ATTESTATION

CONCERNING A MEASURE DIRECTED TO THE PROTECTION OF ADULTS

(Article 15 of Regulation (EU) 20XX/X)

To be issued by a competent authority of the Member State of origin, upon application by an interested person, for the recognition, non-recognition or enforcement of a measure directed at the protection of an adult.

1.Member State where the measure was taken (‘Member State of origin’)

 Belgium  Bulgaria  Czech Republic  Germany  Estonia  Ireland  Greece  Spain

 France  Croatia  Italy  Cyprus  Latvia  Lithuania  Luxembourg  Hungary  Malta

 Netherlands  Austria  Poland  Portugal  Romania  Slovenia  Slovakia  Finland

 Sweden

2.Competent authority of the Member State of origin issuing this attestation

2.1 Name of the competent authority: 

2.2 Address

2.2.1 Street and number/PO box:

2.2.2 Place and postcode:

2.3 Contact details

2.3.1. Telephone:

2.3.2. E-mail:

3.Authority which took the measure, if different from the one indicated in point 2

3.1 Name of the authority: 

3.2 Address:

3.2.1 Street and number/PO box:

3.2.2 Place and postcode:

3.3 Contact details

3.3.1 Telephone:

3.3.2. E-mail:

4.Measure

4.1 Date (dd/mm/yyyy): 

4.2 Reference number:

5.Adult covered by the measure (‘Adult’)

5.1 Surname(s) and given name(s):

5.2 Surname(s) at birth (if different from point 5.1):

5.3 Date (dd/mm/yyyy) and place of birth:

5.4 Nationality

 Belgium  Bulgaria  Czech Republic  Germany  Estonia  Ireland  Greece

 Spain  France  Croatia  Italy  Cyprus  Latvia  Lithuania  Luxembourg

 Hungary  Malta  Netherlands  Austria  Poland  Portugal  Romania  Slovenia  Slovakia  Finland  Sweden

 Other (please specify ISO-code):

 Unknown

5.5 Identification number 1 :

5.5.1 National identity number:

5.5.2 Social security number:

5.5.3 Tax number:

5.5.4 Other (please specify):

5.6 Address

5.6.1 Street and number/PO box:

5.6.2 Place and postcode:

5.6.3 Country

 Belgium  Bulgaria  Czech Republic  Germany  Estonia  Ireland  Greece

 Spain  France  Croatia  Italy  Cyprus  Latvia  Lithuania  Luxembourg

 Hungary  Malta  Netherlands  Austria  Poland  Portugal  Romania  Slovenia

 Slovakia  Finland  Sweden

 Other (please specify ISO-code):

5.7 Contact details

5.7.1 Telephone:

5.7.2 E-mail:

5.7.3 Other contact information:

6.Other Party A 2

6.1. Natural person

6.1.1 Surname(s) and given name(s):

6.1.2 Surname(s) at birth (if different from point 6.1.2):

6.1.3 Date (dd/mm/yyyy) and place of birth:

6.1.4 Identification number 3 :

6.1.4.1 National identity number:

6.1.4.2 Social security number:

6.1.4.3 Tax number:

6.1.4.4 Other (please specify):

6.1.5 Address

6.1.5.1 Street and number/PO box:

6.1.5.2 Place and postcode:

6.1.5.3 Country

 Belgium  Bulgaria  Czech Republic  Germany  Estonia  Ireland

 Greece  Spain  France  Croatia  Italy  Cyprus  Latvia  Lithuania

 Luxembourg  Hungary  Malta  Netherlands  Austria  Poland  Portugal  Romania  Slovenia Slovakia  Finland  Sweden

 Other (please specify ISO-code):

6.2. The Other Party A is a legal person

6.2.1 Name of the organisation:

6.2.2 Registration of the organisation 4

6.2.2.1 Registration number:

6.2.2.2 Designation of the register/registration authority:

6.2.2.3 Date (dd/mm/yyyy) and place of registration:

6.2.3. Address of the organisation

6.2.3.1 Street and number/PO box:

6.2.3.2 Place and postcode:

6.2.3.3 Country

□ Belgium □ Bulgaria □ Czech Republic □ Germany □ Estonia □ Greece □ Spain

□ France □ Croatia □ Italy □ Cyprus □ Latvia □ Lithuania □ Luxembourg

□ Hungary □ Malta □ Netherlands □ Austria □ Poland □ Portugal □ Romania

□ Slovenia □ Slovakia □ Finland □ Sweden

□ Other (please specify ISO– code):

6.2.4 Surname(s) and given name(s) of a person authorised to sign for the organisation:

6.2.5 Other relevant information (please specify):

6.2.6 Contact details

6.2.6.1 Telephone:

6.2.6.2 E-mail:

7. The measure was taken in default of appearance

7.1    Adult or other party in default of appearance 5 :

7.2    That party was served with the document which instituted the proceedings or with an equivalent document:

7.2.1  No

7.2.2  Not known to the competent authority

7.2.3  Yes

7.2.3.1 Date of service (dd/mm/yyyy):

8.The measure is subject to further appeal under the law of the Member State of origin

9.Date of legal effect of the measure in the Member State where the measure was taken (dd/mm/yyyy):

10.The measure was taken when the Adult concerned had not reached the age of 18

10.1 The Adult has reached the age of 18 on (dd/mm/yyyy):

11.The adult was given the opportunity to express his or her views

11.1  Yes, the hearing of the Adult took place on (dd/mm/yyyy):

11.2  Yes, but the Adult refused to be heard.

11.3  No, for the following reasons related to the urgency 6 of the case:

12.4  No, for the following reasons not related to the urgency of the case:

12.Name(s) of party(ies) who benefited from legal aid

12.1  Adult: as indicated in point 5

12.2  Other Party A: as indicated in point 6

12.3  Other Party B as identified on additional sheets attached to this attestation 7

12.4  None of them

12.5  Other – please indicate:

13.The measure:

13.1  concerns the legal capacity of the Adult.

13.2  institutes a protective regime.

13.3  places the Adult under the protection of a judicial or administrative authority.

14.3.1 Name and address of the judicial or administrative authority:

13.4  designates one or several person(s) or body(ies) having charge of the Adult’s person or property, representing or assisting the Adult (if this box is ticked please fill in Point 14)  8 .

13.4.1 the representative appointed is the same as Other Party A

13.4.2 the representative appointed is the same as Other Party B

13.4.3 the representative was not a party to the proceedings

13.4.3.1 Name(s) of the representative:

13.4.3.2 Address of the representative:

13.5  places or authorises the placement of the Adult in an establishment or other place where protection can be provided.

13.5.1 Name and address of the establishment or other place:

13.6  authorises or decides on the administration, conservation or disposal of the Adult’s property.

13.6.1 designation of the Adult’s property 9 :

13.7  authorises a specific intervention for the protection of the person or property of the Adult.

13.8 Other (please specify):

14.Powers of the representative(s) appointed

14.1 Representative A is in charge of the Adult’s person 10

15.1.1  for the following categories of acts:

15.1.2  for the following acts:

15.1.3  subject to the authorisation of :

14.2 Representative A is in charge of the Adult’s property

14.2.1  for the following categories of acts:

14.2.2  for acts concerning:

14.2.2.1  movable property

14.2.2.2  immovable property

14.2.2.3  the following property:

14.2.2.4  subject to the authorisation of :

14.3 Other (please specify): 

15.The measure:

15.1  expires on (dd/mm/yyyy):

15.2  will be reviewed on (dd/mm/yyyy):

15.3  is valid until amended or revoked

15.4  Other (please specify):

16. The measure determines costs and expenses of the proceedings 11

16.1 The decision provides that 12 :

16.1.1  Surname(s) and given name(s):

16.1.2 Name of an organisation or other legal person:

17.2 Must pay to:

17.2.1  Surname(s) and given name(s):

17.2.2  Name of an organisation or other legal person:

17.3 The sum of: …

 Euro (EUR)  Bulgarian lev (BGN)  Croatian kuna (HRK)  Czech koruna (CZK)

 Hungarian forint (HUF)  Polish zloty (PLN)  Romanian leu (RON)

 Swedish krona (SEK)

 Other (please specify (ISO code)):

17.4 Any additional information which might be relevant (for example the bank account details where the sum should be paid):

17.Any additional information which might be relevant:

If additional sheets have been added, state the total number of pages:

Done at:

On (dd/mm/yyyy):

Signature and/or stamp of the competent authority issuing the attestation:

Reference number of the attestation:

ATTESTATION

CONCERNING AN AUTHENTIC INSTRUMENT DIRECTED TO THE PROTECTION OF AN ADULT

(Article 17 of Regulation (EU) 20XX/X)

To be issued to accompany an authentic instrument directed to the protection of an adult upon application by a person wishing to use an authentic instrument in another Member State (‘authentic instrument’).

1.Member State where the authentic instrument was formally drawn up or registered by a competent authority (‘Member State of origin’) 

 Belgium  Bulgaria  Czech Republic  Germany  Estonia  Ireland  Greece  Spain

 France  Croatia  Italy  Cyprus  Latvia  Lithuania  Luxembourg  Hungary  Malta

 Netherlands  Austria  Poland  Portugal  Romania  Slovenia  Slovakia  Finland

 Sweden

2.Competent authority of the Member State of origin issuing this attestation

2.1 Name of the competent authority:

2.2 Address

2.2.1 Street and number/PO box:

2.2.2 Place and postcode:

2.3 Contact details

2.3.1 Telephone:

2.3.2 E-mail:

3.Authority which formally drew up or registered the authentic instrument, if different from that indicated in point 2

3.1 Name of the authority: 

3.2 Address:

3.2.1 Street and number/PO box:

3.2.2 Place and postcode:

3.3 Contact details

3.3.1 Telephone:

3.3.2 E-mail:

4.Authentic instrument

4.1 Date (dd/mm/yyyy):

4.2 Reference number :

5.Adult concerned by the authentic instrument (‘Adult’):

5.1 Surname(s) and given name(s):

5.2 Surname(s) at birth (if different from point 5.1.):

5.3 Date (dd/mm/yyyy) and place of birth:

5.4 Nationality

 Belgium  Bulgaria  Czech Republic  Germany  Estonia  Ireland  Greece

 Spain  France  Croatia  Italy  Cyprus  Latvia  Lithuania  Luxembourg

 Hungary  Malta  Netherlands  Austria  Poland  Portugal  Romania  Slovenia  Slovakia  Finland  Sweden

