| This application concerns the following child: [insert full name of child to whom application relates], who will attain the age of 16 years on .................... 20... |
| NOTE: The following particulars should be completed in full where possible. |
| I | IDENTITY OF THE CHILD AND HIS OR HER PARENTS |
| | Child | |
| | Name and first names: | |
| | Date of birth: | |
| | Place of birth: | |
| | Habitual residence before removal or retention: | |
| | Passport number or identity card number, if any: | |
| | Description [and attach a photograph, if possible]: | |
| | Mother | |
| | Name and first names: | |
| | Date of birth: | |
| | Place of birth: | |
| | Nationality: | |
| | Occupation: | |
| | Habitual residence: | |
| | Other contact details: | |
| | Passport number or identity card number, if any: | |
| | Father | |
| | Name and first names: | |
| | Date of birth: | |
| | Place of birth: | |
| | Nationality: | |
| | Occupation: | |
| | Habitual residence: | |
| | Other contact details: | |
| | Passport number or identity card number, if any: | |
| | Date and place of marriage or civil union of mother and father*: | |
| | *If mother and father have never married or been in a civil union with each other, state “Not married or in a civil union” . |
| II | REQUESTING INDIVIDUAL OR INSTITUTION (who actually exercised custody before the removal or retention): |
| | Name and first names: | |
| | Nationality of individual applicant: | |
| | Occupation of individual applicant: | |
| | Address: | |
| | Other contact details: | |
| | Passport number or identity card number, if any: | |
| | Relationship to the child: | |
| | Name and address of legal adviser, if any: | |
| III | PLACE WHERE THE CHILD IS THOUGHT TO BE |
| | Information concerning the person alleged to have removed or retained the child: |
| | Name and first names: | |
| | Date of birth: | |
| | Place of birth: | |
| | Nationality: | |
| | Occupation: | |
| | Last known address: | |
| | Passport number or identity card number, if any: | |
| | Description [and attach a photograph, if possible]: | |
| | Address of the child: | |
| | Other persons who might be able to supply additional information relating to the whereabouts of the child: [give full name, address, and contact details, if possible]. |
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| IV | TIME, PLACE, DATE, AND CIRCUMSTANCES OF THE WRONGFUL REMOVAL OR RETENTION |
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| V | FACTUAL OR LEGAL GROUNDS JUSTIFYING THE REQUEST |
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| VI | CIVIL PROCEEDINGS IN PROGRESS |
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| VII | CHILD IS TO BE RETURNED TO |
| | Name and first names: | |
| | Date of birth: | |
| | Place of birth: | |
| | Address: | |
| | Telephone No: | |
| | Proposed arrangements for return of the child: |
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| VIII | OTHER REMARKS |
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| IX | LIST OF DOCUMENTS ATTACHED |
| The following documents are attached: |
| *(a) | certified copy of relevant parenting order or decision or agreement concerning custody or access (including contact between parent and child): |
| *(b) | certificate or affidavit as to the applicable law: |
| *(c) | information relating to the social background of the child: |
| *(d) | photograph of the child: |
| *(e) | photograph of the person alleged to have removed or retained the child: |
| *(f) | other [specify]. |
| *Delete if inapplicable. |
| I authorise the requested Central Authority and its agents to act on my behalf and to do all things reasonable and necessary in connection with this application. |
Date: ...................................................................
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Place: ...................................................................
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| Signature [or stamp, or both] of the requesting Central Authority or applicant: |
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