ANNEX IIISupplementary provisions
ANNEX III Text of image EUROPEAN ENFORCEMENT ORDER CERTIFICATE — AUTHENTIC INSTRUMENT 1. Member State of origin: Belgium Czech Republic Germany Estonia Greece Spain France Ireland Italy Cyprus Latvia Lithuania Luxembourg Hungary Malta Netherlands Austria Poland Portugal Slovakia Slovenia Finland Sweden United Kingdom 2. Court/Authority issuing the certificate 2.1. Name: 2.2. Address: 2.3. Tel./fax/e-mail: 3. If different, Court/Authority drawing up or registering the authentic instrument 3.1. Name: 3.2. Address: 3.3. Tel./fax/e-mail: 4. Authentic instrument 4.1. Date: 4.2. Reference number: 4.3. The parties 4.3.1. Name and address of creditor(s): 4.3.2. Name and address of debtor(s): 5. Monetary claim as certified 5.1. Principal Amount: 5.1.1. Currency: Euro Pound sterling Maltese lira Slovenian tolar other (explain) Cyprus pound Hungarian forint Polish zloty Czech koruna Lithuanian litas Swedish kronor Estonian kroon Latvian lats Slovak koruna 5.1.2. If the claim is for periodical payments 5.1.2.1. Amount of each instalment: 5.1.2.2. Due date of first instalment: 5.1.2.3. Due dates of following instalments weekly monthly other (explain) 5.1.2.4. Period of the claim 5.1.2.4.1. Currently indefinite or 5.1.2.4.2. Due date of last instalment: Text of image 5.2. Interest 5.2.1. Interest rate 5.2.1.1. … % or 5.2.1.2. … % above the base rate of the ECB ( 1 ) 5.2.1.3. Other (explain) 5.2.2. Interest to be collected as from: 5.3. Amount of reimbursable costs if specified in the authentic instrument: 6. The authentic instrument is enforceable in the Member State of origin Done at Date Signature and/or stamp ( 1 ) Interest rate applied by the European Central Bank to its main refinancing operations.