ANNEX 4Supplementary provisions
ANNEX 4 Text of image FORM IV Application for a European Certificate of Succession (Article 65 of Regulation (EU) No 650/2012 of the European Parliament and of the Council on jurisdiction, applicable law, recognition and enforcement of decisions and acceptance and enforcement of authentic instruments in matters of succession and on the creation of a European Certificate of Succession (1)) NOTICE TO THE APPLICANT This non-mandatory form may facilitate the gathering of the information needed to issue the European Certificate of Succession. Its annexes enable you to provide additional relevant information in specific situations. Please check beforehand which information is relevant for the purpose of issuing the certificate. Annexes included in the application form (2) Annex I — Details concerning the court or the other competent authority which is dealing with or has dealt with the succession as such (MANDATORY if different from the authority referred to in section 2 of the application form) Annex II — Details concerning the applicant(s) (MANDATORY if the applicant(s) is (are) (a) legal person(s)) Annex III — Details concerning the representative of the applicant(s) (MANDATORY if the applicant(s) is(are) represented) Annex IV — Details of the (ex-)spouse or (ex-)partner of the deceased (MANDATORY if the deceased had a(n) (ex-)spouse or (ex-)partner) Annex V — Details of possible beneficiaries (MANDATORY if different from the applicant or the (ex-) spouse or (ex-)partner) No Annex is included 1. Member State of the authority to which the application is submitted (3) (*) Belgium Bulgaria Czech Republic Germany Estonia Greece Spain France Croatia Italy Cyprus Latvia Lithuania Luxembourg Hungary Malta Netherlands Austria Poland Portugal Romania Slovenia Slovakia Finland Sweden 2. Authority to which the application is submitted (4) 2.1. Name (*): 2.2. Address 2.2.1. Street and number/PO box (*): 2.2.2. Place and postcode (*): 2.3. Other relevant information (please specify): Text of image 3. Details concerning the applicant (natural person) 3.1. Surname and given name(s) (*): 3.2. Surname at birth (if different from point 3.1.): 3.3. Sex (*) 3.3.1. M 3.3.2. F 3.4. Date (dd/mm/yyyy) and place of birth (*): 3.5. Civil status 3.5.1. Single 3.5.2. Married 3.5.3. Registered partner 3.5.4. Divorced 3.5.5. Widowed 3.5.6. Other (please specify): 3.6. Nationality (*) Belgium Bulgaria Czech Republic Germany Estonia Greece Spain France Croatia Italy Cyprus Latvia Lithuania Luxembourg Hungary Malta Netherlands Austria Poland Portugal Romania Slovenia Slovakia Finland Sweden Other (please specify ISO-code): 3.7. Identification number (6): 3.7.1. National identity number: 3.7.2. Social security number: 3.7.3. Tax number: 3.7.4. Other (please specify): 3.8. Address 3.8.1. Street and number/PO box (*): 3.8.2. Place and postcode (*): 3.8.3. Country (*) Belgium Bulgaria Czech Republic Germany Estonia Greece Spain France Croatia Italy Cyprus Latvia Lithuania Luxembourg Hungary Malta Netherlands Austria Poland Portugal Romania Slovenia Slovakia Finland Sweden Other (please specify ISO-code): Text of image 3.9. Telephone: 3.10. Fax 3.11. E-mail: 3.12. Relationship to the deceased (*): Son Daughter Father Mother Grandson Granddaughter Grandfather Grandmother Spouse (7) Registered partner (7) De Facto partner (8) (9) Brother Sister Nephew Niece Uncle Aunt Cousin Other (please specify): 4. The intended purpose of the Certificate (8) 4.1. Heir The Certificate is needed for use in another Member State to demonstrate the status and/or the rights as an heir (please specify): 4.2. Legatee The Certificate is needed for use in another Member State to demonstrate the status and/or the rights as a legatee having direct rights in the succession (please specify): 4.3. Powers of execution of the will The Certificate is needed for use in another Member State to exercise