ANNEX IVSupplementary provisions
ANNEX IV Declaration concerning the preservation of funds (Article 25(1) of Regulation (EU) No 655/2014 of the European Parliament and of the Council of 15 May 2014 establishing a European Account Preservation Order procedure to facilitate cross-border debt recovery in civil and commercial matters) IMPORTANT INFORMATION This declaration is to be transmitted to the issuing court and to the creditor pursuant to Article 25(2) of Regulation (EU) No 655/2014 or to the competent authority of the Member State of enforcement (unless it was issued by that same authority) pursuant to Article 25(3) of that Regulation. The declaration must be issued by the end of the third working day following the implementation of the European Account Preservation Order (‘the Preservation Order’). If, in exceptional circumstances, it is not possible for the bank or other entity to issue the declaration within three working days, it must be issued as soon as possible but by no later than the end of the eighth working day following the implementation of the Preservation Order. The creditor has the duty, pursuant to Article 27 of Regulation (EU) No 655/2014, to take the necessary steps to ensure the release of any amount which, following the implementation of the Preservation Order, exceeds the amount specified in the Preservation Order. The electronic version of the form to be used for the request to release over-preserved amounts is available on the website of the European e-Justice Portal at https://e-justice.europa.eu/content_european_account_preservation_order-378-en.do and it can also be filled in online. If this declaration is issued not by the bank but by the entity responsible for enforcing the Preservation Order, the name, address and other contact details of that entity should be indicated at the end of the form (point 5.11). Country codes Whenever you refer to a Member State in filling in this form, please use the following country codes: AT Austria EL Greece IT Italy PT Portugal BE Belgium ES Spain LT Lithuania RO Romania BG Bulgaria FI Finland LU Luxembourg SE Sweden CY Cyprus FR France LV Latvia SI Slovenia CZ Czech Republic HR Croatia MT Malta SK Slovakia DE Germany HU Hungary NL Netherlands EE Estonia IE Ireland PL Poland Where this form provides for filling in of free text, when filling in the form on paper, please use additional sheets if necessary and number each page. 1. Court that issued the Preservation Order 1.1. Name: 1.2. Address 1.2.1. Street and number/PO box: 1.2.2. Place and postcode: 1.2.3. Member State (please indicate the country code): 1.3. Telephone: ( *1 ) 1.4. Fax ( *1 ) 1.5. Email (if available): 2. The Preservation Order 2.1. Date (dd/mm/yyyy) of the Preservation Order: 2.2. File number of the Preservation Order: 2.3. Total amount to be preserved according to the Preservation Order: 2.4. Currency: ☐ Euro (EUR) ☐ Bulgarian lev (BGN) ☐ Czech koruna (CZK) ☐ Croatian kuna (HRK) ☐ Hungarian forint (HUF) ☐ Polish zloty (PLN) ☐ Romanian leu (RON) ☐ Swedish krona (SEK) ☐ Other (please specify using the ISO code): 3. Creditor 3.1. Surname and given name(s)/name of company or organisation: 3.2. Address 3.2.1. Street and number/PO box: 3.2.2. Place and postcode: 3.2.3. Member State (please indicate the country code): 3.3. Telephone: ( *1 ) 3.4. Fax ( *1 ) 3.5. Email (if available): 4. Debtor 4.1. Surname and given name(s) (any middle name, if known)/name of company or organisation: 4.2. Address 4.2.1. Street and number/PO box: 4.2.2. Place and postcode: 4.2.3. Country (if a Member State, please indicate the country code): 4.3. Telephone: ( *1 ) 4.4. Fax ( *1 ) 4.5. Email (if available): 5 Preserved funds 5.1. Name of the bank: 5.2. Address of the bank 5.2.1. Street and number/PO box: 5.2.2. Place and postcode: 5.2.3. Member State (please indicate the country code): 5.3. Telephone: 5.4. Fax 5.5. Email: 5.6. Have funds been preserved on the basis of the Preservation Order referred to in section 2 above? ☐ Yes. If yes, please move to points 5.7.-5.10. ☐ No. Please provide information as to why the funds have not been preserved (please tick the relevant box(es)): ☐ it was not possible to identify the account with certainty ☐ it was not possible to identify the account which may be preserved under Regulation (EU) No 655/2014 ☐ there are no funds in the account(s) ☐ the account concerned is a joint or nominee account and is not subject to preservation under the law of the Member State of enforcement ☐ the amounts in the account are exempt from seizure under national law ☐ the amounts in the account are preserved pursuant to other protective measures. Please explain: ☐ other. Please explain: 5.7. Amount preserved (if the amount is preserved in several currencies, please indicate the amounts preserved in each of the currency of the funds): 5.8. Currency (please tick several boxes, if applicable): ☐ Euro (EUR) ☐ Bulgarian lev (BGN) ☐ Czech koruna (CZK) ☐ Croatian Kuna (HRK) ☐ Hungarian forint (HUF) ☐ Polish zloty (PLN) ☐ Romanian leu (RON) ☐ Swedish krona (SEK) ☐ Other (please specify using the ISO code): 5.9. If, on implementation of the Preservation Order referred to in section 2 above, an amount less than that specified in the Preservation Order has been preserved, please provide information as to why the full amount has not been preserved (please tick the relevant box(es)): ☐ there are insufficient funds in the account(s) ☐ the account concerned is a joint or nominee account and the law of the Member State of enforcement limits the extent to which such accounts may be subject to preservation ☐ certain amounts in the account are exempt from seizure under national law ☐ certain amounts in the account are preserved pursuant to other protective measures. Please explain: ☐ other. Please explain: 5.10. Date of the implementation of the Preservation Order: (dd/mm/yyyy). 5.11. (Please fill in if applicable) Where this declaration is issued not by the bank but by the entity responsible for enforcing the Preservation Order, the name and address of that entity (street and number/PO box, place and postcode, Member State) and the telephone number, fax and email address: Done at: Date: (dd/mm/yyyy) Signature and/or stamp: ( *1 ) Optional