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CERTIFICATE CONCERNING DECISIONS ORDERING THE RETURN OF A CHILD TO ANOTHER MEMBER STATE PURSUANT TO THE 1980 HAGUE CONVENTION AND ANY PROVISIONAL, INCLUDING PROTECTIVE, MEASURES TAKEN IN ACCORDANCE WITH ARTICLE 27(5) OF THE REGULATION ACCOMPANYING THEM (Point (c) of Article 36(1) of Council Regulation (EU) 2019/1111 ) IMPORTANT To be issued, upon application by a party, by the court of a Member State of origin of a return decision as communicated to the Commission pursuant to Article 103 of the Regulation, where the return decision needs to be enforced in another Member State due to a further abduction of the child(ren) after return was ordered, or where the return decision contains a provisional, including a protective, measure based on Article 27(5) of the Regulation to protect the child from the grave risk referred to in point (b) of Article 13(1) of the 1980 Hague Convention.

1. MEMBER STATE OF ORIGIN OF THE DECISION ORDERING THE RETURN OF THE CHILD(REN)*

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) TO BE RETURNED ACCORDING TO 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. MEMBER STATE TO WHICH THE CHILD(REN) SHOULD BE RETURNED ACCORDING TO THE DECISION* 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) 7. IF AND TO THE EXTENT STATED IN THE DECISION, THE CHILD(REN) IS (ARE) TO BE RETURNED TO 7.1. Party 1 7.1.1. Natural person 7.1.1.1. Surname(s) 7.1.1.2. Given name(s) 7.1.1.3. Date of birth (dd/mm/yyyy) 7.1.1.4. Place of birth (if available) 7.1.1.5. Identity number or social security number (if applicable and available) 7.1.1.6. Address (if available) 7.1.1.6.1. as stated in the decision … 7.1.1.6.2. any additional information (for example, concerning a different current address) … 7.1.2. Legal person, institution or other body 7.1.2.1. Full name 7.1.2.2. Identification number (if applicable and available) 7.1.2.3. Address (if available) 7.2. Party 2

7.2.1. Natural person 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. Legal person, institution or other body 7.2.2.1. Full name 7.2.2.2. Identification number (if applicable and available) 7.2.2.3. Address (if available) 8. PRACTICAL ARRANGEMENTS FOR THE RETURN (IF AND TO THE EXTENT STATED IN THE DECISION) …… 9. THE DECISION INCLUDES (A) PROVISIONAL, INCLUDING PROTECTIVE, MEASURES BASED ON ARTICLE 27(5) OF THE REGULATION TO PROTECT THE CHILD FROM THE GRAVE RISK REFERRED TO IN POINT (B) OF ARTICLE 13(1) OF THE 1980 HAGUE CONVENTION* 9.1. No 9.2. Yes 9.2.1. Description of the measure(s) ordered …… 10. PARTY AGAINST WHOM ENFORCEMENT IS SOUGHT* 10.1. Surname(s)* 10.2. Given name(s)* 10.3. Date of birth (dd/mm/yyyy)* 10.4. Place of birth (if available) 10.5. Identity number or social security number (if applicable and available)

10.6. Address (if available) 10.6.1. as stated in the decision … 10.6.2. any additional information (for example, concerning a different current address) … 11. THE DECISION IS SUBJECT TO FURTHER APPEAL UNDER THE LAW OF THE MEMBER STATE OF ORIGIN* 11.1. No 11.2. Yes 12. THE DECISION IS ENFORCEABLE IN THE MEMBER STATE OF ORIGIN* 12.1. No 12.2. Yes, without any restrictions (please indicate the date (dd/mm/yyyy) on which the decision became enforceable): …/…/…… 12.3. Yes, but only against the party as indicated in point … (please fill in) 12.3.1. Please indicate the date (dd/mm/yyyy) on which the decision became enforceable against this party: …/…/…… 13. AS OF THE DATE OF ISSUANCE OF THE CERTIFICATE, THE DECISION HAS BEEN SERVED UPON THE PARTY(IES) AGAINST WHOM ENFORCEMENT IS SOUGHT AS INDICATED IN POINT 10* 13.1. No 13.2. Not known to the court 13.3. Yes 13.3.1. Date of service (dd/mm/yyyy) 13.3.2. 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 14. THE DECISION WAS GIVEN IN DEFAULT OF APPEARANCE* 14.1. No 14.2. Yes 14.2.1. Party in default of appearance as indicated in point …(please fill in)

14.2.2. That party was served with the document which instituted the proceedings or with an equivalent document 14.2.2.1. No 14.2.2.2. Not known to the court 14.2.2.3. Yes 14.2.2.3.1. Date of service (dd/mm/yyyy) 15. THE CHILD(REN) AS INDICATED IN POINT 5 WAS (WERE) CAPABLE OF FORMING HIS OR HER (THEIR) OWN VIEWS* 15.1. Child as indicated in point 5.1.

15.1.1. Yes (then please fill in point 16) 15.1.2. No 15.2. Child as indicated in point 5.2.

15.2.1. Yes (then please fill in point 16) 15.2.2. No 15.3. Child as indicated in point 5.3.

15.3.1. Yes (then please fill in point 16) 15.3.2. No 16. THE CHILD(REN) CAPABLE OF FORMING HIS OR HER (THEIR) OWN VIEWS AS INDICATED IN POINT 15 WAS (WERE) GIVEN A GENUINE AND EFFECTIVE OPPORTUNITY TO EXPRESS HIS OR HER (THEIR) VIEWS IN ACCORDANCE WITH ARTICLE 21 OF THE REGULATION 16.1. Child as indicated in point 5.1 16.1.1. Yes 16.1.2. No, for the following reasons:… 16.2. Child as indicated in point 5.2 16.2.1. Yes 16.2.2. No, for the following reasons:… 16.3. Child as indicated in point 5.3 16.3.1. Yes 16.3.2. No, for the following reasons: …

17. NAME(S) OF PARTY(IES) WHO BENEFITED FROM LEGAL AID IN ACCORDANCE WITH ARTICLE 74(1) OF THE REGULATION 17.1. Party(ies) 17.1.1. as indicated in point … (please fill in) 17.1.2. as indicated in point … (please fill in) 18. COSTS AND EXPENSES OF THE PROCEEDINGS 18.1. 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)): 18.2. Any additional information on costs 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): … If additional pages have been attached, please state the number of pages: … Done at …, date (dd/mm/yyyy) …. Signature and/or stamp