extended confiscation) □ is subject to confiscation under any other provisions relating to powers of confiscation, including confiscation without a final conviction, under the law of the issuing State following proceedings in relation to a criminal offence 2. Please indicate if the order concerns: □ an amount of money □ specific item(s) of property (corporeal or incorporeal, movable or immovable) □ property of equivalent value (in the context of value-based confiscation)

3. If the order concerns an amount of money or property of equivalent value to that amount of money:

— The amount for execution in the executing State, in figures and words (indicate currency): … — The total amount covered by the order, in figures and words (indicate currency): … Additional information:

— Grounds for believing that the affected person has property/income in the executing State: … — Description of the property/source of income of the affected person (when possible): … — Exact location of the property/source of income of the affected person (if not known, the last known location): … — Details of the bank account of the affected person (if known): …

3. Is the criminal offence in relation to which the confiscation order is issued punishable in the issuing State by a custodial sentence of a maximum of at least three years and included in the list of criminal offences set out below? (please tick the relevant box). Where the confiscation order concerns several criminal offences, please indicate numbers in the list of criminal offences below (corresponding to the criminal offences as described under points 1 and 2 above). □ participation in a criminal organisation □ terrorism □ trafficking in human beings □ sexual exploitation of children and child pornography □ illicit trafficking in narcotic drugs and psychotropic substances □ illicit trafficking in weapons, munitions and explosives □ corruption □ fraud, including fraud and other criminal offences affecting the Union's financial interests as defined in Directive (EU) 2017/1371 □ laundering of the proceeds of crime □ counterfeiting currency, including the euro □ computer-related crime □ environmental crime, including illicit trafficking in endangered animal species and in endangered plant species and varieties □ facilitation of unauthorised entry and residence □ murder or grievous bodily injury □ illicit trade in human organs and tissue □ kidnapping, illegal restraint or hostage-taking □ racism and xenophobia □ organised or armed robbery □ illicit trafficking in cultural goods, including antiques and works of art □ swindling □ racketeering and extortion □ counterfeiting and piracy of products □ forgery of administrative documents and trafficking therein □ forgery of means of payment □ illicit trafficking in hormonal substances and other growth promoters □ illicit trafficking in nuclear or radioactive materials □ trafficking in stolen vehicles □ rape □ arson □ crimes within the jurisdiction of the International Criminal Court □ unlawful seizure of aircraft or ships □ sabotage

4. Any other relevant information (e.g. relation between the property and the criminal offence): … SECTION G: Where a confiscation certificate has been transmitted to more than one executing State, provide the following information: 1. A confiscation certificate has been transmitted to the following other executing State(s) (State and authority): … … 2. A confiscation certificate has been transmitted to more than one executing State for the following reasons: Where the confiscation order concerns specific items of property: □ Different items of property covered by the order are believed to be located in different executing States □ The confiscation of a specific item of property requires action in more than one executing State Where the confiscation order concerns an amount of money: □ The property concerned has not been frozen under Regulation (EU) 2018/1805 □ The estimated value of the property which may be confiscated in the issuing State and in any one executing State is not likely to be sufficient for the confiscation of the full amount covered by the order □ Other specific needs: … 3. Value of assets, if known, in each executing State: … …

4. Where the confiscation of the specific item(s) of property requires action in more than one executing State, description of the action to be taken in the executing State: … SECTION H: Proceedings resulting in the confiscation order Please indicate if the person against whom the confiscation order was issued appeared in person at the trial that resulted in the confiscation order linked to a final conviction: 1. □ Yes, the person appeared in person at the trial.

2. □ No, the person did not appear in person at the trial 3. □ No, in accordance with national procedural rules there were no hearings held.

4. If you have ticked the box under point 2, please confirm the existence of one of the following: 4.1a.□ the person was summoned in person on (day/month/year) … and thereby informed of the scheduled date and place of the trial that resulted in the confiscation order and was informed that a confiscation order could be handed down if he or she does not appear at the trial OR 4.1b.□ the person was not summoned in person but actually received, by other means, official information of the scheduled date and place of the trial that resulted in the confiscation order, in such a manner that it was established unequivocally that he or she was aware of the scheduled trial, and was informed that a confiscation order may be handed down if he or she does not appear at the trial OR 4.2.□ being aware of the scheduled trial, the person had given a mandate to a lawyer, who was either appointed by the person concerned or by the state, to defend him or her at the trial, and was actually defended by that lawyer at the trial OR 4.3.□ □ the person was served with the confiscation order on (day/month/year) … and was expressly informed about the right to a retrial or an appeal, in which he or she had the right to participate and which allowed a re-examination of the merits of the case including an examination of fresh evidence, and which could lead to the original confiscation order being reversed, and □ the person expressly stated that he or she did not contest the confiscation order OR □ the person did not request a retrial or appeal within the applicable time limits

5. If you have ticked the box under points 4.1b, 4.2 or 4.3, please provide information about how the relevant condition has been met: … SECTION I: Alternative measures, including custodial sanctions 1. Please indicate whether the issuing State allows for the application by the executing State of alternative measures where it is not possible to execute the confiscation order, either wholly or partially: □ Yes □ No 2. If yes, state which measures may be applied: □ Custody (maximum period): … □ Community service (or equivalent) (maximum period): … □ Other measures (description): … SECTION J: Decision to restitute property to, or compensate, the victim

1. Please indicate, where relevant: □ An issuing authority or another competent authority of the issuing State has issued a decision to compensate the victim with, or restitute to the victim, the following sum of money: … □ An issuing authority or another competent authority of the issuing State has issued a decision to restitute the following property other than money to the victim: … □ Proceedings to restitute property to, or compensate, the victim are pending in the issuing State and the outcome will be communicated to the executing authority 2. Details of the decision to restitute property to, or compensate, the victim: Authority that issued the decision (official name): … Date of the decision: … Date on which the decision became final: … Reference number of the decision (if available): … Description of the property to be restituted: … Name of the victim: … Address of the victim: … The issuing authority shall be notified in case of direct transfer to the victim. SECTION K: Details of the issuing authority Name of authority: … Name of the contact person: … Post held (title/grade): … File No: … Address: … Tel. No (country code) (area/city code): …

Fax No (country code) (area/city code): … Email: … Languages in which it is possible to communicate with the issuing authority: … If different from above, the contact details of the person(s) to contact for additional information or to make practical arrangements for the execution of the order or the transfer of the property: … Name/Title/Organisation: … Address: … Email/Tel. No: … Signature of the issuing authority and/or its representative certifying the content of the confiscation certificate as accurate and correct: … Name: … Post held (title/grade): … Date: … Official stamp (if available): … SECTION L: Central authority Where a central authority has been made responsible for the administrative transmission and reception of confiscation certificates in the issuing State, please indicate: Name of the central authority: … Name of the contact person: … Post held (title/grade): … File No: … Address: … Tel. No (country code) (area/city code): … Fax No (country code) (area/city code): … Email: … SECTION M: Payment details of the Issuing State IBAN: … BIC: … Name of bank account holder: … SECTION N: Attachments Please indicate any attachments to the certificate: