ANNEX IXSupplementary provisions
ANNEX IX Appeal against a decision on a remedy (Article 37 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) To be filled in by the court Case number: Received by the court on: (dd/mm/yyyy) IMPORTANT INFORMATION Language Fill in this form in the language of the court to which you are sending your application. Please note that the form is available in 23 official languages of the European Union 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. The language version with which you are familiar may help you in filling in the form in the required language. On the website of the European e-Justice Portal you can also find information as to whether a given Member State has indicated that it will accept documents addressed to the competent authority in another official language of the European Union (Article 50(1)(o) of Regulation (EU) No 655/2014). The list of the competent courts for an appeal under Regulation (EU) No 655/2014 is available on the website of the European e-Justice Portal at https://e-justice.europa.eu/content_european_account_preservation_order-379-en.do. Supporting documents Please note that this form must be accompanied by all relevant supporting documents. Please also attach a copy of the decision that is being appealed. 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 On the website of the European e-Justice Portal you can find certain information on the payment of the court fees in the proceedings at issue in the Member State concerned. 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 at which the appeal is lodged 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): 2. Applicant for an appeal 2.1. The applicant for an appeal is, in the proceedings leading to the issuing of the European Account Preservation Order (‘the Preservation Order’) (please tick the relevant box): ☐ Creditor ☐ Debtor 2.2. Surname and given name(s)/name of company or organisation: 2.3. Address 2.3.1. Street and number/PO box: 2.3.2. Place and postcode: 2.3.3. Country (if a Member State, please indicate the country code): 2.4. Telephone: ( *1 ) 2.5. Fax ( *1 ) 2.6. Email (if available): 2.7. Name of party's representative, if any, and contact details 2.7.1. Surname and given name(s): 2.7.2. Address 2.7.2.1. Street and number/PO box: 2.7.2.2. Place and postcode: 2.7.2.3. Country (if a Member State, please indicate the country code): 2.7.3. Email: 3. The other party 3.1. The other party is, in the proceedings leading to the issuing of the Preservation Order (please tick the relevant box): ☐ Creditor ☐ Debtor 3.2. Surname and given name(s)/name of company or organisation: 3.3. Address 3.3.1. Street and number/PO box: 3.3.2. Place and postcode: 3.3.3. Country (if a Member State, please indicate the country code): 3.4. Telephone: ( *2 ) 3.5. Fax ( *2 ) 3.6. Email (if available): 3.7. Name of party's representative, if any and if known, and contact details, if available 3.7.1. Surname and given name(s): 3.7.2. Address 3.7.2.1. Street and number/PO box: 3.7.2.2. Place and postcode: 3.7.2.3. Country (if a Member State, please indicate the country code): 3.7.3. Email: 4. Court that issued the Preservation Order 4.1. Name: 4.2. Address 4.2.1. Street and number/PO box: 4.2.2. Place and postcode: 4.2.3. Member State (please indicate country code): 4.3. Telephone: ( *2 ) 4.4. Fax ( *2 ) 4.5. Email (if available): 5. The Preservation Order 5.1. Date (dd/mm/yyyy) of the Preservation Order: 5.2. File number of the Preservation Order: 5.3. Total amount to be preserved according to the Preservation Order: 5.4. 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): 6. Court or competent enforcement authority that issued the decision on the remedy (not to be filled in if the court is the same as the court (referred to in section 4) that issued the Preservation Order) 6.1. Name: 6.2. Address 6.2.1. Street and number/PO box: 6.2.2. Place and postcode: 6.2.3. Member State (please indicate the country code): 6.3. Telephone: ( *3 ) 6.4. Fax ( *3 ) 6.5. Email (if available): 7. The decision on the remedy: 7.1. Date (dd/mm/yyyy) of the decision: 7.2. Reference number of the decision: 7.3. The decision on the remedy was issued on the application for a remedy by the (please tick the relevant box): ☐ Creditor in the proceedings leading to the issuing of the Preservation Order ☐ Debtor in the proceedings leading to the issuing of the Preservation Order 8. Application for an appeal against the decision on the remedy I hereby lodge an appeal against the decision referred to in section 7 for the following reasons: 9. Evidence Please list the evidence supporting your application for an appeal: I declare that the information provided is true to the best of my knowledge and is given in good faith. If additional sheets have been added, please state the total number of pages and number each page: Done at: Date: (dd/mm/yyyy) Name, signature and/or stamp: ( *1 ) Optional ( *2 ) Optional ( *3 ) Optional