Council Regulation (EC) No 4/2009Show full title

ANNEX II

EXTRACT FROM A DECISION/COURT SETTLEMENT IN MATTERS RELATING TO MAINTENANCE OBLIGATIONS SUBJECT TO PROCEEDINGS FOR RECOGNITION AND A DECLARATION OF ENFORCEABILITY

(Article 28 and Article 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(1))

IMPORTANT

To be issued by the court of origin

To be issued only if the decision or court settlement is enforceable in the Member State of origin

Mention only information which is given in the decision or court settlement or of which the court of origin has been made aware

1. Nature of the document



Decision



Court settlement

Date and reference number: …

2. Court of origin

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  Italy  Cyprus  Latvia  Lithuania  Luxembourg  Hungary  Malta  Netherlands  Austria  Poland  Portugal  Romania  Slovenia  Slovakia  Finland  Sweden

2.3. Telephone/Fax/E-mail: …

3. Claimant(s)(2) (3)

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: …

3.1.5.

Has benefited from

3.1.5.1. legal aid:



Yes



No

3.1.5.2. exemption from costs and expenses:



Yes



No

3.1.5.3. free proceedings before an administrative authority listed in Annex X of Regulation (EC) No 4/2009:



Yes



No

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: …

3.2.5.

Has benefited from

3.2.5.1. legal aid:



Yes



No

3.2.5.2. exemption from costs and expenses:



Yes



No

3.2.5.3. free proceedings before an administrative authority listed in Annex X of Regulation (EC) No 4/2009:



Yes



No

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: …

3.3.5.

Has benefited from

3.3.5.1. legal aid:



Yes



No

3.3.5.2. exemption from costs and expenses:



Yes



No

3.3.5.3. free proceedings before an administrative authority listed in Annex X of Regulation (EC) No 4/2009:



Yes



No

4. Defendant(s)(2) (3)

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: …

4.1.5.

Has benefited from

4.1.5.1. legal aid:



Yes



No

4.1.5.2. exemption from costs and expenses:



Yes



No

4.1.5.3. free proceedings before an administrative authority listed in Annex X of Regulation (EC) No 4/2009:



Yes



No

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: …

4.2.5.

Has benefited from

4.2.5.1. legal aid:



Yes



No

4.2.5.2. exemption from costs and expenses:



Yes



No

4.2.5.3. free proceedings before an administrative authority listed in Annex X of Regulation (EC) No 4/2009:



Yes



No

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: …

4.3.5.

Has benefited from

4.3.5.1. legal aid:



Yes



No

4.3.5.2. exemption from costs and expenses:



Yes



No

4.3.5.3. free proceedings before an administrative authority listed in Annex X of Regulation (EC) No 4/2009:



Yes



No

5. Terms of the decision/court settlement

5.1. Currency

 Euro (EUR)  Bulgarian lev (BGN)  Czech koruna (CZK)  Estonian kroon (EEK)  Hungarian forint (HUF)  Lithuanian litas (LTL)  Latvian lats (LVL)  Polish zloty (PLN)  Romanian leu (RON)  Swedish krona (SEK)  Other (please specify ISO code): …

5.2. Maintenance claim(4)

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

…

(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

Due date(dd/mm/yyyy)	Amount

5.2.1.4.

 Sum to be paid regularly

• Once a week

• Once a month

• Other (state frequency): …

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

Amount: …

Form of payment: …

…

…

5.2.1.6.

 Interest (if specified in the decision/court settlement)

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

…

(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

Due date(dd/mm/yyyy)	Amount

5.2.2.4.

 Sum to be paid regularly

• Once a week

• Once a month

• Other (state frequency): …

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

Amount: …

Form of payment: …

…

…

5.2.2.6.

 Interest (if specified in the decision/court settlement)

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

…

(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

Due date(dd/mm/yyyy)	Amount

5.2.3.4.

 Sum to be paid regularly

• Once a week

• Once a month

• Other (state frequency): …

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

Amount: …

Form of payment: …

…

…

5.2.3.6.

 Interest (if specified in the decision/court settlement)

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 and expenses

The decision/court settlement 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 court of origin:

…

(1)

OJ L 7, 10.1.2009, p. 1.

(2)

If the parties are not the claimant or defendant in the decision/court settlement, they should be identified as either the claimant or the defendant without distinction.

(3)

If the decision/court settlement concerns more than three claimants or three defendants, attach an additional sheet.

(4)

If the decision/court settlement concerns more than three maintenance claims, attach an additional sheet