CERTIFICATE REFERRED TO IN ARTICLE 42(1) CONCERNING THE RETURN OF THE CHILD

ANNEX IV

CERTIFICATE REFERRED TO IN ARTICLE 42(1) CONCERNING THE RETURN OF THE CHILD (¹)

Certificate referred to in Article 42(1) concerning the return of the child

1. Member State of origin

2. Court or authority issuing the certificate

2.1. Name

2.2. Address

2.3. Tel./fax/e-mail

Tel.:

Fax:

E-mail:

2.3. Tel./fax/e-mail

3. Person to whom the child has to be returned (to the extent stated in the judgment)

3.1. Full name

3.2. Address

3.3. Date and place of birth (where available)

Date of birth:

Place of birth:

3.3. Date and place of birth (where available)

4. Holders of parental responsibility (²)

4.1. Mother

4.1.1. Full name

4.1.2. Address (where available)

4.1.3. Date and place of birth (where available)

Date of birth:

Place of birth:

4.1.3. Date and place of birth (where available)

4.2. Father

4.2.1. Full name

4.2.2. Address (where available)

4.2.3. Date and place of birth (where available)

Date of birth:

Place of birth:

4.2.3. Date and place of birth (where available)

4.3. Other

4.3.1. Full name

4.3.2. Address (where available)

4.3.3. Date and place of birth (where available)

Date of birth:

Place of birth:

4.3.3. Date and place of birth (where available)

5. Respondent (where available)

5.1. Full name

5.2. Address (where available)

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