the powers of execution of the will (please specify the powers and, as the case may be, to which asset(s) they relate): Text of image 4.4. Powers of administration of the estate The Certificate is needed for use in another Member State to exercise the powers of administration of the estate (please specify the powers and, as the case may be, to which asset(s) they relate): 5. Details concerning the deceased 5.1. Surname and given name(s) (*): 5.2. Surname at birth (if different from point 5.1.): 5.3. Sex (*) 5.3.1. M 5.3.2. F 5.4. Date (dd/mm/yyyy) and place of birth (town/country (ISO code)) (*): 5.5. Date (dd/mm/yyyy) and place of death (town/country (ISO code)) (*): 5.6. Civil status at the time of death (10) (*) 5.6.1. Single 5.6.2. Married 5.6.3. Registered partner 5.6.4. Divorced 5.6.5. Widowed 5.6.6. Other (please specify): 5.7. Nationality (*) Belgium Bulgaria Czech Republic Germany Estonia Greece Spain France Croatia Italy Cyprus Latvia Lithuania Luxembourg Hungary Malta Netherlands Austria Poland Portugal Romania Slovenia Slovakia Finland Sweden Other (please specify ISO-code): Text of image 5.8. Identification number (6) 5.8.1. National identity number: 5.8.2. Birth certificate number: 5.8.3. Death certificate number: 5.8.4. Social security number: 5.8.5. Tax number: 5.8.6. Other (please specify): 5.9. Address at the time of death (11) 5.9.1. Street and number/PO box (*): 5.9.2. Place and postcode (*): 5.9.3. Country (*) Belgium Bulgaria Czech Republic Germany Estonia Greece Spain France Croatia Italy Cyprus Latvia Lithuania Luxembourg Hungary Malta Netherlands Austria Poland Portugal Romania Slovenia Slovakia Finland Sweden Other (please specify ISO-code): 6. Additional information 6.1. Elements on which you found your claimed right to the succession (**) 6.1.1. I am a beneficiary under a disposition of property upon death 6.1.2. I am a beneficiary by operation of law 6.2. Elements on which you found your power to execute the will of the deceased (***) 6.2.1. I was designated as executor in a disposition of property upon death 6.2.2. I have been appointed executor by a court 6.2.3. Other (please specify): 6.3. Elements on which you found your power to administer the estate of the deceased (***) 6.3.1. I am the administrator under a disposition of property upon death 6.3.2. I have been appointed administrator by a court 6.3.3. I have been designated as administrator by an out of court agreement between the beneficiaries 6.3.4. I have the power to administer by operation of law 6.4. Has the deceased made at least one disposition of property upon death? (*) 6.4.1. Yes 6.4.2. No 6.4.3. Don’t know Text of image 6.5. Has the deceased specified which law should govern the succession (choice of law)? (*) 6.5.1. Yes 6.5.2. No 6.5.3. Don’t know 6.6. At the time of death, was the deceased joint owner with a person, other than his/her (ex-)spouse or (ex-) partner mentioned in Annex IV, of one or more assets forming part of the estate? (*) 6.6.1. Yes (please give details of the person(s) concerned and specify asset(s)): 6.6.2. No 6.6.3. Don’t know 6.7. Are there any (other) possible beneficiaries?* 6.7.1. Yes (12) 6.7.2. No 6.7.3. Don’t know 6.8. Have any of the beneficiaries explicitly accepted the succession? (*) 6.8.1. Yes (please specify): 6.8.2. No 6.8.3. Don’t know 6.9. Have any of the beneficiaries explicitly waived the succession? (*) 6.9.1. Yes (please specify): 6.9.2. No 6.9.3. Don’t know 6.10. Any other information which you deem useful for the purposes of the issue of the Certificate (in addition to the information in section 4 of the application form or in the Annexes): Text of image 7. Documents attached to the application form The applicant shall provide all relevant documents to prove the information contained in this form. Therefore — if possible and when the Authority specified under section 2 does not have it yet — please append the original