ANNEX I附則
ANNEX I A. Common format for undertaking to repay costs of consular protection in case of financial assistance UNDERTAKING TO REPAY COSTS OF CONSULAR PROTECTION (FINANCIAL ASSISTANCE) — (Article 14(1) of Directive (EU) 2015/637) I, (Mr/Ms) (full name in block capitals) … holder of passport No … issued at … hereby acknowledge receipt from the Embassy/Consulate of … … at … of the sum of … as an advance for the purpose of … … (including any applicable fee) and/or undertake and promise to repay on demand to the Ministry of Foreign Affairs/Government of [Member State of nationality] … in accordance with the national law of that Member State the equivalent of that sum or the equivalent of all costs as paid on my account or advanced to me, including costs incurred by the member(s) of my family accompanying me, in (currency) … at the rate of exchange prevailing on the day on which the advance was made or the costs were paid. My address ( *1 ) (in block capitals) (country) … is: … … … DATE … SIGNATURE … B. Common format for undertaking to repay costs of consular protection in case of repatriation UNDERTAKING TO REPAY COSTS OF CONSULAR PROTECTION (REPATRIATION) — (Article 14(1) of Directive (EU) 2015/637) I, (Mr/Ms) (full name in block capitals) … born at (town) … in (country) … on (date) … holder of passport No … issued at … on … and ID No … and Social security No and competent authority (if applicable/where relevant) … hereby undertake to repay on demand to the Government of … in accordance with the national law of that Member State the equivalent of all costs as paid on my account or advanced to me by the consular officer of the … Government at … for the purpose of, or in connection with, the repatriation to … of myself and the members of my family accompanying me, and to pay all appropriate consular fees in respect of the repatriation. These are: (i) ( *2 ) Fares Subsistence Miscellaneous costs LESS the contribution made by me CONSULAR FEES: Repatriation fee Attendance fee Passport/emergency fees (… hours at … per hour …) (ii) ( *2 ) All sums on my account for the purpose of, or in connection with, the repatriation of myself and the members of my family accompanying me which cannot be determined at the time this undertaking to repay is signed by me. My address ( *3 ) (in block capitals) (country) … is: … … … DATE … SIGNATURE … ( *1 ) if you have no permanent address, please indicate a contact address. ( *2 ) Delete as appropriate: The Consular Officer and the applicant should initial each deletion in the margin. ( *3 ) If you have no permanent address, please indicate a contact address.