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CERTIFICATE CONCERNING AN AUTHENTIC INSTRUMENT OR AN AGREEMENT ON DIVORCE OR LEGAL SEPARATION (Point (a) of Article 66(1) of Council Regulation (EU) 2019/1111 ). IMPORTANT To be issued, upon application by a party, only if the Member State which empowered the public authority or other authority to formally draw up or register the authentic instrument or register the agreement had jurisdiction under Section 1 of Chapter II of the Regulation, as indicated in point 2, and the authentic instrument or agreement has binding legal effect in that Member State, as indicated in point 7.5 or 8.4.

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. THE MEMBER STATE OF ORIGIN HAD JURISDICTION UNDER SECTION 1 OF CHAPTER II OF THE REGULATION* 2.1. Yes 3. COURT OR COMPETENT AUTHORITY ISSUING THE CERTIFICATE* 3.1. Name* 3.2. Address* 3.3. Tel./fax/e-mail*

4. NATURE OF THE DOCUMENT* 4.1. Authentic instrument (then please fill in point 7) 4.2. Agreement (then please fill in point 8) 5. OBJECT OF THE AUTHENTIC INSTRUMENT OR AGREEMENT* 5.1. Divorce 5.2. Legal separation 6. MARRIAGE* 6.1. Spouses* 6.1.1.

6.1.1.1. Surname(s)* 6.1.1.2. Given name(s)* 6.1.1.3. Date of birth (dd/mm/yyyy)* 6.1.1.4. Place of birth 6.1.1.5. Identity number or social security number (if applicable and available) 6.1.1.6. Address (if available) 6.1.1.6.1. as stated in the authentic instrument or agreement … 6.1.1.6.2. any additional information (for example, concerning a different current address) … 6.1.2.

6.1.2.1. Surname(s)* 6.1.2.2. Given name(s)* 6.1.2.3. Date of birth (dd/mm/yyyy)* 6.1.2.4. Place of birth 6.1.2.5. Identity number or social security number (if applicable and available) 6.1.2.6. Address (if available) 6.1.2.6.1. as stated in the authentic instrument or agreement … 6.1.2.6.2. any additional information (for example, concerning a different current address) … 6.2. Date, country and place of marriage* 6.2.1. Date (dd/mm/yyyy)* 6.2.2. Country* 6.2.3. Place (if available) 7. AUTHENTIC INSTRUMENT

7.1. Public authority or other authority empowered for that purpose which has drawn up or registered the authentic instrument (if different from court or competent authority as indicated in point 3) 7.1.1. Name 7.1.2. Address 7.2. Date (dd/mm/yyyy) on which the authentic instrument was drawn up by the authority as indicated in point 3 or in point 7.1 7.3. Reference number of the authentic instrument (if applicable) 7.4. Date (dd/mm/yyyy) on which the authentic instrument was registered in the Member State of origin (if different from the date indicated in point 7.2) 7.4.1. Reference number in the register (if applicable) 7.5. Date (dd/mm/yyyy) as of which the authentic instrument has binding legal effect in the Member State of origin 8. AGREEMENT 8.1. Public authority which registered the agreement (if different from the court or competent authority as indicated in point 3) 8.1.1. Name 8.1.2. Address 8.2. Date (dd/mm/yyyy) of registration of the agreement 8.3. Reference number in the register (if applicable) 8.4. Date (dd/mm/yyyy) as of which the agreement has binding legal effect in the Member State of origin Done at …, date (dd/mm/yyyy) Signature and/or stamp