 Other (please specify ISO-code):

 Unknown

5.5 Identification number 13 :

5.5.1 National identity number:

5.5.2 Social security number:

5.5.3 Tax number:

5.5.4 Other (please specify):

5.6. Address

5.6.1 Street and number/PO box:

5.6.2. Place and postcode:

5.6.3 Country

 Belgium  Bulgaria  Czech Republic  Germany  Estonia  Ireland  Greece

 Spain  France  Croatia  Italy  Cyprus  Latvia  Lithuania  Luxembourg

 Hungary  Malta  Netherlands  Austria  Poland  Portugal  Romania  Slovenia

 Slovakia  Finland  Sweden

 Other (please specify ISO-code):

5.7 Contact details

5.7.1 Telephone:

5.7.2 E-mail:

5.7.3 Other contact information:

6.Authenticity of the authentic instrument

6.1 □ Under the law of the Member State of origin, the authentic instrument has specific evidentiary effects compared to other written documents.

6.1.1 □ No

6.1.2 □ Yes. The specific evidentiary effects concern the following elements:

6.1.2.1 □ the date on which the authentic instrument was drawn up.

6.1.2.2 □ the place where the authentic instrument was drawn up.

6.1.2.3 □ the origin of any signature of the Adult.

6.1.2.4 □ the content of any declaration by the Adult

6.1.2.5 □ the facts that the competent authority declares as having been verified in its presence.

6.1.2.6 □ the actions which the competent authority declares to have carried out.

6.1.2.7 □ other (please specify):

6.2 □ Under the law of the Member State of origin, the authentic instrument may lose its specific evidentiary effects on the basis of (please indicate if relevant):

6.2.1 □ a judicial decision

6.2.1.1 □ given in an ordinary judicial procedure.

6.2.1.2 □ given in a special judicial procedure provided by the law for this purpose.

6.2.2 □ Other (please specify):

6.3 □ To the knowledge of the competent authority issuing the attestation, the authentic instrument has not been challenged in the Member State of origin as to its authenticity.

7. Legal acts and relationships recorded in the authentic instrument

7.1 To the knowledge of the competent authority issuing the attestation, the authentic instrument:

7.1.1 □ is not challenged as to the legal acts and/or legal relationships recorded

7.1.2 □ is being challenged as to the legal acts and/or legal relationships recorded on specific points not covered by this attestation (please specify):

7.2 Other relevant information (please specify):

8.Powers of representation

8.1 The authentic instrument records powers of representation granted by the Adult

8.2 Representative (person mandated to act in support or on behalf of the Adult)

8.2.1 Surname(s) and given name(s) or name of the organisation:

8.2.2 Where applicable, identification number 14

8.2.2.1 National identity number:

8.2.2.2 Social security number:

8.2.2.3. Tax number:

8.2.2.4 Other (please specify):

8.2.3 Where applicable, registration of the legal person 15

8.2.3.1 Registration number:

8.2.3 2 Designation of the register/registration authority:

8.2.3.3 Date (dd/mm/yyyy) and place of registration:

8.2.4 Address

8.2.4.1 Street and number/PO box:

8.2.4.2 Place and postcode:

8.2.4.3 Country

 Belgium  Bulgaria  Czech Republic  Germany  Estonia  Ireland

 Greece  Spain  France  Croatia  Italy  Cyprus  Latvia  Lithuania

 Luxembourg  Hungary  Malta  Netherlands  Austria  Poland  Portugal

 Romania  Slovenia  Slovakia  Finland  Sweden

 Other (please specify ISO-code):

8.3 In case more than one representative is appointed, the representatives act

 together (jointly) 16 ;

 concurrently 17 (if necessary please specify):

 separately 18  (if necessary please specify):

 as substitutes 19 (if necessary please specify):

8.4 The powers of representation cover the following matters :

8.4.1  economic and financial matters

8.4.2  health

8.4.3  welfare and other personal matters

8.4.4  business or professional affairs or Adult’s share in (a) corporation(s)

8.4.5  legal representation of the Adult

8.4.6  choice of the applicable law

8.4.7  choice of jurisdiction

8. 4.8  other, please specify:

8.1.5 The powers of representation

8.1.5.1 care currently in force

8.1.5.1.1 Date of entry into force (dd/mm/yyyy): …

8.1.5.2  will enter into force in the future

8.1.5.2.1  upon confirmation by a competent authority

8.1.5.2.2  upon unilateral declaration of the representative

8.1.5.2.3  upon a decision of a third party

8.1.5.2.4  Where applicable, type of evidence required (e.g. a medical certificate):

9.Advance directives

9.1 The authentic instrument records advance directives (instructions given and wishes made by a person) on the following matters

9.1.1  Health, if necessary please specify:

9.1.2  Welfare, including place of residence, if necessary please specify:

9.1.3  Other personal matters, if necessary please specify:

9.1.4  Economic and financial matters, if necessary please specify:

9.1.5  Choice of a natural person as a representative to be taken into account by the authorities taking a measure directed to the protection of the Adult

