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CERTIFICATE CONCERNING AN AUTHENTIC INSTRUMENT OR AGREEMENT IN MATTERS OF PARENTAL RESPONSIBILITY (Point (b) 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 2 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 12.5 or 13.4. The certificate must not be issued if there are indications that the content of the authentic instrument or agreement is against the best interests of the child.

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 2 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 12) 4.2. Agreement (then please fill in point 13) 5. PARTIES TO THE AUTHENTIC INSTRUMENT OR AGREEMENT* 5.1. Party 1* 5.1.1. Natural person 5.1.1.1. Surname(s) 5.1.1.2. Given name(s) 5.1.1.3. Date of birth (dd/mm/yyyy) 5.1.1.4. Place of birth (if available) 5.1.1.5. Identity number or social security number (if applicable and available) 5.1.1.6. Address (if available) 5.1.1.6.1. as stated in the decision … 5.1.1.6.2. any additional information (for example, concerning a different current address) … 5.1.2. Legal person, institution or other body 5.1.2.1. Full name 5.1.2.2. Identification number (if applicable and available) 5.1.2.3. Address (if available) 5.2. Party 2 5.2.1. Natural person 5.2.1.1. Surname(s) 5.2.1.2. Given name(s) 5.2.1.3. Date of birth (dd/mm/yyyy) 5.2.1.4. Place of birth (if available) 5.2.1.5. Identity number or social security number (if applicable and available)

5.2.1.6. Address (if available) 5.2.1.6.1. as stated in the decision … 5.2.1.6.2. any additional information (for example, concerning a different current address) … 5.2.2. Legal person, institution or other body 5.2.2.1. Full name 5.2.2.2. Identification number (if applicable and available) 5.2.2.3. Address (if available) 6. CHILD(REN) COVERED BY THE AUTHENTIC INSTRUMENT OR AGREEMENT* 6.1. Child 1* 6.1.1. Surname(s)* 6.1.2. Given name(s)* 6.1.3. Date of birth (dd/mm/yyyy)* 6.1.4. Place of birth (if available) 6.1.5. Identity number or social security number (if applicable and available) 6.2. Child 2 6.2.1. Surname(s) 6.2.2. Given name(s) 6.2.3. Date of birth (dd/mm/yyyy) 6.2.4. Place of birth (if available) 6.2.5. Identity number or social security number (if applicable and available) 6.3. Child 3 6.3.1. Surname(s) 6.3.2. Given name(s) 6.3.3. Date of birth (dd/mm/yyyy) 6.3.4. Place of birth (if available) 6.3.5. Identity number or social security number (if applicable and available) 7. RIGHTS OF CUSTODY 7.1. Rights of custody attributed or agreed in the authentic instrument or agreement …… 7.2. Attributed to the following party(ies) 7.2.1. Party 1

7.2.1.1. Natural person 7.2.1.1.1. Surname(s) 7.2.1.1.2. Given name(s) 7.2.1.1.3. Date of birth (dd/mm/yyyy) 7.2.1.1.4. Place of birth (if available) 7.2.1.1.5. Identity number or social security number (if applicable and available) 7.2.1.1.6. Address (if available) 7.2.1.1.6.1. as stated in the decision … 7.2.1.1.6.2. any additional information (for example, concerning a different current address) … 7.2.1.2. Legal person, institution or other body 7.2.1.2.1. Full name 7.2.1.2.2. Identification number (if applicable and available) 7.2.1.2.3. Address (if available) 7.2.2. Party 2 7.2.2.1. Natural person 7.2.2.1.1. Surname(s) 7.2.2.1.2. Given name(s) 7.2.2.1.3. Date of birth (dd/mm/yyyy) 7.2.2.1.4. Place of birth (if available) 7.2.2.1.5. Identity number or social security number (if applicable and available) 7.2.2.1.6. Address (if available) 7.2.2.1.6.1. as stated in the decision … 7.2.2.1.6.2. any additional information (for example, concerning a different current address) … 7.2.2.2. Legal person, institution or other body 7.2.2.2.1. Full name 7.2.2.2.2. Identification number (if applicable and available) 7.2.2.2.3. Address (if available)

7.3. The authentic instrument or agreement 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. RIGHTS OF ACCESS 8.1. Rights of access attributed or agreed in the authentic instrument or agreement …… 8.2. Attributed to the following party(ies) 8.2.1. Party 1 8.2.1.1. Surname(s) 8.2.1.2. Given name(s) 8.2.1.3. Date of birth (dd/mm/yyyy) 8.2.1.4. Place of birth (if available) 8.2.1.5. Identity number or social security number (if applicable and available) 8.2.1.6. Address (if available) 8.2.1.6.1. as stated in the authentic instrument or agreement … 8.2.1.6.2. any additional information (for example, concerning a different current address) … 8.2.2. Party 2 8.2.2.1. Surname(s) 8.2.2.2. Given name(s) 8.2.2.3. Date of birth (dd/mm/yyyy) 8.2.2.4. Place of birth (where available) 8.2.2.5. Identity number or social security number (if applicable and available) 8.2.2.6. Address (if available) 8.2.2.6.1. as stated in the authentic instrument or agreement …

