The elements put in Italic are optional. It is suggested to remove subsections that are not selected.    ,
    Where this form is transmitted by electronic means, its structure and lay-out may be adapted to the requirements and possibilities of the electronic communication system, provided that the set of data and information contained therein is not substantially altered.    ,
 Name of the language(s) of this document ,
Declaration specifying reasons and circumstances for a request for precautionary measures  ,
 based on: ,   Article 16 of Directive 2010/24/EU     …  ,
This declaration is linked to the request for precautionary measures,
with the following reference:,Ref. …,
sent by the following applicant State:,,
to the following requested State:,,
  1.   General information   ,
,  1.1.    The claim(s) is (are) the subject of an instrument permitting enforcement in the applicant State which is contested.    ,
,  1.2.    The claim(s) is (are) the subject of an instrument permitting enforcement in the applicant State which is not contested.    ,
,  1.3.    The claim(s) is (are) not yet subject of an instrument permitting enforcement in the applicant State.    ,
,  1.4.    The claim(s) is (are) not contested.    ,
,  1.5.    The claim(s) may no longer be contested by and administrative appeal/by an appeal to the courts.    ,
,  1.6.    The claim(s) is (are) contested but the laws, regulations and administrative practices in force in the State of the applicant authority allow to take precautionary measures.    ,
  2.   Justifying documents and/or reasons   ,
,  2.1.   This request is accompanied by a uniform instrument permitting recovery in the requested State.     Note: this uniform instrument permitting enforcement in the requested State also allows the requested State to take precautionary measures (for requests based on Directive 2010/24/EU: see the second subparagraph of Article 12(1) of that Directive).    ,
,  2.2.    This request is based on an administrative decision (attached) permitting precautionary measures in the applicant State, which contains the following evaluation:    ,
,,  2.2.1.    Administrative evaluation of the need to take precautionary measures assessed by:    ,
,, name of the authority: ,,
,, address of the authority: ,,
,, date of this decision: , DD/MM/YYYY ,
,, details contact person: ,,
,,  2.2.2.    Circumstances    ,
,,, The instrument permitting enforcement is contested. ,
,,, The claim(s) is (are) not yet the subject of an instrument permitting enforcement. ,
,,, The contesting of the claim(s) by the debtor was already rejected in first instance, but this decision is not final. ,
,,  2.2.3.    This authority has allowed precautionary measures in the applicant State in accordance with its national law, on the following date:    , DD/MM/YYYY ,
,,  2.2.4.    The precautionary measures are considered to be justified for the following reasons, demonstrating the urgency and the risk that collection and recovery could be thwarted or seriously hindered:    ,
,,, high (estimated) amount of the (expected) debt/significant debiting ,
,,, suspicion of fraud ,
,,, Person(s) concerned making themselves insolvent ,
,,, restructuring of assets ,
,,, alienation of property ,
,,, attempt to hide/conceal/dissipate assets ,
,,, careless business management ,
,,, frequent change of residence ,
,,, relocation of property abroad ,
,,, debtor not respecting earlier payment agreements ,
,,, other elements/reasons: … ,
,, Short explanation (recommended): … ,
,  2.3.    This request is based on a judicial confirmation (attached) that precautionary measures are justified:    ,
,,  2.3.1.    Judicial evaluation of the need to take precautionary measures assessed by:    ,
,, name of the Court: ,,
,, address of the Court: ,,
,, date of the decision: , DD/MM/YYYY ,
,, (Details contact person:) ,,
,,  2.3.2.    The Court decided:    ,
,,, at the unilateral request of the tax authorities ,
,,, following the contesting of the claim by the debtor, by another person liable or by another person subject to the precautionary measures ,
,,  2.3.3.    This Court has allowed precautionary measures in the applicant State in accordance with its national law, on the following date:    , DD/MM/YYYY ,
,  2.4.    This request for precautionary measures is based on the reasons mentioned in the attached document(s).    ,
,  2.5.    Precautionary measures are justified for the following reasons, demonstrating the urgency and the risk that collection and recovery could be thwarted or seriously hindered:    ,
,, high (estimated) amount of the (expected) debt/significant levels of debt ,
,, Suspicion of fraud ,
,, Person(s) concerned making themselves insolvent ,
,, restructuring of assets ,
,, alienation of property ,
,, attempt to hide/conceal/dissipate assets ,
,, careless business management ,
,, frequent change of residence ,
,, relocation of property abroad ,
,, debtor not respecting earlier payment agreements ,
,, other elements/reasons: … ,
,, Short explanation (recommended): … ,
  3.   Other information   ,
,  3.1.    The authorities of the requested State are requested not to inform the debtor or other person concerned before the start of the precautionary measures.    ,
,  3.2.    Other information: …    ,