9.1.5.1 Surname(s) and given name(s) of the chosen representative:

9.1.5.2 Surname(s) of the chosen representative at birth (if different from point 9.1.5.1):

9.1.5.3 Date (dd/mm/yyyy) and place of birth:

9.1.5.5 Identification number 20 :

9.1.5.5.1 National identity number:

9.1.5.5.2 Social security number:

9.1.5.5.3 Tax number:

9.1.5.5.4 Other (please specify):

9.1.5.6 Address

9.1.5.6.1 Street and number/PO box:

9.1.5.6.2 Place and postcode:

9.1.5.6.3 Country

 Belgium  Bulgaria  Czech Republic  Germany  Estonia  Ireland

 Greece  Spain  France  Croatia  Italy  Cyprus  Latvia  Lithuania

 Luxembourg  Hungary  Malta  Netherlands  Austria  Poland  Portugal

 Romania  Slovenia  Slovakia  Finland  Sweden

 Other (please specify ISO-code):

9.1.6  Choice of a legal person as a representative to be taken into account by the authorities taking a measure directed to the protection of the Adult

9.1.6.1 Name of the organisation:

9.1.6.2 Registration of the organisation 21  

9.1.6.2.1 Registration number:

9.1.6.2.2 Designation of the register/registration authority:

9.1.6.2.3 Date (dd/mm/yyyy) and place of registration:

9.1.6.3 Address of the organisation

9.1.6.3.1 Street and number/PO box:

9.1.6.3.2 Place and postcode:

9.1.6.3.3 Country

□ Belgium □ Bulgaria □ Czech Republic □ Germany □ Estonia □ Greece □ Spain

□ France □ Croatia □ Italy □ Cyprus □ Latvia □ Lithuania □ Luxembourg

□ Hungary □ Malta □ Netherlands □ Austria □ Poland □ Portugal □ Romania

□ Slovenia □ Slovakia □ Finland □ Sweden

□ Other (please specify ISO– code):

9.1.6.4 Surname(s) and given name(s) of a person authorised to sign for the organisation:

9.1.6.5 Other relevant information (please specify):

9.1.6.6 Contact details

9.1.6.6.1 Telephone:

9.1.6.6.2 E–mail:

9.2 Other information in relation to the advance directives

9.2.1 Under the law of the state of origin:

9.2.1.1  advance directives have binding effects

9.2.1.2  advance directives should be treated as statements of wishes and preferences expressed by the Adult and should be given due respect

9.2.2 Other relevant information in relation to the advance directives:

10.Other information recorded in the authentic instrument:

11.Registration

11.1  The authentic instrument or one of its part is registered

in a register of the Member State of origin

in a register of another Member State

12.Any additional information which might be relevant:

If additional sheets have been added, state the total number of pages:

Done at:

On (dd/mm/yyyy):

Signature and/or stamp of the competent authority issuing the attestation:

Reference number of the attestation:

IMPORTANT

This Certificate is for use by a representative or representatives, who need to invoke their powers to represent an adult who, by reason of an impairment or insufficiency of his or her personal faculties, is not in a position to protect his or her interests.

This Certificate may be used to demonstrate that the person designated in this Certificate as a representative of the adult is authorised to represent the adult.

This Certificate is issued by a competent authority of a Member State where the measure was taken or powers of representation were confirmed (‘issuing authority’). The original of this Certificate remains in the possession of that issuing authority and only its certified copies are issued. The Certificate is valid until the date indicated in the appropriate box at the end of this form.

Effects of this Certificate in the Union:

-The person indicated in the Certificate as the adult’s representative is presumed to have the powers mentioned in the Certificate with no conditions and/or restrictions being attached to those powers other than those stated in the Certificate.

-Any person who, acting on the basis of the information certified in a valid Certificate, deals with someone indicated in the Certificate as the adult’s representative with respect to a certain matter, shall be considered to have dealt with someone with authority to represent the adult in that matters, unless the person knows that the contents of the Certificate are not accurate or valid or is unaware of such inaccuracy or invalidity due to gross negligence.

-The Certificate has these effects in the European Union, with the exception of Denmark [and Ireland].

1.Competent authority that issued the Certificate

(‘Issuing authority’)

1.1 Member State of the issuing authority

□ Belgium □ Bulgaria □ Czech Republic □ Germany □ Estonia □ Ireland □ Greece

□ Spain □ France □ Croatia □ Italy □ Cyprus □ Latvia □ Lithuania □ Luxembourg

□ Hungary □ Malta □ Netherlands □ Austria □ Poland □ Portugal □ Romania □ Slovenia □ Slovakia □ Finland □ Sweden

1.2 Name and designation of the issuing authority:

1.3 Address of the issuing authority

1.3.1 Street and number/PO box:

1.3.2 Place and postcode:

1.4 Contact details

1.4.1 Telephone:

1.4.2 E–mail:

2.Details concerning the adult to be represented

(‘Adult’)

2.1 Surname(s) and given name(s):

2.2 Surname(s) at birth (if different from point 2.1):

2.3 Date of birth (dd/mm/yyyy):

2.4 Place of birth (town/country/(ISO code)):

2.5 Nationality

□ Belgium □ Bulgaria □ Czech Republic □ Germany □ Estonia □ Ireland □ Greece

□ Spain □ France □ Croatia □ Italy □ Cyprus □ Latvia □ Lithuania □ Luxembourg

□ Hungary □ Malta □ Netherlands □ Austria □ Poland □ Portugal □ Romania □ Slovenia □ Slovakia □ Finland □ Sweden

