OMB Control No: 0970-0488
Expiration date: XX/XX/XXXX
Convention on the International Recovery of Child Support and Other Forms of Family Maintenance
Abstract of a Decision
(Article 25(3) b))
Name of the State of origin of the decision:
(identify territorial unit if applicable)
Competent authority issuing the Abstract
Name:
Address:
2.3 |
Telephone number: |
|
2.4 |
Fax number: |
|
2.5 |
E-mail: |
|
The decision1
Type of authority: judicial authority or administrative authority2
Name and place of authority:
(address if applicable)
3.4 |
Date of the decision: |
(dd/mm/yyyy) |
3.5 |
Date of effect of the decision: |
(dd/mm/yyyy) |
3.6 |
Reference number of the decision: |
|
3.7 |
Names of the parties to the decision: |
|
3.8 Decision results from:
Divorce or legal separation proceedings
Parentage establishment proceedings
Maintenance proceedings
Parental responsibility proceedings
Other:
Name of the debtor:
PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to provide an abstract of a decision in an application under the 2007 Hague Child Support Convention. Public reporting burden for this collection of information is estimated to average 1 hour 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 For the definition of decision see Article 19(1).
2 The Administrative Authority referred to in this Statement meets the requirements of Article 19(3).
5.
5.1
5.1.1
Terms of decision
Maintenance payable for one person or a group of persons (specify currency3 for each amount)
Name(s) and date(s) of birth of the person(s) entitled to support / maintenance, arrears and other payments
Family name(s): Given name(s): Date of birth: (dd/mm/yyyy)
Family name(s): Given name(s): Date of birth: (dd/mm/yyyy)
Family name(s): Given name(s): Date of birth: (dd/mm/yyyy)
Terms of payment of support / maintenance
maintenance in the amount of every:
week two weeks month 3 months
6 months
year other (specify):
This payment includes arrears retroactive maintenance
interest health insurance school fees other payments, arrangements or conditions (specify):
Terms of payment of arrears
As of
(dd/mm/yyyy) the total amount of arrears is in the
amount of . Beginning (dd/mm/yyyy) the
debtor shall pay arrears in the amount of every:
week two weeks month 3 months 6 months
year single payment other (specify):
Terms of payment of retroactive maintenance
As of (dd/mm/yyyy) the total amount of retroactive
maintenance is in the amount of . Beginning
(dd/mm/yyyy) the debtor shall pay retroactive maintenance in the amount of
every:
week two weeks month 3 months 6 months
year single payment other (specify):
3 Currency should be specified using the ISO code.
4 Where different payments are provided for different periods please replicate this information for such periods with the understanding that at the new beginning date the former amount is replaced by the new one.
Include extract of the decision if necessary.
Other payments as provided in the decision
Beginning (dd/mm/yyyy) the debtor shall pay interest in the amount of every:
week two weeks month 3 months 6 months
year other (specify):
Beginning (dd/mm/yyyy) the debtor shall pay health insurance in the amount of every:
week two weeks month 3 months 6 months
year other (specify):
Beginning (dd/mm/yyyy) the debtor shall pay school fees in the amount of every:
week two weeks month 3 months 6 months
year other (specify):
Beginning (dd/mm/yyyy) the debtor shall make other
payments, arrangements or conditions (specify*):
to be paid in the amount of every:
week two weeks month 3 months 6 months
year other (specify):
Lump sum
The debtor shall pay the lump sum amount of on
Due date (dd/mm/yyyy)
Another frequency (specify):
Maintenance payments for more than one person on an individual basis (specify currency5 for each amount)
Family name(s): Given name(s): Date of birth: (dd/mm/yyyy)
6 Beginning
(dd/mm/yyyy) the debtor shall pay support /
maintenance in the amount of every:
week two weeks month 3 months 6 months
year other (specify):
This payment includes arrears retroactive maintenance
interest health insurance school fees other payments, arrangements or conditions (specify):
Beginning (dd/mm/yyyy) the debtor shall pay arrears in the amount of every:
week two weeks month 3 months 6 months
year single payment other (specify):
Beginning (dd/mm/yyyy) the debtor shall pay retroactive
maintenance in the amount of every:
week two weeks month 3 months 6 months
year single payment other (specify):
Beginning (dd/mm/yyyy) the debtor shall pay interest in the amount of every:
week two weeks month 3 months 6 months
year other (specify):
Beginning (dd/mm/yyyy) the debtor shall pay health insurance in the amount of every:
week two weeks month 3 months 6 months
year other (specify):
Beginning (dd/mm/yyyy) the debtor shall pay school fees in the amount of every:
week two weeks month 3 months 6 months
year other (specify):
Beginning (dd/mm/yyyy) the debtor shall make other
payments, arrangements or conditions (specify*):
to be paid in the amount of every:
week two weeks month 3 months 6 months
year other (specify):
Lump sum
The debtor shall pay the lump sum amount of on
Due date (dd/mm/yyyy)
Another frequency (specify):