or a copy of the document which satisfies the conditions necessary to establish its authenticity. Death certificate or declaration of presumed death Court decision Choice of court agreement Will or joint will (13): Certificate of the register of wills Agreement as to succession (13): Declaration relating to a choice of law (13): Marriage contract or contract regarding a relationship which may have comparable effects to marriage (13): Declaration of acceptance of the succession Declaration of waiver of the succession Document relating to the designation of an administrator Document relating to the inventory of the estate Document relating to the distribution or sharing out of the estate Power of attorney Other (please specify): If additional sheets and Annexes have been added, state the total number of pages (*): Total number of documents attached to this application form (*): Done at (*): on (*) (dd/mm/yyyy) Signature (*): I declare that, to my best knowledge, no dispute is pending relating to the elements which I want certified in the Certificate. Done at (*): on (*) (dd/mm/yyyy) Signature (*): Text of image FORM IV — ANNEX I Court or other competent authority which is dealing with or has dealt with the succession as such (to be completed ONLY if different from section 2 of the application form) 1. Name and designation of court or competent authority (*): 2. Address 2.1. Street and number/PO box (*): 2.2. Place and postcode (*): 2.3. Country (*) Belgium Bulgaria Czech Republic Germany Estonia Greece Spain France Croatia Italy Cyprus Latvia Lithuania Luxembourg Hungary Malta Netherlands Austria Poland Portugal Romania Slovenia Slovakia Finland Sweden Other (please specify ISO-code): 3. Telephone (*): 4. Fax 5. E-mail: 6. Reference number of the case: 7. Other relevant information (please specify): Text of image FORM IV — ANNEX II Details concerning the applicant(s) (to be completed ONLY if the applicant(s) is(are) (a) legal person(s)) (14) 1. Organisation name (*): 2. Registration of the organisation 2.1. Registration number: 2.2. Designation of the register/registration authority (*): 2.3. Date (dd/mm/yyyy) and place of registration: 3. Address of the organisation 3.1. Street and number/PO box (*): 3.2. Place and postcode (*): 3.3. Country (*) Belgium Bulgaria Czech Republic Germany Estonia Greece Spain France Croatia Italy Cyprus Latvia Lithuania Luxembourg Hungary Malta Netherlands Austria Poland Portugal Romania Slovenia Slovakia Finland Sweden Other (please specify ISO-code): 4. Telephone (*): 5. Fax 6. E-mail: 7. Surname and given name(s) of person authorised to sign for the organisation (*): 8. Other relevant information (please specify): Text of image FORM IV — ANNEX III Details concerning the representative(s) of the applicant(s) (15) (to be completed ONLY if the applicant(s) is(are) represented) 1. Surname and given name(s) or organisation name (*): 2. Registration of the organisation 2.1. Registration number: 2.2. Designation of the register/registration authority (*): 2.3. Date (dd/mm/yyyy) and place of registration: 3. Address 3.1. Street and number/PO box (*): 3.2. Place and postcode (*): 3.3. Country (*) Belgium Bulgaria Czech Republic Germany Estonia Greece Spain France Croatia Italy Cyprus Latvia Lithuania Luxembourg Hungary Malta Netherlands Austria Poland Portugal Romania Slovenia Slovakia Finland Sweden Other (please specify ISO-code): 4. Telephone: 5. Fax 6. E-mail: 7. Representative capacity (*) Guardian Parent Person authorised to sign for a legal person Person with power of attorney Other (please specify): Text of image FORM IV — ANNEX IV Details concerning the (ex-)spouse(s) or (ex-)partner(s) of the deceased (16) (to be completed ONLY if the deceased had a (ex-)spouse or (ex-)partner) 1. Is the (ex-) spouse or (ex-) partner the applicant? (*) 1.1. Yes (see information provided in section 3 of the application form — if relevant, please