□ Other (please specify ISO– code):

□ Unknown

2.6 Identification number (please indicate the most relevant number(s))

2.6.1 National identity number:

2.6.2 Social security number:

2.6.3 Tax number:

2.6.4 Other (please specify):

2.7 Address

2.7.1 Street and number/PO box:

2.7.2 Place and postcode:

2.7.3 Country

□ Belgium □ Bulgaria □ Czech Republic □ Germany □ Estonia □ Ireland □ Greece

□ Spain □ France □ Croatia □ Italy □ Cyprus □ Latvia □ Lithuania □ Luxembourg

□ Hungary □ Malta □ Netherlands □ Austria □ Poland □ Portugal □ Romania

□ Slovenia □ Slovakia □ Finland □ Sweden

□ Other (please specify ISO– code):

2.8 Contact details

2.8.1 Telephone:

2.8.2 E– mail:

2.8.3 Other contact information:

If the basis for the representation is a measure directed to the protection of the adult:

3.Source measure

3.1 The source measure was taken by:

□ the same authority that issues this Certificate

□ another competent authority in the Member State

3.2 If the measure was not taken by the competent authority that issues this Certificate, please indicate the name and designation of the competent authority that has taken the measure:

3.3 Reference number of the source measure:

3.4 Date when the source measure was taken (dd/mm/yyyy):

3.5 □ The source measure is registered in a Member State protection register 22

3.5.1 Additional details identifying the register:

3.5.2 Reference number of the source measure in the register:

3.6 □ The measure is subject to an appeal under the law of the Member State of origin

3.6.1 □ The measure that is subject to an appeal under the law of the Member State of origin is provisionally applicable

3.7 Based on the measure, the representative can act

3.7.1in the capacity of :

3.7.2 under the following law 23 :

If the basis for the representation is a confirmed powers of representation:

4.Source confirmed powers of representation

4.1 The powers of representation were confirmed by:

□ the same competent authority that issues this Certificate

□ another competent authority

4.2 If the powers of representation were not confirmed by the authority that issues this Certificate, please indicate the name and designation of the competent authority that has confirmed them:

4.3 Date when the powers of representation were drawn up by the Adult (dd/mm/yyyy):

4.4 Date of confirmation of the source confirmed powers of representation (dd/mm/yyyy):

4.5 Reference number of the source confirmed powers of representation:

4.6 □ The source confirmed powers of representation are registered in a Member State register 24

4.6.1 Additional details identifying the register:

4.6.2 Reference number of the source confirmed powers of representation in the register:

5.Representative(s) of the Adult

5.1 The number of the Adult’s representatives

□ One

□ More than one – Please indicate the number of the Adult’s representatives:

If the Adult has more than one representative, please fill in the Sections 6 (Details concerning the representative of the Adult), 7 (the powers of a representative) and 8 (limitations of the powers of the representative) for each of the representatives separately, attaching a sheet for each representative and numbering the representatives as the ‘Representative A’, ‘Representative B’ etc., as necessary.

5.2 If the Adult has more than one representative, how can the representatives represent the Adult? (Please choose one of the options)

□ Each of the Adult’s representatives can act alone or they can act together

□ All Adult’s representatives have to act together or in agreement

□ Each representative acts within the scope of powers entrusted to him or her and the representatives’ powers do not overlap

□ Other. Please explain the specific rules or arrangements concerning the Adult’s representation 25 :

6.Details concerning the representative of the Adult

(‘Representative’)

6.1 If the Representative is a natural person

6.1.1 Surname(s) and given name(s):

6.1.2 Date (dd/mm/yyyy) and place of birth (town/country/(ISO code)):

6.1.3 Identification number (please indicate the most relevant number)

6.1.3.1 National identity number:

6.1.3.2 Social security number:

6.1.3.3 Tax number:

6.1.3.4 Other (please specify):

6.1.4 Address

6.1.4.1 Street and number/PO box:

6.1.4.2 Place and postcode:

6.1.4.3 Country

□ Belgium □ Bulgaria □ Czech Republic □ Germany □ Estonia □ Ireland □ Greece

□ Spain □ France □ Croatia □ Italy □ Cyprus □ Latvia □ Lithuania □ Luxembourg

□ Hungary □ Malta □ Netherlands □ Austria □ Poland □ Portugal □ Romania

□ Slovenia □ Slovakia □ Finland □ Sweden

□ Other (please specify ISO– code):

6.1.5 Contact details

6.1.5.1 Telephone:

6.1.5.2 E–mail:

6.1.5.3 Other contact information:

6.2 If the Representative is a legal person

6.2.1 Name of the organisation:

6.2.2 Registration of the organisation (please indicate the most relevant number if applicable)

6.2.2.1 Registration number:

6.2.2.2 Designation of the register/registration authority:

6.2.2.3 Date (dd/mm/yyyy) and place of registration:

6.2.3. Address of the organisation

6.2.3.1 Street and number/PO box:

6.2.3.2 Place and postcode:

6.2.3.3 Country

□ Belgium □ Bulgaria □ Czech Republic □ Germany □ Estonia □ Greece □ Spain

□ France □ Croatia □ Italy □ Cyprus □ Latvia □ Lithuania □ Luxembourg

□ Hungary □ Malta □ Netherlands □ Austria □ Poland □ Portugal □ Romania

□ Slovenia □ Slovakia □ Finland □ Sweden

□ Other (please specify ISO– code):

6.2.4 Surname(s) and given name(s) of a person authorised to sign for the organisation:

6.2.5 Other relevant information (please specify):

6.2.6 Contact details

6.2.6.1 Telephone:

6.2.6.2 E–mail:

7.Powers of the Representative

7.1 Are the Representative’s powers limited to a particular intervention (i.e. limited to representing the Adult with respect to a specific legal act, transaction or other similar specific purpose)?

