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REQUEST FOR SPECIFIC MEASURES (Article 53 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 ()) PART A To be completed by the requesting Central Authority 1. REQUESTING CENTRAL AUTHORITY 1.1. Name: … 1.2. Address: 1.2.1. Street and number/PO box: … 1.2.2. Place and postal code: … 1.2.3. Member State  Belgium  Bulgaria  Czech Republic  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 1.3. Telephone: … 1.4. Fax … 1.5. E-mail: … 1.6. Reference number: … 1.7. Person responsible for following up the request: 1.7.1. Surname and given name(s): … 1.7.2. Telephone: … 1.7.3. E-mail: … 2. REQUESTED CENTRAL AUTHORITY 2.1. Name: …

2.2. Address: 2.2.1. Street and number/PO box: … 2.2.2. Place and postal code: … 2.2.3. Member State  Belgium  Bulgaria  Czech Republic  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 3. REQUEST 3.1. The purpose of the specific measure requested is to: 3.1.1.  help locate the debtor or the creditor (see points 3.3. and 3.4.) 3.1.2.  facilitate the search for information on the income or assets of the debtor or the creditor (see points 3.3. and 3.4.) 3.1.3.  facilitate the obtaining of documentary or other evidence 3.1.4.  obtain assistance in establishing parentage 3.1.5.  initiate or facilitate the institution of proceedings to obtain a necessary provisional measure which is territorial in nature 3.1.6.  facilitate service of a document 3.2. Grounds for the request: … … … … … 3.3. The information requested relates to:

3.3.1.  the following debtor 3.3.1.1. Surname and given name(s): … 3.3.1.2. Date (dd/mm/yyyy) and place of birth (): … 3.3.1.3. Last known address: … 3.3.1.4. Identity number or social security number (): … 3.3.1.5. Any other information which may be useful (): … … 3.3.2.  the following creditor 3.3.2.1. Surname and given name(s): … 3.3.2.2. Date (dd/mm/yyyy) and place of birth (): … 3.3.2.3. Last known address: … 3.3.2.4. Identity number or social security number (): … 3.3.2.5. Any other information which may be useful (): … … 3.4. Information requested 3.4.1.  Current address of the debtor/creditor 3.4.2.  Income of the debtor/creditor 3.4.3.  Assets of the debtor/creditor, including the location of the assets of the debtor/creditor The creditor has produced a copy of the decision, court settlement or authentic instrument to be enforced, if appropriate accompanied by the relevant form.  There is a risk that notifying the person concerned by the collection of this information may prejudice the effective recovery of the maintenance claim (Article 63(2) of Regulation (EC) No 4/2009). Done at …, on … (dd/mm/yyyy)

Name and signature of the authorised official of the requesting Central Authority: … PART B To be completed by the requested Central Authority 4. REFERENCE NUMBER OF THE REQUESTED CENTRAL AUTHORITY: 5. PERSON RESPONSIBLE FOR FOLLOWING UP THE REQUEST: … 5.1. Surname and given name(s): … 5.2. Telephone: … 5.3. Fax … 5.4. E-mail: … 6. MEASURES TAKEN AND RESULTS OBTAINED … … … … 7. INFORMATION COLLECTED: 7.1. Without recourse to Articles 61, 62 and 63 of Regulation (EC) No 4/2009: 7.1.1. Debtor’s/creditor’s address: … … 7.1.2. Debtor’s/creditor’s revenue: … … 7.1.3. Debtor’s/creditor’s assets: … … 7.2. Pursuant to Articles 61, 62 and 63 of Regulation (EC) No 4/2009: 7.2.1. Debtor’s/creditor’s address: … … … 7.2.2. Existence of debtor’s income: 7.2.3. Existence of debtor’s assets: IMPORTANT (In the event of the application of Articles 61, 62 and 63 of Regulation (EC) No 4/2009)

Except for information merely indicating the existence of an address, income or assets in the requested Member State, the information referred to in Article 61(1) may not be disclosed to the person having applied to the requesting Central Authority, subject to the application of procedural rules before a court (Article 62(2), second subparagraph, of Regulation (EC) No 4/2009).

8. INABILITY TO COMMUNICATE THE REQUESTED INFORMATION The requested Central Authority is not able to provide the information requested, for the following reasons: … … … Done at …, on … (dd/mm/yyyy) Name and signature of the authorised official of the requested Central Authority: …