Certificate issued in accordance with Article 14

ANNEX II

Form II

Certificate issued in accordance with Article 14 of the Regulation (EU) No 606/2013 of the European Parliament and of the Council on mutual recognition of protection measures in civil matters

1. Date of issuing of the certificate (dd/mm/yyyy):

2. Reference number of the certificate:

3. Applicant

3.1. Please indicate whether the applicant is:

3.1.1. The protected person

3.1.2. The person causing the risk

3.2. Surname and given name(s)/name :

3.3. Identity number [optional]

3.4. Date of birth (dd/mm/yyyy):

3.5. Place of birth [optional]

4. Authority which suspended or withdrew the protection measure, suspended or limited its enforceability or withdrew the cretificate in accordance with point (b) of Article 9(1) of the Regulation (EU) No 606/2013 (if different from the authority issuing this certificate) [optional]

4.1. Official name

4.2. Full Address

4.2.1. Street and number/PO box:

4.2.2. City:

4.2.3. Postal Code:

4.2.4. Member State:

4.3. Tel. No:

4.4. Fax No [optional]

4.5. E-mail [optional]

4.6. Contact person [optional]

4.6.1. Surname and given name(s):