1 Request for Specific Measures

OMB Control No: 0970-0488
Expiration date: NN/NN/NNNN

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Request for Specific Measures
(Article 7(1))

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 section 7 d, e, f and g should only be provided in
the Restricted Information on the Potential Applicant page of this form.
1. Requesting Central Authority

2. Contact person in requesting State

a. Address

a. Address (if different)

b. Telephone number

b. Telephone number (if different)

c. Fax number

c. Fax number (if different)

d. E-mail

d. E-mail (if different)

e. Reference number

e. Language(s)

3.

Requested Central Authority: _________________________________________________
Address: ___________________________________________________________________

4.

Grounds for the request:

5.



To assist the potential applicant in making an application under Article 10.
Please explain: __________________________________________________________



To assist the potential applicant in determining whether an application under
Article 10 should be initiated.
Please explain: __________________________________________________________

The potential applicant is:

The person for whom maintenance would be sought or is payable

The representative of the person for whom maintenance would be sought or is
payable

The debtor

The representative of the debtor

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
recognition or for recognition and enforcement under the 2007 Hague Child Support Convention. Public reporting burden for this collection of information is estimated to
average 0.17 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.

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6.

The following specific measure(s) is (are) requested:

6.1.

Help to locate the debtor or the creditor (Art. 6(2) b)):

The debtor, or

The person to whom maintenance is payable, or

The person for whom maintenance is payable, or

Both the person to whom maintenance is payable and the person for whom
maintenance is payable

6.2.

Help to obtain relevant financial information (Art. 6(2) c))

Income of:
 the debtor, or
 the person to whom maintenance is payable, or
 the person for whom maintenance is payable, or
 both the person to whom maintenance is payable and the person for whom
maintenance is payable

Assets of:
 the debtor or
 the person to whom maintenance is payable, or
 the person for whom maintenance is payable, or
 both the person to whom maintenance is payable and the person for whom
maintenance is payable

Location of the assets of:
 the debtor or
 the person to whom maintenance is payable, or
 the person for whom maintenance is payable, or
 both the person to whom maintenance is payable and the person for whom
maintenance is payable

Other financial circumstances of:
 the debtor, or
 the person to whom maintenance is payable, or
 the person for whom maintenance is payable, or
 both the person to whom maintenance is payable and the person for whom
maintenance is payable.
Please specify: _________________________________________________________

6.3.

Facilitate the obtaining of documentary or other evidence (Art. 6(2) g))

Birth certificate or equivalent

Acknowledgement of parentage by the debtor

Formal statement providing evidence relating to parentage

Decision of competent authority concerning parentage

Genetic test results

Adoption certificate

Certificate of marriage or similar relationship and date of divorce / separation

Formal statement providing evidence relating to common residence of the parties

Agreement between the parties relating to maintenance

Evidence of attendance at secondary or post-secondary educational institution

Evidence of disability

Financial Circumstances Form

Statement of arrears or payment history

Other evidence. Please specify: ____________________________________________

Decision of the requested State concerning a maintenance obligation. Please specify:
______________________________________________________________________
Include supporting documents:
 Abstract of the Decision
 Statement of Enforceability of the Decision
 Statement of Proper Notice of Proceedings / Decision

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6.4.

Provide assistance in establishing parentage where necessary for the recovery of
maintenance (Art. 6(2) h))

Co-ordinate genetic testing

Seek a voluntary acknowledgment of parentage

Seek a legal determination of parentage

Refer request to the appropriate competent authority

Provide advice on the appropriate procedure(s)

Other, please specify: ____________________________________________________

6.5.

Initiate or facilitate the institution of proceedings to obtain any necessary provisional
measures that are territorial in nature and the purpose of which is to secure the outcome
of a pending maintenance application (Art. 6(2) i))
Please specify: _______________________________________________________________

6.6.

Facilitate service of documents (Art. 6(2) j))
Please specify and attach document(s): ___________________________________________

7.

Particulars of the potential applicant
The potential applicant is:

The person for whom maintenance would be sought or is payable

The representative of the person for whom maintenance would be sought or is
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:

_________________________________________________
_________________________________________________

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f.

Fax number:

_________________________________________________

g.

E-mail:

_________________________________________________

It is not necessary to provide a date of birth in the case of a representative.
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8.

Particulars of the person(s) for whom maintenance would be sought or is payable

8.1.



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

8.2.



Maintenance would be sought or is 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

Family name(s):

_____________________________________

Given name(s):

_____________________________________

Date of birth

_____________________________________ (dd/mm/yyyy)

Maintenance basis:
 parentage

 in loco parentis or equivalent relationship

Family name(s):

_____________________________________

Given name(s):

_____________________________________

Date of birth

_____________________________________ (dd/mm/yyyy)

Maintenance basis:
 parentage

 in loco parentis or equivalent relationship

b.

c.

8.3.



Maintenance would be sought or is 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: ________________________________________________
8.4.



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

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9.

Information in relation to the debtor and, where applicable, the creditor

9.1.

Particulars (if known) of the debtor


The person is the same as the potential applicant named above

a.

Family name(s):

____________________________________

b.

Given name(s):

____________________________________

c.

Date of birth:

____________________________________ (dd/mm/yyyy)

d.

Residential address:

____________________________________
____________________________________

e.

Postal address:

____________________________________
____________________________________

9.2.

If the debtor is the potential applicant, particulars (if known and applicable) of the
representative of the person(s) for whom maintenance is payable
a.

Family name(s):

_________________________________________________

b.

Given name(s):

_________________________________________________

c.

Address:

_________________________________________________
_________________________________________________

d.

Telephone numbers: _________________________________________________
_________________________________________________

9.3.

e.

Fax number:

_________________________________________________

f.

E-mail:

_________________________________________________

Information that may assist with the location of the potential 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
_____________________________________________________________________

10.

Attach and specify other relevant documents: ____________________________________
___________________________________________________________________________

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11.

Attestations



This request for specific measures was completed by the requesting Central Authority.



This request for specific measures complies with the requirement of the Convention
(Article 7(1)). The information contained in this request for specific measures corresponds
to and is in conformity with the information and documents provided by the potential
applicant to the requesting Central Authority. The request for specific measures is
forwarded by the Central Authority on behalf of and with the consent of the potential
applicant.

Name: _______________________________ (in block letters) Date: _________________
Authorised representative of the Central Authority

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(dd/mm/yyyy)

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Restricted Information on the Potential Applicant
Request for Specific Measures
(Article 7(1))
N.B. The requesting Central Authority has determined that information under sections 7 d, e, f
and g 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: _____________________________

7.

Particulars of the potential 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:
_________________________________________________



This request for specific measures was completed by the requesting Central Authority.



This request for specific measures complies with the requirement of the Convention
(Article 7(1)). The information contained in this request for specific measures corresponds
to and is in conformity with the information and documents provided by the potential
applicant to the requesting Central Authority. The request for specific measures is
forwarded by the Central Authority on behalf of and with the consent of the potential
applicant.

Name: _______________________________ (in block letters) Date: _________________
Authorised representative of the Central Authority
(dd/mm/yyyy)

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