8.2.2.6.2. any additional information (for example, concerning a different current address) … 8.3. The authentic instrument or agreement 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. OTHER RIGHTS IN MATTERS OF PARENTAL RESPONSIBILITY 9.1. Right(s) attributed or agreed in the authentic instrument or agreement …… 9.2. Attributed to the following party(ies) 9.2.1. Party 1 9.2.1.1. Natural person 9.2.1.1.1. Surname(s) 9.2.1.1.2. Given name(s) 9.2.1.1.3. Date of birth (dd/mm/yyyy) 9.2.1.1.4. Place of birth (if available) 9.2.1.1.5. Identity number or social security number (if applicable and available) 9.2.1.1.6. Address (if available) 9.2.1.1.6.1. as stated in the decision … 9.2.1.1.6.2. any additional information (for example, concerning a different current address) … 9.2.1.2. Legal person, institution or other body 9.2.1.2.1. Full name 9.2.1.2.2. Identification number (if applicable and available) 9.2.1.2.3. Address (if available) 9.2.2. Party 2 9.2.2.1. Natural person

9.2.2.1.1. Surname(s) 9.2.2.1.2. Given name(s) 9.2.2.1.3. Date of birth (dd/mm/yyyy) 9.2.2.1.4. Place of birth (if available) 9.2.2.1.5. Identity number or social security number (if applicable and available) 9.2.2.1.6. Address (if available) 9.2.2.1.6.1. as stated in the decision … 9.2.2.1.6.2. any additional information (for example, concerning a different current address) … 9.2.2.2. Legal person, institution or other body 9.2.2.2.1. Full name 9.2.2.2.2. Identification number (if applicable and available) 9.2.2.2.3. Address (if available) 9.3. The authentic instrument or agreement entails the handover of the child(ren) 9.3.1. No 9.3.2. Yes 9.3.2.1. Details of the handover relevant for enforcement if not already indicated in point 9.1 (for example, to whom, which child(ren), periodical or single handover) …… 10. THE CHILD(REN) AS INDICATED IN POINT 6 WAS (WERE) CAPABLE OF FORMING HIS OR HER (THEIR) OWN VIEWS* 10.1. Child as indicated in point 6.1 10.1.1. Yes (then please fill in point 11) 10.1.2. No 10.2. Child as indicated in point 6.2 10.2.1. Yes (then please fill in point 11) 10.2.2. No 10.3. Child as indicated in point 6.3

10.3.1. Yes (then please fill in point 11) 10.3.2. No 11. THE CHILD(REN) CAPABLE OF FORMING HIS OR HER (THEIR) OWN VIEWS AS INDICATED IN POINT 10 WAS (WERE) GIVEN A GENUINE AND EFFECTIVE OPPORTUNITY TO EXPRESS HIS OR HER (THEIR) VIEWS 11.1. Child as indicated in point 6.1.

11.1.1. Yes 11.1.2. No, for the following reasons: … 11.2. Child as indicated in point 6.2.

11.2.1. Yes 11.2.2. No, for the following reasons: … 11.3. Child as indicated in point 6.3.

11.3.1. Yes 11.3.2. No, for the following reasons: … 12. AUTHENTIC INSTRUMENT 12.1. 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) 12.1.1. Name 12.1.2. Address 12.2. Date (dd/mm/yyyy) on which the authentic instrument was drawn up by the authority as indicated in point 3 or in point 12.1 12.3. Reference number of the authentic instrument (if applicable) 12.4. 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 12.2) 12.4.1. Reference number in the register (if applicable)

12.5. Date (dd/mm/yyyy) as of which the authentic instrument has binding legal effect in the Member State of origin 13. AGREEMENT 13.1. Public authority which registered the agreement (if different from the court or competent authority as indicated in point 3) 13.1.1. Name 13.1.2. Address 13.2. Date (dd/mm/yyyy) of registration of the agreement 13.3. Reference number in the register (if applicable) 13.4. Date (dd/mm/yyyy) as of which the agreement has binding legal effect in the Member State of origin 14. THE AUTHENTIC INSTRUMENT OR AGREEMENT IS ENFORCEABLE IN THE MEMBER STATE OF ORIGIN* 14.1. Concerning rights of custody as indicated in point 7 14.1.1. No 14.1.1.1. The authentic instrument or agreement does not contain an enforceable obligation.

14.1.2. Yes, without any restrictions (please indicate the date (dd/mm/yyyy) on which the authentic instrument or agreement became enforceable) …/…/…… 14.1.3. Yes, but only against the following party as indicated in point … (please fill in) … 14.1.4. Yes, but limited to the following part(s) of the authentic instrument or agreement (please specify) … 14.2. Concerning rights of access as indicated in point 8 14.2.1. No

14.2.1.1. The authentic instrument or agreement does not contain an enforceable obligation.

14.2.2. Yes, without any restrictions (please indicate the date (dd/mm/yyyy) on which the authentic instrument or agreement became enforceable) …/…/…… 14.2.3. Yes, but only against the following party as indicated in point … (please fill in) … 14.2.4. Yes, but limited to the following part(s) of the authentic instrument or agreement (please specify) … 14.3. Concerning other rights as indicated in point 9 14.3.1. No 14.3.1.1. The authentic instrument or agreement does not contain an enforceable obligation.

14.3.2. Yes, without any restrictions (please indicate the date (dd/mm/yyyy) on which the authentic instrument or agreement became enforceable) …/…/…… 14.3.3. Yes, but only against the following party as indicated in point … (please fill in) … 14.3.4. Yes, but limited to the following part(s) of the authentic instrument or agreement (please specify) … Done at …, date (dd/mm/yyyy) Signature and/or stamp