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CERTIFICATE CONCERNING CERTAIN DECISIONS GRANTING RIGHTS OF ACCESS (Point (a) of Article 42(1) and point (a) of Article 47(1) of Council Regulation (EU) 2019/1111 ) IMPORTANT To be issued, upon application by a party, by the court that has given the decision only if the conditions of Article 47(3) of the Regulation, as indicated in points 11 to 14, are met. If not, Annex III of the Regulation should be used.

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 WHICH GAVE THE DECISION AND IS ISSUING THE CERTIFICATE* 2.1. Name* 2.2. Address* 2.3. Tel./fax/e-mail* 3. DECISION* 3.1. Date (dd/mm/yyyy)* 3.2. Reference number* 4. CHILD(REN) COVERED BY THE DECISION* 4.1. Child 1* 4.1.1. Surname(s)* 4.1.2. Given name(s)* 4.1.3. Date of birth (dd/mm/yyyy)* 4.1.4. Place of birth (if available)

4.1.5. Identity number or social security number (if applicable and available) 4.2. Child 2 4.2.1. Surname(s) 4.2.2. Given name(s) 4.2.3. Date of birth (dd/mm/yyyy) 4.2.4. Place of birth (if available) 4.2.5. Identity number or social security number (if applicable and available) 4.3. Child 3 4.3.1. Surname(s) 4.3.2. Given name(s) 4.3.3. Date of birth (dd/mm/yyyy) 4.3.4. Place of birth (if available) 4.3.5. Identity number or social security number (if applicable and available) 5. PARTY(IES) WHO WAS (WERE) GRANTED RIGHTS OF ACCESS* 5.1. Party 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) 5.1.6. Address (if available) 5.1.6.1. as stated in the decision … 5.1.6.2. any additional information (for example, concerning a different current address) … 5.2. Party 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) 5.2.6. Address (if available) 5.2.6.1. as stated in the decision …

5.2.6.2. any additional information (for example, concerning a different current address) … 6. RIGHTS OF ACCESS GRANTED ACCORDING TO THE DECISION AND PRACTICAL ARRANGEMENTS FOR THEIR EXERCISE (TO THE EXTENT STATED IN THE DECISION) …… 7. PARTY(IES) AGAINST WHOM ENFORCEMENT IS SOUGHT* 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. THE DECISION IS SUBJECT TO FURTHER APPEAL UNDER THE LAW OF THE MEMBER STATE OF ORIGIN* 8.1. No 8.2. Yes 9. THE DECISION IS ENFORCEABLE IN THE MEMBER STATE OF ORIGIN* 9.1. No 9.2. Yes, without any restrictions (please indicate the date (dd/mm/yyyy) on which the decision became enforceable): …/…/…… 9.3. Yes, but only against the party as indicated in point … (please fill in) 9.3.1. Please indicate the date (dd/mm/yyyy) on which the decision became enforceable against this party: …/…/…… 9.4. Yes, but limited to the following part(s) of the decision (please specify) … 9.4.1. Please indicate the date (dd/mm/yyyy) on which this (these) part(s) of the decision became enforceable: …/…/…… 10. AS OF THE DATE OF ISSUANCE OF THE CERTIFICATE, THE DECISION HAS BEEN SERVED UPON THE PARTY(IES) AGAINST WHOM ENFORCEMENT IS SOUGHT* 10.1. Upon the party as indicated in point 7.1* 10.1.1. No 10.1.2. Not known to the court 10.1.3. Yes

10.1.3.1. Date of service (dd/mm/yyyy) 10.1.3.2. 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 10.2. Upon the party as indicated in point 7.2 10.2.1. No 10.2.2. Not known to the court 10.2.3. Yes 10.2.3.1. Date of service (dd/mm/yyyy) 10.2.3.2. 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 11. ALL PARTIES CONCERNED WERE GIVEN AN OPPORTUNITY TO BE HEARD* 11.1. Yes (if not, Annex III of the Regulation should be used) 12. THE CHILD(REN) AS INDICATED IN POINT 4 WAS (WERE) CAPABLE OF FORMING HIS OR HER (THEIR) OWN VIEWS* 12.1. Child as indicated in point 4.1 12.1.1. Yes (then please fill in point 13) 12.1.2. No 12.2. Child as indicated in point 4.2 12.2.1. Yes (then please fill in point 13) 12.2.2. No 12.3. Child as indicated in point 4.3 12.3.1. Yes (then please fill in point 13) 12.3.2. No 13. THE CHILD(REN) CAPABLE OF FORMING HIS OR HER (THEIR) OWN VIEWS AS INDICATED IN POINT 12 WAS (WERE) GIVEN A GENUINE AND EFFECTIVE OPPORTUNITY TO EXPRESS HIS OR HER (THEIR) VIEWS IN ACCORDANCE WITH ARTICLE 21 OF THE REGULATION

13.1. Child as indicated in point 4.1 13.1.1. Yes (if not, Annex III of the Regulation should be used) 13.2. Child as indicated in point 4.2 13.2.1. Yes (if not, Annex III of the Regulation should be used) 13.3. Child as indicated in point 4.3 13.3.1. Yes (if not, Annex III of the Regulation should be used) 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 in sufficient time and in such a way as to enable that (those) party(ies) to arrange for his or her (their) defence 14.2.2.1. Yes 14.2.2.1.1. Date of service (dd/mm/yyyy) 14.2.2.2. No, but the party in default of appearance nevertheless accepted the decision unequivocally (if not, Annex III of the Regulation should be used) 15. NAME(S) OF PARTY(IES) WHO BENEFITED FROM LEGAL AID IN ACCORDANCE WITH ARTICLE 74(1) OF THE REGULATION 15.1. Party(ies) 15.1.1. as indicated in point … (please fill in) 15.1.2. as indicated in point … (please fill in) 16. COSTS AND EXPENSES OF THE PROCEEDINGS

16.1. The decision also covers matrimonial matters, and the information on costs relating to the proceedings under this Regulation is provided solely in the certificate concerning decisions in matrimonial matters.

16.2. The decision also covers other 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.

16.3. 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)): 16.4. 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) …

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