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EXTRACT FROM AN AUTHENTIC INSTRUMENT IN MATTERS RELATING TO MAINTENANCE OBLIGATIONS SUBJECT TO PROCEEDINGS FOR RECOGNITION AND A DECLARATION OF ENFORCEABILITY (Articles 48 and 75(2) of Council Regulation (EC) No 4/2009 of 18 December 2008 on jurisdiction, applicable law, recognition and enforcement of decisions and cooperation in matters relating to maintenance obligations ()) IMPORTANT To be issued by the competent authority in the Member State of origin To be issued only if the authentic instrument is enforceable in the Member State of origin Mention only information which is given in the authentic instrument or of which the competent authority has been made aware 1. DATE AND REFERENCE NUMBER OF THE AUTHENTIC INSTRUMENT: …

2. NATURE OF THE AUTHENTIC INSTRUMENT 2.1.  Instrument formally drawn up or registered on: … (dd/mm/yyyy)  Agreement concluded or authenticated on: … (dd/mm/yyyy) 2.2. Competent authority: 2.2.1. Name: … 2.2.2. Address: 2.2.2.1. Street and number/PO box: … 2.2.2.2. Place and postal code: … 2.2.2.3. Member State:  Belgium  Bulgaria  Czech Republic  Denmark  Germany  Estonia Ireland  Greece  Spain  France  Croatia  Italy  Cyprus  Latvia  Lithuania  Luxembourg  Hungary  Malta  Netherlands  Austria  Poland  Portugal  Romania  Slovenia  Slovakia  Finland  Sweden  United Kingdom 2.2.3. Telephone/Fax/E-mail: …

3. CREDITOR(S) ()3.1. Person A 3.1.1. Surname and given name(s): … 3.1.2. Date (dd/mm/yyyy) and place of birth: … 3.1.3. Identity number or social security number: … 3.1.4. Address: 3.1.4.1. Street and number/PO box: … 3.1.4.2. Place and postal code: … 3.1.4.3. Country: … 3.2. Person B 3.2.1. Surname and given name(s): … 3.2.2. Date (dd/mm/yyyy) and place of birth: … 3.2.3. Identity number or social security number: … 3.2.4. Address: 3.2.4.1. Street and number/PO box: … 3.2.4.2. Place and postal code: … 3.2.4.3. Country: … 3.3. Person C 3.3.1. Surname and given name(s): … 3.3.2. Date (dd/mm/yyyy) and place of birth: … 3.3.3. Identity number or social security number: … 3.3.4. Address: 3.3.4.1. Street and number/PO box: … 3.3.4.2. Place and postal code: … 3.3.4.3. Country: …

4. DEBTOR(S) ()4.1. Person A 4.1.1. Surname and given name(s): … 4.1.2. Date (dd/mm/yyyy) and place of birth: … 4.1.3. Identity number or social security number: … 4.1.4. Address: 4.1.4.1. Street and number/PO box: … 4.1.4.2. Place and postal code: … 4.1.4.3. Country: … 4.2. Person B 4.2.1. Surname and given name(s): … 4.2.2. Date (dd/mm/yyyy) and place of birth: … 4.2.3. Identity number or social security number: … 4.2.4. Address: 4.2.4.1. Street and number/PO box: … 4.2.4.2. Place and postal code: … 4.2.4.3. Country: … 4.3. Person C 4.3.1. Surname and given name(s): … 4.3.2. Date (dd/mm/yyyy) and place of birth: … 4.3.3. Identity number or social security number: … 4.3.4. Address: 4.3.4.1. Street and number/PO box: … 4.3.4.2. Place and postal code: … 4.3.4.3. Country: …