□ Yes

□ No, the powers are not limited to a particular intervention.

7.1.1 If the representation is limited to a particular intervention, please provide details about the nature of that intervention:

If they are not limited to a particular intervention, please fill in Sections 7.2 to 7.5.

7.2 Representation related to the Adult’s property

7.2.1 □ The Representative has any representative powers and/or rights related to Adult’s property matters, e.g. the administration, conservation or disposal of the Adult’s property and management of Adult’s assets

7.2.1.1 The Representative has the following powers and/or rights concerning the Adult’s immovable property:

□ continuous administration and conservation of the Adult’s immovable property and assets

□ to acquire immovable property in the Adult’s name or on the Adult’s behalf

□ conclude, renew and/or terminate vis– à– vis a third party a lease of immovable property belonging to the Adult

□ to sell the Adult’s immovable property

□ to donate the Adult’s immovable property

□ to dispose of the Adult’s immovable property other than by selling or donating it

□ to carry out works, alterations and repairs of the Adult’s immovable property, including a major ones

□ to enter, modify, or terminate a contractual relation concerning carrying out improvement works, alterations and repairs of the Adult’s immovable property

□ to create and terminate rights in rem on the Adult’s immovable property (usufruct, use, servitude, etc.) or otherwise encumber the Adult’s immovable property

□ to take out a mortgage on the Adult’s immovable property

□ to repay, modify, discharge or otherwise legally act with respect to a mortgage on the Adult’s immovable property

□ to represent the Adult in matters concerning the administration of an Adult’s building and/or land, including shared administration with other owners of the immovable property or inhabitants

□ to submit, receive, amend and/or withdraw applications and forms concerning the Adult’s immovable property

□ to make declarations concerning the Adult’s immovable property

□ to carry out legal acts and/or legal transactions with respect to the above matters related to Adult’s immovable property

□ to discharge of the Adult's responsibilities and legal obligations with respect to the above matters related to Adult’s immovable property

□ to assist the Adult with discharging of the Adult's responsibilities and legal obligations with respect to the above matters related to Adult’s immovable property

□ to conduct legal proceedings in the Adult’s name or on the Adult’s behalf with respect to the above matters related to Adult’s immovable property

□ to conduct, in the Adult’s name or on the Adult’s behalf, only specific legal proceedings with respect to the above matters related to Adult’s immovable property – Please specify the legal proceedings:

□ Other powers and/or rights of the Representative related to the Adult’s immovable property – Please specify:

7.2.1.2 The Representative has the following powers and/or rights concerning other property besides immovable one (hereinafter as: ‘other property’): (Please select any powers and/or rights with respect to other property of the Adult)

□ continuous administration and conservation of the Adult’s other property

□ to acquire other property in the Adult's name or on the Adult's behalf

□ to sell Adult’s other property

□ to make donations and/or gifts from the Adult’s other property

□ to make donations and/or gifts from the Adult’s other property under conditions 26  – Please specify:

□ to dispose of the Adult’s other property by other means than by selling or donating it

□ to enter in the Adult’s name or on the Adult’s behalf into liabilities concerning the Adult’s other property

□ to receive payments, income, capital and/or valuables

□ to manage and/or modify the Adult’s bank account(s), including all related transactions and legal acts

□ to receive information, including any account statements, from banks and similar institutions concerning the Adult’s bank account(s) and other property

□ to receive access and/or login details to the Adult’s bank account(s)

□ to open a new bank account in the Adult’s name or on the Adult’s behalf

□ to apply for the issue of (a) credit card(s) to the Adult’s bank account(s) and to receive it

□ to apply for the issue of (a) debit card(s) to the Adult’s bank account(s) and to receive it

□ to establish, modify or terminate direct deposits or scheduled payments from the Adult’s bank account(s)

□ to close Adult’s bank account(s) and transfer or withdraw funds from the account(s)

□ to withdraw money and make payments from the Adult’s bank account(s)

□ to use the Adult’s financial means and make payments

□ to use the Adult’s financial means and make payments to fulfil existing legal obligations of the Adult vis– à– vis third parties concerning other property (such as repayment of credit cards etc.)

