ANNEX IV

EXTRACT FROM AN AUTHENTIC INSTRUMENT IN MATTERS RELATING TO MAINTENANCE OBLIGATIONS SUBJECT TO PROCEEDINGS FOR RECOGNITION AND A DECLARATION OF ENFORCEABILITY

(Article 48 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 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.

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  Germany  Estonia  Ireland  Greece  Spain  France  Italy  Cyprus  Latvia  Lithuania  Luxembourg  Hungary  Malta  Netherlands  Austria  Poland  Portugal  Romania  Slovenia  Slovakia  Finland  Sweden

2.2.3.Telephone/Fax/E-mail: …

3.Creditor(s)(2)

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)(2)

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 instrument

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(3)

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

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

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

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

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:

…

(2)

If the authentic instrument concerns more than three creditors or three debtors, attach an additional sheet.

(3)

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