5. CONTENTS OF THE AUTHENTIC INSTRUMENT5.1. Currency  Euro (EUR)  Lev (BGN)  Czech koruna (CZK)  Danish krone (DKK)  Pound sterling (GBP)  Kuna (HRK)  Forint (HUF)  Zloty (PLN)  Leu (RON)  Krona (SEK)  Other (please specify ISO code): … 5.2. Maintenance claim () 5.2.1. Maintenance claim A 5.2.1.1. The maintenance is to be paid by … (surname and given name(s)) to … (surname and given name(s) of the person to whom the sum must actually be paid) Person for whom maintenance is owed: … (surname and given name(s)) 5.2.1.2.  Amount to be paid in one sum Period covered, where applicable: … (from date (dd/mm/yyyy) to date (dd/mm/yyyy) or event) Due date: … (dd/mm/yyyy) Amount: … 5.2.1.3.  Amount to be paid in instalments 5.2.1.4.  Sum to be paid regularly  Once a week  Once a month  Other (state frequency): … Amount: … From: … (dd/mm/yyyy) Due day/date: …  If applicable, until (date (dd/mm/yyyy) or event): … If the maintenance claim is subject to indexation, please indicate how that indexation is to be calculated: … … Indexation applicable as from: … (dd/mm/yyyy) 5.2.1.5.  Amount due retroactively Period covered: … ((dd/mm/yyyy) to (dd/mm/yyyy)) Amount: … Form of payment: … … … 5.2.1.6.  Interest (if specified in the authentic instrument) If the maintenance claim is subject to interest, please indicate the rate: … … Interest due as from: … (dd/mm/yyyy) 5.2.1.7.  Payment in kind (please specify): … … … … 5.2.1.8.  Other form of payment (please specify): … … … … 5.2.2. Maintenance claim B 5.2.2.1. The maintenance is to be paid by … (surname and given name(s)) to … (surname and given name(s) of the person to whom the sum must actually be paid) … Person for whom maintenance is owed: … (surname and given name(s)) 5.2.2.2.  Amount to be paid in one sum Period covered, where applicable: … (from date (dd/mm/yyyy) to date (dd/mm/yyyy) or event) Due date: … (dd/mm/yyyy) Amount: … 5.2.2.3.  Amount to be paid in instalments 5.2.2.4.  Sum to be paid regularly  Once a week  Once a month  Other (state frequency): … Amount: … From: … (dd/mm/yyyy) Due day/date: …  If applicable, until (date (dd/mm/yyyy) or event): … If the maintenance claim is subject to indexation, please indicate how that indexation is to be calculated: … Indexation applicable as from: … (dd/mm/yyyy) 5.2.2.5.  Amount due retroactively Period covered: … ((dd/mm/yyyy) to (dd/mm/yyyy)) Amount: … Form of payment: … … … 5.2.2.6.  Interest (if specified in the authentic instrument) If the maintenance claim is subject to interest, please indicate the rate: … Interest due as from: … (dd/mm/yyyy) 5.2.2.7.  Payment in kind (please specify): … … … … 5.2.2.8.  Other form of payment (please specify): … … … … 5.2.3. Maintenance claim C 5.2.3.1. The maintenance is to be paid by … (surname and given name(s)) to … (surname and given name(s) of the person to whom the sum must actually be paid) … Person for whom maintenance is owed: … (surname and given name(s)) 5.2.3.2.  Amount to be paid in one sum Period covered, where applicable: … (from date (dd/mm/yyyy) to date (dd/mm/yyyy) or event) Due date: … (dd/mm/yyyy) Amount: … 5.2.3.3.  Amount to be paid in instalments 5.2.3.4.  Sum to be paid regularly  Once a week  Once a month  Other (state frequency): … Amount: … From: … (dd/mm/yyyy) Due day/date: …  If applicable, until (date (dd/mm/yyyy) or event): … If the maintenance claim is subject to indexation, please indicate how that indexation is to be calculated: … … Indexation applicable as from: … (dd/mm/yyyy) 5.2.3.5.  Amount due retroactively Period covered: … ((dd/mm/yyyy) to (dd/mm/yyyy)) Amount: … Form of payment: … … … 5.2.3.6.  Interest (if specified in the authentic instrument) If the maintenance claim is subject to interest, please indicate the rate: … Interest due as from: … (dd/mm/yyyy) 5.2.3.7.  Payment in kind (please specify): … … … … 5.2.3.8.  Other form of payment (please specify): … … … … 5.3. Costs The authentic instrument provides that … (surname and given name(s)) must pay the sum of … to … (surname and given name(s)).

If additional pages have been attached, state the number of pages: … Done at: … on: … (dd/mm/yyyy) Signature and/or stamp of the competent authority: …