ANNEX IISupplementary provisions
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: … 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) ( *1 ) ( *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: … Address: 3.1.4.1. Street and number/PO box: … 3.1.4.2. Place and postal code: … 3.1.4.3. Country: … 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: … Address: 3.2.4.1. Street and number/PO box: … 3.2.4.2. Place and postal code: … 3.2.4.3. Country: … 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: … Address: 3.3.4.1. Street and number/PO box: … 3.3.4.2. Place and postal code: … 3.3.4.3. Country: … 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) ( *1 ) ( *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: … Address: 4.1.4.1. Street and number/PO box: … 4.1.4.2. Place and postal code: … 4.1.4.3. Country: … 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: … Address: 4.2.4.1. Street and number/PO box: … 4.2.4.2. Place and postal code: … 4.2.4.3. Country: … 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: … Address: 4.3.4.1. Street and number/PO box: … 4.3.4.2. Place and postal code: … 4.3.4.3. Country: … 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 ( *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 Period covered, where applicable: … (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): … Amount: … 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 Period covered: … ((dd/mm/yyyy) to (dd/mm/yyyy)) Amount: … Form of payment: … … … 5.2.1.6. Interest (if specified in the decision/court settlement) If the maintenance claim is subject to interest, please indicate the rate: … 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 Period covered, where applicable: … (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): … Amount: … 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 Period covered: … ((dd/mm/yyyy) to (dd/mm/yyyy)) Amount: … Form of payment: … … … 5.2.2.6. Interest (if specified in the decision/court settlement) If the maintenance claim is subject to interest, please indicate the rate: … 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 Period covered, where applicable: … (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): … Amount: … 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 Period covered: … ((dd/mm/yyyy) to (dd/mm/yyyy)) Amount: … Form of payment: … … … 5.2.3.6. Interest (if specified in the decision/court settlement) If the maintenance claim is subject to interest, please indicate the rate: … 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 . ( *1 ) 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. ( *2 ) If the decision/court settlement concerns more than three claimants or three defendants, attach an additional sheet. ( *3 ) If the decision/court settlement concerns more than three maintenance claims, attach an additional sheet