□ to use the Adult’s financial means and make payments to cover his or her costs for performing the role as a Representative

□ to use the Adult’s financial means and make payments for the purpose of – Please specify:

□ to reutilise excess capital and income

□ to receive information on the Adult’s other financial instruments

□ to manage and/or modify (a) contract(s) for Adult’s securities and financial instruments

□ to terminate (a) contract(s) for the management of Adult’s securities and financial instruments

□ to act in the Adult’s name or on Adult’s behalf concerning transactions involving securities and financial instruments

□ to discharge of any Adult’s debts and/or other obligations that are legally enforceable

□ to discharge of any Adult’s debts and/or other obligations

□ to carry out legal acts and/or legal transactions concerning other property

□ to carry out (a) contract(s) entered into by the Adult concerning other property

□ to discharge of the Adult's responsibilities and legal obligations concerning other property

□ to assist the Adult with discharging of the Adult's responsibilities and legal obligations concerning other property

□ to conduct legal proceedings in the Adult’s name or on the Adult’s behalf concerning Adult’s other property

□ to conduct, in the Adult’s name or on the Adult’s behalf, only the following legal proceedings concerning the Adult’s other property – Please specify the legal proceedings:

□ Other powers and/or rights of the Representative related to other property – Please specify:

Comments:

7.2.1.3 The Representative has the following powers and/or rights related to succession: (Please select those which apply)

□ to accept inheritance or other performance from an estate

□ to refuse inheritance or other performance from an estate

□ to refuse inheritance or other performance from an estate if the estate is over– indebted

□ to represent the Adult in any succession proceedings, including with respect to judicial authorities and/or financial or taxation ones

□ Other powers and/or rights of the Representative related to succession – Please specify:

Comments:

7.3 Representation related to the Adult’s person and the Adult’s personal welfare

7.3.1 □ The representative has any powers and/or rights concerning health– related interests of the Adult

7.3.1.1 The Representative has the following health– related powers and/or rights: (Please select those which apply)

□ to accompany the Adult for a healthcare treatment

□ to receive information concerning the Adult’s health

□ to consult medical documentation of the Adult

□ to authorise the release of medical documentation to other parties

□ to represent the Adult’s interests in health– related matters

□ to decide on an outpatient care of the Adult

□ to decide on an inpatient care of the Adult

□ to give a consent, to refuse to give a consent or to withdraw a consent to a health treatment, examination of other medical intervention

□ to decide on the continuation or discontinuation of health treatment, with the exception of life– sustaining treatment 27

□ to decide on the continuation or discontinuation of health treatment, including (dis)continuation of life– sustaining treatment 28

□ to carry out legal acts and/or legal transactions with respect to the above matters concerning healthcare interests of the Adult

□ to submit, receive, amend and/or withdraw applications and forms with respect to the above matters concerning healthcare interests of the Adult

□ to conduct legal proceedings in the Adult’s name or on the Adult’s behalf with respect to the above matters concerning healthcare interests of the Adult

□ to conduct, in the Adult’s name or on the Adult’s behalf, only specific legal proceedings with respect to the above matters concerning healthcare interests of the Adult: – Please specify the legal proceedings:

□ Other health– related powers and/or rights of the Representative – Please specify:

Comments:

7.3.2 □ The Representative has any powers and/or rights concerning the Adult’s place of residence or housing

7.3.2.1 The Representative has the following powers and/or rights: (Please select those which apply)

□ to determine the place of residence of the Adult with the consent of the Adult

□ to determine the place of residence of the Adult with the consent of other person or authority

□ to determine the place of residence of the Adult

□ to conclude, modify or terminate a contract with an establishment or with a place providing housing

□ to conclude, modify or terminate a contract with an establishment or with a place providing housing with care or where protection of the Adult can be provided

□ so long as this is necessary, to decide on a transfer or admission of the Adult for an inpatient stay in a hospital or similar institution

□ to conclude a lease for an apartment or other form of housing intended for the Adult’s living and to modify or terminate that contract

□ to determine other practical matters concerning the Adult’s household

□ to represent the Adult in matters concerning the administration of a building and/or land where the Adult lives, including shared administration with other owners or inhabitants

□ to carry out legal acts and/or legal transactions with respect to the above matters concerning the Adult’s place of residence or housing

□ to submit, receive, amend and/or withdraw applications and forms with respect to the above matters concerning Adult’s place of living and housing

□ to discharge of the Adult's responsibilities and legal obligations with respect to the above matters concerning Adult’s place of residence or housing

□ to assist the Adult with discharging of the Adult's responsibilities and legal obligations with respect to the above matters concerning Adult’s place of residence or housing

□ to conduct legal proceedings in the Adult’s name or on the Adult’s behalf with respect to the above matters concerning the Adult’s place of residence or housing

□ to conduct, in the Adult’s name or on the Adult’s behalf, only specific legal proceedings with respect to the above matters concerning Adult’s place of residence or housing – Please specify the legal proceedings:

□ Other powers and/or rights concerning the Adult’s place of residence or housing – Please specify:

Comments:

7.3.3 The Representative has also the following other powers and/or rights related to the Adult’s person and or the Adult’s personal welfare: (Please select those which apply)

□ to determine what contact, if any, the Adult is to have with (a) specific person(s)

□ to make an order prohibiting (a) specific person(s) from having contact with the Adult

□ to take actions which will have the effect on the Adult’s membership in association or other organisations

□ to take any act relating to the Adult’s pet or domestic animal

□ Other powers and/or rights related to the Adult’s person and or the Adult’s personal welfare – Please specify:

Comments:

7.4 Representation related to the Adult’s legal and business affairs

7.4.1 The Representative has the following general powers and/or rights related to a management of the Adult’s legal and business affairs (Please select those which apply):