specify which applicant): 1.2. No 1.2.1. Surname and give name(s) (*): 1.2.2. Surname at birth (if different from point 1.2.1.): 1.2.3. Sex (*) 1.2.3.1. M 1.2.3.2. F 1.2.4. Date (dd/mm/yyyy) and place of birth (*): 1.2.5. Civil status 1.2.5.1. Single 1.2.5.2. Married 1.2.5.3. Registered partner 1.2.5.4. Divorced 1.2.5.5. Widowed 1.2.5.6. Other (please specify): 1.2.6. Nationality (*) Belgium Bulgaria Czech Republic Germany Estonia Greece Spain France Croatia Italy Cyprus Latvia Lithuania Luxembourg Hungary Malta Netherlands Austria Poland Portugal Romania Slovenia Slovakia Finland Sweden Other (please specify ISO-code): 1.2.7. Identification number (6) 1.2.7.1. National identity number: 1.2.7.2. Social security number: 1.2.7.3. Tax number: 1.2.7.4. Other (please specify): Text of image 1.2.8. Address 1.2.8.1. Street and number/PO box (*): 1.2.8.2. Place and postcode (*): 1.2.8.3. Country (*) Belgium Bulgaria Czech Republic Germany Estonia Greece Spain France Croatia Italy Cyprus Latvia Lithuania Luxembourg Hungary Malta Netherlands Austria Poland Portugal Romania Slovenia Slovakia Finland Sweden Other (please specify ISO-code): 1.2.9. Telephone: 1.2.10. E-mail: 1.2.11. Relationship to the deceased at the time of death (*) 1.2.11.1. Married to the deceased 1.2.11.2. Registered partner of the deceased 1.2.11.3. Divorced from the deceased 1.2.11.4. Legally separated from the deceased 1.2.11.5. Other (please specify): 2. Address of the couple at the time of marriage or registration of the partnership 2.1. Street and number/PO box: 2.2. Place and postcode: 2.3. Country Belgium Bulgaria Czech Republic Germany Estonia Greece Spain France Croatia Italy Cyprus Latvia Lithuania Luxembourg Hungary Malta Netherlands Austria Poland Portugal Romania Slovenia Slovakia Finland Sweden Other (please specify ISO-code): 3. Address of the spouse or partner at the time of death of the deceased (if different from point 5.9. of the application form) 3.1. Street and number/PO box: 3.2. Place and postcode: 3.3. Country Belgium Bulgaria Czech Republic Germany Estonia Greece Spain France Croatia Italy Cyprus Latvia Lithuania Luxembourg Hungary Malta Netherlands Austria Poland Portugal Romania Slovenia Slovakia Finland Sweden Other (please specify ISO-code): Text of image 4. Nationality of the deceased at the time of marriage/registration of the partnership: Belgium Bulgaria Czech Republic Germany Estonia Greece Spain France Croatia Italy Cyprus Latvia Lithuania Luxembourg Hungary Malta Netherlands Austria Poland Portugal Romania Slovenia Slovakia Finland Sweden Other (please specify ISO-code): 5. Nationality of the spouse or partner at the time of marriage/registration of the partnership with the deceased: Belgium Bulgaria Czech Republic Germany Estonia Greece Spain France Croatia Italy Cyprus Latvia Lithuania Luxembourg Hungary Malta Netherlands Austria Poland Portugal Romania Slovenia Slovakia Finland Sweden Other (please specify ISO-code): 6. Date (dd/mm/yyyy) and place of marriage/registration of the partnership with the deceased: 7. Authority celebrating the marriage/registration of the partnership with the deceased: 8. Had the spouse/partner and the deceased specified which law should govern the matrimonial property regime of the marriage or the property consequences of the registered partnership (choice of law)? (*) 8.1. Yes 8.2. No 8.3. Don’t know 9. Had the spouse/partner and the deceased entered into a marriage contract or a contract regarding a relationship which may have comparable effects to marriage? (*) 9.1.1. Yes 9.1.2. No 9.1.3. Don’t know 10. If known, information on the matrimonial property regime(s) or equivalent property regime(s) of the deceased (in particular, please specify whether the property regime is liquidated and the assets shared): Text of image FORM IV — ANNEX V Details of possible beneficiaries (other than the applicant, the (ex-)spouse or (ex-)partner) (17) 