EUROPEAN SMALL CLAIMS PROCEDURE - FORM D

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ANNEX IV

EUROPEAN SMALL CLAIMS PROCEDURE

FORM D

CERTIFICATE CONCERNING A JUDGMENT IN THE EUROPEAN SMALL CLAIMS PROCEDURE OR A COURT SETTLEMENT

(Article 20(2) and 23a of Regulation (EC) No 861/2007 of the European Parliament and of the Council establishing a European Small Claims Procedure)

To be filled in by the court/tribunal

1. Court/tribunal

Country

Please specify

1.1. Name:

1.2. Street and number/PO box:

1.3. City and postal code:

1.4 Country:

2. Claimant

2.1. Corporate name of company or organisation:

Surname:

First name:

2.1. Surname, first name/name of company or organisation:

2.2. Personal identification number or passport number/ registration number (*):

2.3. Street and number/PO box:

2.4. City and postal code:

2.5. Country:

2.5 Country:

2.6. Telephone (*):

2.7. E-mail (*):

2.8. Claimant’s representative, if any, and contact details :

2.8.1. Surname, first name/name of company or organisation

2.8.2. Address

2.8.3. Postal code

2.8.4. City

2.8.5. Country

2.8. Claimant’s representative, if any, and contact details (*(*):

2.9. Other details (*):

3. Defendant

3.1. Corporate name of company or organisation:

Surname:

First name:

3.1. Surname, first name/name of company or organisation:

3.2. Personal identification number or passport number/ registration number (*):

3.3. Street and number/PO box:

3.4. City and postal code:

3.5. Country:

3.5 Country:

3.6. Telephone (*):

3.7. E-mail (*):

3.8. Defendant’s representative, if any, and contact details :

3.8.1. Surname, first name/name of company or organisation

3.8.2. Address

3.8.3. Postal code

3.8.4. City

3.8.5. Country

3.8. Defendant’s representative, if any, and contact details(*):

3.9. Other details (*):

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