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FORM referred to in Article 12 of DIRECTIVE 2011/99/EU OF THE EUROPEAN PARLIAMENT AND OF THE COUNCIL OF 13 DECEMBER 2011 ON THE EUROPEAN PROTECTION ORDER NOTIFICATION OF A BREACH OF THE MEASURE TAKEN ON THE BASIS OF THE EUROPEAN PROTECTION ORDER The information contained in this form is to be treated with appropriate confidentiality (a) Details of the identity of the person causing danger: Surname: Forename(s): Maiden or previous name, where applicable: Aliases, where applicable: Sex: Nationality: Identity number or social security number (if any): Date of birth: Place of birth: Address: Language(s) understood (if known):

(b) Details of the identity of the protected person: Surname: Forename(s): Maiden or previous name, where applicable: Sex: Nationality: Date of birth: Place of birth: Address: Language(s) understood (if known):

(c) Details of the European protection order: Order issued on: File reference (if any): Authority which issued the order: Official name: Address:

(d) Details of the authority responsible for the execution of the protection measure, if any, which was taken in the executing State in line with the European protection order: Official name of the authority: Name of the person to be contacted: Position (title/grade): Address: Tel. No (country code) (area code) (number): Fax No (country code) (area code) (number): E-mail: Languages that may be used for communication:

(e) Breach of the prohibition(s) or restriction(s) imposed by the competent authorities of the executing State following recognition of the European protection order and/or other findings which could result in taking any subsequent decision: The breach concerns the following prohibition(s) or restriction(s) (more than one box may be ticked): a prohibition from entering certain localities, places or defined areas where the protected person resides or visits; a prohibition or regulation of contact, in any form, with the protected person, including by phone, electronic or ordinary mail, fax or any other means; a prohibition or regulation on approaching the protected person closer than a prescribed distance; any other measure, corresponding to the protection measure at the basis of the European protection order, taken by the competent authorities of the executing State following recognition of the European protection order Description of the breach(es) (place, date and specific circumstances): In accordance with Article 11(2):

— measures taken in the executing State as a consequence of the breach:

— possible legal consequence of the breach in the executing State: Other findings which could result in taking any subsequent decision Description of the findings:

(f) Details of the person to be contacted if additional information is to be obtained concerning the breach: Surname: Forename(s): Address: Tel. No (country code) (area/city code) (number): Fax No (country code) (area/city code) (number): E-mail: Languages that may be used for communication: Signature of the authority issuing the form and/or its representative, to confirm that the contents of the form are correct: Name: Position (title/grade): Date: Official stamp (where applicable):