5 Currency should be specified using the ISO code.
6 Where different payments are provided for different periods please replicate this information for such periods with the understanding that at the new beginning date the former amount is replaced by the new one.
Include extract of the decision if necessary.
7 Beginning
(dd/mm/yyyy) the debtor shall pay support /
maintenance in the amount of every:
week two weeks month 3 months 6 months
year other (specify):
This payment includes arrears retroactive maintenance
interest health insurance school fees other payments, arrangements or conditions (specify):
Beginning (dd/mm/yyyy) the debtor shall pay arrears in the amount of every:
week two weeks month 3 months 6 months
year single payment other (specify):
Beginning (dd/mm/yyyy) the debtor shall pay retroactive
maintenance in the amount of every:
week two weeks month 3 months 6 months
year single payment other (specify):
Beginning (dd/mm/yyyy) the debtor shall pay interest in the amount of every:
week two weeks month 3 months 6 months
year other (specify):
Beginning (dd/mm/yyyy) the debtor shall pay health insurance in the amount of every:
week two weeks month 3 months 6 months
year other (specify):
Beginning (dd/mm/yyyy) the debtor shall pay school fees in the amount of every:
week two weeks month 3 months 6 months
year other (specify):
Beginning (dd/mm/yyyy) the debtor shall make other
payments, arrangements or conditions (specify*):
to be paid in the amount of every:
week two weeks month 3 months 6 months
year other:
Lump sum
The debtor shall pay the lump sum amount of on
Due date (dd/mm/yyyy)
Another frequency (specify):
7 Where different payments are provided for different periods please replicate this information for such periods with the understanding that at the new beginning date the former amount is replaced by the new one.
Include extract of the decision if necessary.
8 Beginning
(dd/mm/yyyy) the debtor shall pay support /
maintenance in the amount of every:
week two weeks month 3 months 6 months
year other (specify):
This payment includes arrears retroactive maintenance
interest health insurance school fees other payments, arrangements or conditions (specify):
Beginning (dd/mm/yyyy) the debtor shall pay arrears in the amount of every:
week two weeks month 3 months 6 months
year single payment other (specify):
Beginning (dd/mm/yyyy) the debtor shall pay retroactive
maintenance in the amount of every:
week two weeks month 3 months 6 months
year single payment other (specify):
Beginning (dd/mm/yyyy) the debtor shall pay interest in the amount of every:
week two weeks month 3 months 6 months
year other (specify):
Beginning (dd/mm/yyyy) the debtor shall pay health insurance in the amount of every:
week two weeks month 3 months 6 months
year other (specify):
Beginning (dd/mm/yyyy) the debtor shall pay school fees in the amount of every:
week two weeks month 3 months 6 months
year other (specify):
Beginning (dd/mm/yyyy) the debtor shall make other
payments, arrangements or conditions (specify*):
to be paid in the amount of every:
week two weeks month 3 months 6 months
year other (specify):
Lump sum
The debtor shall pay the lump sum amount of on
Due date (dd/mm/yyyy)
Another frequency (specify):
8 Where different payments are provided for different periods please replicate this information for such periods with the understanding that at the new beginning date the former amount is replaced by the new one.
