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 [attach a photograph, if possible]: | |
| Parents | |
| Information concerning identity of parents of the child (complete for each parent): |
| | |
| 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: | |
| | |
| 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 parents | |
| If parents 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]. |
| |
| |
IV | TIME, PLACE, DATE, AND CIRCUMSTANCES OF THE WRONGFUL REMOVAL OR RETENTION |
| |
| |
| |
V | FACTUAL OR LEGAL GROUNDS JUSTIFYING THE REQUEST |
| |
| |
| |
VI | CIVIL PROCEEDINGS IN PROGRESS |
| |
| |
| |
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: |
| |
| |
| |
VIII | OTHER REMARKS |
| |
| |
| |
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: ...................................................................
|
Place: ...................................................................
|
Signature [or stamp, or both] of the requesting Central Authority or applicant: |
|