OMB Control No: 0970-0488

Expiration date: 03/31/2026

Convention on the International Recovery of Child Support and Other Forms of Family Maintenance

Application for Recognition

or Recognition and Enforcement
( Article 10(1) a)  Article 10(2) a)  Article 30)

CONFIDENTIALITY AND PERSONAL DATA PROTECTION NOTICE

Personal data gathered or transmitted under the Convention shall be used only for the purposes for
which it was gathered or transmitted. Any authority processing such information shall ensure its
confidentiality, in accordance with the law of its State.

An authority shall not disclose or confirm information gathered or transmitted in application of this
Convention if it determines that to do so could jeopardise the health, safety or liberty of a person in
accordance with Article 40.
 A determination of non-disclosure has been made by a Central Authority in accordance
with Article 40. If this box is ticked, information under sections 2 d, e, f and g and 5 should only be
provided in the Restricted Information on the Applicant page of this form.

1. Requesting Central Authority file reference number: _____________________________

2. Particulars of the applicant

The applicant is:
 The person for whom maintenance is sought or payable
 The representative of the person for whom maintenance is sought or payable
 The debtor
 The representative of the debtor
a. Family name(s): _________________________________________________
b. Given name(s): _________________________________________________
c. Date of birth: 1 _____________________________________ (dd/mm/yyyy)
or
a. Name of the public body: ____________________________________
b. Family name(s) of the contact person: ____________________________________
c. Given name(s) of the contact person: ____________________________________
and
d. Address: _________________________________________________
_________________________________________________
e. Telephone numbers: _________________________________________________
_________________________________________________
f. Fax number: _________________________________________________
g. E-mail: _________________________________________________

PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to provide a statement
of proper notice in an application under the 2007 Hague Child Support Convention. Public reporting burden for this collection of information is estimated to
average 0.5 hours per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of
information. This is a mandatory collection of information per 45 CFR 303.7. An agency may not conduct or sponsor, and a person is not required to respond
to, a collection of information subject to the requirements of the Paperwork Reduction Act of 1995, unless it displays a currently valid OMB control number. The
OMB # is 0970-0488 and the expiration date is 3/31/2026. If you have any comments on this collection of information, please contact the ACF Reports Clearance
Officer by email at ocseinternational@acf.hhs.gov.

1
It is not necessary to provide a date of birth in the case of a representative.
 Convention on the International Recovery of Child Support and Other Forms of Family Maintenance

3. Particulars of the person(s) for whom maintenance is sought or payable

3.1  Maintenance is sought or payable for the applicant named above
Maintenance basis:
 parentage  in loco parentis or equivalent relationship
 marriage  analogous relationship to marriage
 affinity (please identify): _________________________________
 grandparent  sibling  grandchild
 other: ________________________________________________

3.2  Maintenance is sought or payable for the following child(ren)

a. Family name(s): _____________________________________
Given name(s): _____________________________________
Date of birth _____________________________________ (dd/mm/yyyy)
Maintenance basis:
 parentage  in loco parentis or equivalent relationship
b. Family name(s): _____________________________________
Given name(s): _____________________________________
Date of birth _____________________________________ (dd/mm/yyyy)
Maintenance basis:
 parentage  in loco parentis or equivalent relationship
c. Family name(s): _____________________________________
Given name(s): _____________________________________
Date of birth _____________________________________ (dd/mm/yyyy)
Maintenance basis:
 parentage  in loco parentis or equivalent relationship

3.3  Maintenance is sought or payable for the following person

Family name(s): _____________________________________
Given name(s): _____________________________________
Date of birth _____________________________________ (dd/mm/yyyy)
Maintenance basis:
 marriage  analogous relationship to marriage
 affinity (please identify): _________________________________
 grandparent  sibling  grandchild
 other: ________________________________________________

3.4  Maintenance is sought or payable for additional children or persons, additional

particulars are attached
 Convention on the International Recovery of Child Support and Other Forms of Family Maintenance

4.1 Particulars (if known) of the debtor

 The person is the same as the applicant named above
a. Family name(s): ____________________________________
b. Given name(s): ____________________________________
c. Date of birth: ____________________________________ (dd/mm/yyyy)
d. Residential address: ____________________________________
____________________________________
e. Postal address: ____________________________________
____________________________________

4.2 If the debtor is the applicant, particulars (if known and applicable) of the representative
of the person(s) for whom maintenance is sought or payable
a. Family name(s): _________________________________________________
b. Given name(s): _________________________________________________
c. Address: _________________________________________________
_________________________________________________
d. Telephone numbers: _________________________________________________
_________________________________________________
e. Fax number: _________________________________________________
f. E-mail: _________________________________________________

4.3 Information that may assist with the location of the respondent
a. Personal identification number: ____________________________________
(include name of country or territorial unit that issued the number)
b. Any other information that may assist with the location of the respondent
_____________________________________________________________________

5. Payments
a. Details for electronic transfer of payments (if applicable)
Name of the bank: ________________________________
NBIC: 2 ________________________________
SWIFT-address: ________________________________
3
IBAN: ________________________________
Account number: ________________________________
Name of account holder: ________________________________
Reference: 4 ________________________________

