Form 1 Application for Modification of a Decision

OMB Control No: 0970-0488

Expiration date: XX/XX/XXXX

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

Application for Modification of a Decision

( Article 10(1) e)  Article10(1) f)  Article 10(2) b)  Article 10(2) c))

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

1. Family name(s):

2. Given name(s):

3. Date of birth:¹ (dd/mm/yyyy)

4. Address:

5. Telephone numbers:

6. Fax number:

7. E-mail:

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

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:

PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to submit an application for the modification of a decision 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. If you have any comments on this collection of information, please contact the ACF Reports Clearance Officer by email at infocollection@acf.hhs.gov.

¹ It is not necessary to provide a date of birth in the case of a representative.

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

1. Family name(s): Given name(s):

Date of birth: (dd/mm/yyyy)

Maintenance basis:

• parentage  in loco parentis or equivalent relationship

1. Family name(s): Given name(s):

Date of birth: (dd/mm/yyyy)

Maintenance basis:

• parentage  in loco parentis or equivalent relationship

1. Family name(s): Given name(s):

Date of birth: (dd/mm/yyyy)

Maintenance basis:

• parentage  in loco parentis or equivalent relationship

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:

4.1

• Maintenance is sought or payable for additional children or persons, additional particulars are attached

Particulars (if known) of the debtor

• The person is the same as the applicant named above

1. Family name(s):

2. Given name(s):

3. Date of birth: (dd/mm/yyyy)

4. Residential address:

5. Postal address:

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

   1. Family name(s):

   2. Given name(s):

   3. Address:

4. Telephone numbers:

5. Fax number:

6. E-mail:

5.

Information that may assist with the location of the respondent

1. Personal identification number: (including name of country or territorial unit that issued the number)

2. Any other information that may assist with the location of the respondent

Payments

1. Details for electronic transfer of payments (if applicable)

Name of the bank: NBIC: ²

SWIFT-address:

IBAN:³

Account number: Name of account holder: Reference:⁴

2. Details for payments by cheques (if applicable)

Cheque payable to: Cheque to be sent to: (address)

Reference:³

² National Bank Identification Code.

³ International Bank Account Number.

⁴ Where needed to affect payment.

6.

6.1

6.2

6.3

The decision

Type of authority:  judicial authority or  administrative authority

Name and place of authority: (address if applicable)

6.4	Date of the decision:	(dd/mm/yyyy)
6.5	Date of effect of the decision:	(dd/mm/yyyy)
6.6	Reference number of the decision:
6.7	Names of the parties:

7. The following changes have occurred since the decision was made or last modified:

   • Change in the income of the creditor or its financial situation

   • Change in the income of the debtor or its financial situation

   • Change in the income or financial situation of the person who has care of the child

   • Change in circumstances of the person for whom maintenance is sought

   • Change in child care arrangements

   • Change in cost of living

   • Change of currency exchange rate

   • Decision was made by consent, and the amount ordered to be paid is no longer appropriate or adequate

   • Other. Please specify:

7. The following modifications are sought by the applicant:

   • Increasing the amount of maintenance

Please specify the new amount and currency:

• Decreasing the amount of maintenance

Please specify the new amount and currency:

• Modifying the frequency of payments, please specify:

  • week  two weeks  month  3 months  6 months

  • year  other (specify):

• Modifying the method of payment

Please specify:

• Modifying the nature of payments

Please specify:

• Reducing or cancelling arrears

Please specify reasons:

• Terminating the maintenance obligation

Please specify reasons: Please specify termination date: (dd/mm/yyyy)

• Other. Please specify:

7. The following documents are attached to establish the basis for modification of the maintenance decision and to assist in establishing, where necessary, the amount of the maintenance:

   • Complete text of the decision from the State of origin

   • Evidence establishing a change in income or other change in circumstances

   • Written agreement between the parties related to modification of the maintenance

   • Financial Circumstances Form

   • Written submissions in support of application

   • Other evidence in accordance with the law of the requested State

7.  Please initiate enforcement measures once the decision is established

7. Other information:

7. If the applicant is the debtor in the case of an application under Article 10(2) c), please tick the applicable boxes:

   • The creditor is not habitually resident in the State of origin.

   • The creditor is habitually resident in the State of origin, but the following provision of Article 18 applies or may apply:

     • The parties agreed in writing to the jurisdiction of the requested State in accordance with Article 18(2) a) ( agreement attached);⁵

     • The creditor may submit to the jurisdiction of the requested State in accordance with Article 18(2) b);

     • The competent authority in the State of origin cannot, or refuses to, exercise jurisdiction in accordance with Article 18(2) c) ( decision attached); or,

     • The decision made in the State of origin cannot be recognized or declared enforceable in the Contracting State where proceedings for a new or modified decision are contemplated in accordance with Article 18(2) d) ( decision attached).

7. 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)

⁵ The first condition of Article 18(2) does not apply in disputes relating to maintenance obligations in respect of children.

Restricted Information on the Applicant

Application for Modification of a Decision

( Article 10(1) e)  Article10(1) f)  Article 10(2) b)  Article 10(2) c))

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

   1. Family name(s):

   2. Given name(s):

   3. Date of birth: (dd/mm/yyyy)

   4. Address:

5. Telephone numbers:

6. Fax number:

7. E-mail:

5. Payments

   1. Details for electronic transfer of payments (if applicable)

Name of the bank: NBIC:

SWIFT-address:

IBAN:

Account number: Name of account holder: Reference:

2. 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)