Include extract of the decision if necessary.
Maintenance payments directed to a public body (specify currency9 for each amount)
Name of the public body:
Family name(s) of the contact person:
Given name(s) of the contact person:
Address:
Telephone numbers:
Fax number:
E-mail:
10 Beginning
(dd/mm/yyyy) the debtor shall pay support /
maintenance in the amount of every:
week two weeks month 3 months 6 months
year other (specify):
This payment includes arrears retroactive maintenance
interest health insurance school fees other payments, arrangements or conditions (specify):
Beginning (dd/mm/yyyy) the debtor shall pay arrears in the amount of every:
week two weeks month 3 months 6 months
year single payment other (specify):
Beginning (dd/mm/yyyy) the debtor shall pay retroactive
maintenance in the amount of every:
week two weeks month 3 months 6 months
year single payment other (specify):
Beginning (dd/mm/yyyy) the debtor shall pay interest in the amount of every:
week two weeks month 3 months 6 months
year other (specify):
Beginning (dd/mm/yyyy) the debtor shall pay health insurance in the amount of every:
week two weeks month 3 months 6 months
year other (specify):
Beginning (dd/mm/yyyy) the debtor shall pay school fees in the amount of every:
week two weeks month 3 months 6 months
year other (specify):
Beginning (dd/mm/yyyy) the debtor shall make other
payments, arrangements or conditions (specify*):
to be paid in the amount of every:
week two weeks month 3 months 6 months
year other (specify):
Lump sum
The debtor shall pay the lump sum amount of on
Due date (dd/mm/yyyy)
Another frequency (specify):
9 Currency should be specified using the ISO code.
10 Where different payments are provided for different periods please replicate this information for such periods with the understanding that at the new beginning date the former amount is replaced by the new one.
Include extract of the decision if necessary.
The decision is silent about indexation
The maintenance is indexed by operation of law.
The maintenance should be indexed every year by _0_.0_0_% %
The maintenance should be indexed as follows:
Interest where maintenance payments are late
The decision is silent about interest where maintenance payments are late
The interest on late payments is by operation of law.
Unpaid amounts generate interest where payments are late at the following rate:
_0_.0_0_% per month 3 months 6 months year
The interest is: simple or compound
Effect of the decision
This decision shall remain in effect:
Until the child(ren) has (have) reached the age of:
Until the child(ren) is (are) self-supporting
Until the child(ren) has (have) completed education (specify):
Until the creditor is self-supporting
Unless and until it is changed or discontinued by further decision or by operation of law
Other:
Costs and expenses
The decision is silent about costs and expenses
The debtor is ordered to pay costs and expenses
The creditor is ordered to pay costs and expenses
Costs and expenses amount to: (specify currency11)
This Abstract accurately reflects the content of the decision, described under item 3 above, in relation to maintenance for the persons listed under items 5.1. and 5.2. a, b and c above.
Name: (in block letters) Date:
Name of the official from the competent authority of the State of origin (dd/mm/yyyy)
This Abstract was completed by the official from the competent authority of the State of origin whose name appears above and is transmitted by the requesting Central Authority.
Name: (in block letters) Authorised representative of the Central Authority
Date:
(dd/mm/yyyy)
Requesting Central Authority reference number:
(For Central Authority use only)
11 Currency should be specified using the ISO code.
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
File Title | Annex A2 - Abstract of a Decision |
Subject | OMB 0970-0488 |
Author | Hague Conference |
File Modified | 0000-00-00 |
File Created | 2023-07-29 |