2
National Bank Identification Code.
3
International Bank Account Number.
4
Where needed to effect payment.
 Convention on the International Recovery of Child Support and Other Forms of Family Maintenance

b. Details for payments by cheques (if applicable)

Cheque payable to: ________________________________
Cheque to be sent to: ________________________________
(address) ________________________________
________________________________
5
Reference: ________________________________

6.  This is an application for recognition only; do not initiate enforcement measures

7. Bases for recognition and enforcement (Article 20) (please tick all relevant boxes)

Date of decision: ___________ (dd/mm/yyyy) State of origin: _______________________

 The respondent was habitually resident in the State of origin at the time
proceedings were instituted;
 The respondent has submitted to the jurisdiction either expressly or by
defending on the merits of the case without objecting to the jurisdiction at the
first available opportunity;
 The creditor was habitually resident in the State of origin at the time proceedings
were instituted;
 The child for whom the maintenance was ordered was habitually resident in the
State of origin at the time proceedings were instituted, provided that the
respondent has lived with the child in that State or has resided in that State and
provided support for the child there;
 There has been agreement to the jurisdiction by the parties in writing or
evidenced by writing (except in disputes relating to maintenance obligations in
respect of children);
 The maintenance decision was made by an authority exercising jurisdiction on a
matter of personal status or parental responsibility and that jurisdiction was not
based solely on the nationality of one of the parties; or
 In a case where the State addressed has made a reservation in accordance with
Article 20(2), there are factual circumstances in which the law of that State in
similar circumstances would confer or would have conferred jurisdiction on its
authorities to make such a decision. Please specify:
____________________________________________________________________
____________________________________________________________________

8. Appearance of the respondent

 The respondent appeared or was represented in the proceedings in the State of
origin
 The respondent did not appear and was not represented in the proceedings in the
State of origin (see attached Statement of Proper Notice (Art. 25(1) c))

9.  Financial Circumstances Form attached (Art. 11(2) a) and b))

5
Where needed to effect payment.
 Convention on the International Recovery of Child Support and Other Forms of Family Maintenance

10.  Where the application is for the recovery of maintenance other than
maintenance obligations arising from a parent-child relationship towards a
person under the age of 21 years, the applicant (creditor) has benefited from
legal assistance in the State of origin (Articles 17 and 25(1) f))
 Where the application is for the recovery of maintenance including maintenance
obligations arising from a parent-child relationship towards a person under the
age of 21 years, the applicant (debtor) has benefited from legal assistance in the
State of origin (Articles 17 and 25(1) f))
* See Transmittal Form for the list of documents in support of the application.

11. Other information: __________________________________________________________

___________________________________________________________________________

12. Attestations
 This application was completed by the applicant and reviewed by the requesting Central
Authority.

 This application complies with the requirement of the Convention (Article 12(2)). The
information contained in this application and the attached documents correspond to and
are in conformity with the information and documents provided by the applicant to the
requesting Central Authority. The application is forwarded by the Central Authority on
behalf of and with the consent of the applicant.

Name: _______________________________ (in block letters) Date: ________________

Authorised representative of the Central Authority (dd/mm/yyyy)
 Convention on the International Recovery of Child Support and Other Forms of Family Maintenance

Restricted Information on the Applicant

Application for Recognition or Recognition and Enforcement
( Article 10(1) a)  Article 10(2) a)  Article 30)

N.B. The requesting Central Authority has determined that information under sections 2 d, e, f
and g and 5 on this page shall not be disclosed or confirmed for the protection of the health,
safety or liberty of a person. Such a determination shall according to Article 40(2) be taken into
account by the requested Central Authority.

1. Requesting Central Authority file reference number: _____________________________

2. Particulars of the applicant

a. Family name(s): _________________________________________________
b. Given name(s): _________________________________________________
c. Date of birth: _____________________________________ (dd/mm/yyyy)
d. Address: _________________________________________________
_________________________________________________
e. Telephone numbers: _________________________________________________
_________________________________________________
f. Fax number: _________________________________________________
g. E-mail: _________________________________________________

5. Payments
a. Details for electronic transfer of payments (if applicable)
Name of the bank: ________________________________
NBIC: ________________________________
SWIFT-address: ________________________________
IBAN: ________________________________
Account number: ________________________________
Name of account holder: ________________________________
Reference: ________________________________
b. Details for payments by cheques (if applicable)
Cheque payable to: ________________________________
Cheque to be sent to: ________________________________
(address) ________________________________
________________________________
Reference: ________________________________

 This application was completed by the applicant and reviewed by the requesting Central
Authority.

 This application complies with the requirement of the Convention (Article 12(2)). The
information contained in this application and the attached documents correspond to and
are in conformity with the information and documents provided by the applicant to the
requesting Central Authority. The application is forwarded by the Central Authority on
behalf of and with the consent of the applicant.

Name: _______________________________ (in block letters) Date: ________________

Authorised representative of the Central Authority (dd/mm/yyyy)