1. Beneficiary A 1.1. Surname and given name(s) or organisation name (*): 1.2. Surname at birth (if different from point 1.1.): 1.3. Identification number (6) 1.3.1. National identity number: 1.3.2. Social security number: 1.3.3. Tax number: 1.3.4. Registration number: 1.3.5. Other (please specify): 1.4. Address 1.4.1. Street and number/PO box (*): 1.4.2. Place and postcode (*): 1.4.3. Country (*) Belgium Bulgaria Czech Republic Germany Estonia Greece Spain France Croatia Italy Cyprus Latvia Lithuania Luxembourg Hungary Malta Netherlands Austria Poland Portugal Romania Slovenia Slovakia Finland Sweden Other (please specify ISO-code): 1.5. Telephone: 1.6. E-mail: Text of image 1.7. Relationship to the deceased Son Daughter Father Mother Grandson Granddaughter Grandfather Grandmother Brother Sister Nephew Niece Uncle Aunt Cousin Other (please specify): 1.8. Beneficiary (*) 1.8.1. under a disposition of property upon death 1.8.2. by operation of law 2. Beneficiary B 2.1. Surname and given name(s) or organisation name (*): 2.2. Surname at birth (if different from point 2.1.): 2.3. Identification number (6) 2.3.1. National identity number: 2.3.2. Social security number: 2.3.3. Tax number: 2.3.4. Registration number: 2.3.5. Other (please specify): 2.4. Address 2.4.1. Street and number/PO box (*): 2.4.2. Place and postcode (*): 2.4.3. Country (*) Belgium Bulgaria Czech Republic Germany Estonia Greece Spain France Croatia Italy Cyprus Latvia Lithuania Luxembourg Hungary Malta Netherlands Austria Poland Portugal Romania Slovenia Slovakia Finland Sweden Other (please specify ISO-code): 2.5. Telephone: 2.6. E-mail: Text of image 2.7. Relationship to the deceased Son Daughter Father Mother Grandson Granddaughter Grandfather Grandmother Brother Sister Nephew Niece Uncle Aunt Cousin Other (please specify): 2.8. Beneficiary (*) 2.8.1. under a disposition of property upon death 2.8.2. by operation of law (*) Mandatory information. (**) Mandatory information if the purpose of the certificate is to certify rights to the succession. (***) Mandatory information if the purpose of the certificate is to certify powers to execute the will or to administer the estate. (1) OJ L 201, 27.7.2012, p. 107. (2) Please tick the boxes which apply. (3) This should be the Member State whose courts have jurisdiction pursuant to Regulation (EU) No 650/2012. (4) If another authority is dealing or has dealt with the succession as such, please complete and append Annex I. (5) For legal persons, please complete and append Annex II. If there is more than one applicant, attach an additional sheet. For representatives, please complete and append Annex III. (6) Please indicate the most relevant number if applicable. (7) Please complete and append Annex IV. (8) The concept of de facto partner includes legal institutions of cohabitation which exist in some Member States such as ‘sambo’ (Sweden) or ‘avopuoliso’ (Finland). (9) Please tick more than one tick box if relevant. (10) If the deceased was married or in a relationship which may have comparable effects to marriage, please complete and append Annex IV. (11) If the deceased had several residential addresses at the time of death, please indicate the most relevant one. (12) For beneficiaries who are not an applicant or an (ex-)spouse or (ex-)partner, please complete and append Annex V. (13) If neither the original nor a copy is appended, please indicate where the original may be located. (14) If more than one legal person applies, please attach an additional sheet. (15) If more than one representative, please attach an additional sheet. (16) If more than one person, please attach an additional sheet. (17) Refer to section 3 of the application form, Annexes II or IV. Please indicate in particular all the direct descendants of the deceased of whom you are aware. If you are aware of more than two possible beneficiaries, please attach additional sheet.