□ to make decisions and actions related to running the Adult’s business, trade, or other professional activities that are of an interim, temporary or routine nature

□ to make decisions and actions related to running the Adult’s business, trade, or other professional activities, including interventions with a permanent or structural impact on the course of the business, trade, or other professional activity

□ to make decisions and actions in connection with the Adult's shareholding in a company, including the exercise of shareholder rights (e.g. exercising voting rights at shareholder meetings) and other interventions, including the sale of a share

□ to conclude, renew and/or terminate a lease of business premises for the Adult’s business, trade, or other professional activities

□ to take actions which will have the effect on the Adult’s membership in business corporations or the Adult’s share in a corporation

□ to represent the Adult in dealings with banks and financial and/or credit institutions

□ to represent the Adult in dealings with insurance providers with respect to an insurance policies on matters within the scope of the Representative’s powers, including the conclusion, modification, renewal and/or termination of those policies

□ to represent the Adult in dealings with insurance providers with respect to insurance policies concerning the Adult’s property and assets, including the conclusion, modification, renewal and/or termination of those policies

□ to represent the Adult in dealings with insurance providers with respect to insurance policies concerning the Adult’s business or professional activities, including the conclusion, modification, renewal and/or termination of those policies

□ to represent the Adult in dealings with insurance providers with respect to insurance policies concerning the Adult’s person, including the conclusion, modification, renewal and/or termination of those policies

□ to represent the Adult in dealings with pension and social authorities

□ to represent the Adult in dealings with taxation and finance authorities

□ to represent the Adult in dealings with public authorities

□ to represent the Adult in dealings with other authorities or private entities

□ to represent the Adult when contracting with third parties

□ to make decisions related to the conclusions, modification or termination of contracts with respect to the above matters concerning Adult’s legal and business affairs

□ to carry out legal acts and/or legal transactions with respect to the above matters concerning the Adult’s legal and business affairs

□ to submit, receive, amend and/or withdraw applications and forms with respect to the above matters concerning Adult’s legal and business affairs

□ to discharge of the Adult's responsibilities and legal obligations with respect to the above matters concerning Adult’s legal and business affairs

□ to assist the Adult with discharging of the Adult's responsibilities and legal obligations with respect to the above matters concerning Adult’s legal and business affairs

□ to conduct legal proceedings in the Adult’s name or on the Adult’s behalf with respect to the above matters concerning Adult’s legal and business affairs

□ to conduct, in the Adult’s name or on the Adult’s behalf, only specific legal proceedings with respect to the above matters concerning Adult’s legal and business affairs – Please specify the legal proceedings:

□ Other powers and/or rights related to a discharge of the Adult’s legal and business affairs – Please specify:

Comments:

7.5 Other powers and/or rights of the Representative 

7.5.1 The Representative has the following other powers and/or rights: (Please select those which apply)

□ to delegate all his or her powers and rights to a third party

□ to delegate some of his or her powers and rights to a third party

□ to appoint his or her deputies with respect to all his or her powers and rights

□ to appoint his or her deputies with respect to some of his or her powers and rights Please specify:

□ to appoint an asset manager for the Adult’s property

□ to receive mail addressed to the Adult

□ within the scope of the Representative’s powers, to receive, open and read mail, including electronic mail, addressed to the Adult

□ Other powers and/or rights of the Representative – Please specify if there are other powers and/or rights of the Representative not mentioned in any of the above sections of the Certificate

Comments:

8.Limitations of the powers of the Representative

8.1 Are the above powers and/or rights of the Representative specifically limited to a particular Member State or territory?

□ No

□ Yes – Please specify which powers and/or rights are limited and the nature of the geographical limitation:

8.2 In the following matters, the Representative can act only subject to a consent by an authority, other entity, or a person 29 : (Please elaborate on those matters and the necessary consents)

8.2.1 This list of necessary consents is

□ illustrative

□ exhaustive

8.3 In the following matters, the Representative can act only subject to certain other conditions 30 : (Please elaborate on those matters and the related conditions)

8.3.1 This list of conditions is

□ illustrative

□ exhaustive

8.4 The Representative is not entitled to represent the Adult in the following

8.4.1 This list is of matters outside of the scope of Representative’s powers is

□ illustrative

□ exhaustive

8.4.2 The following powers are retained by the Adult under the applicable law 31 :

8.4.3 The following powers are retained by the Adult under the source measure or source confirmed powers of representation:

9.Validity of the Certificate

9.1 The issuing authority has considered the appropriate period of validity of the Certificate 32 and determined that the Certificate should be valid until (dd/mm/yyy):

9.2 Any comments concerning the period of validity of the Certificate:

10.Any additional information which might be relevant:

The issuing authority certifies that it has taken all steps pursuant to Article 38 of the Regulation (EU) 20XX/X, in particular that it:

-verified elements pursuant to Article 38(1) of the Regulation;

-consulted, where feasible, the system of interconnection pursuant to Article 38(3) of the Regulation;

-took or will take all necessary steps to inform the Adult and any person with legitimate interest about the issuance of this Certificate pursuant to Article 38(8) of the Regulation;

-determined the appropriate period of validity of the Certificate pursuant to Article 38(9) of the Regulation.

Reference number of the Certificate:

Date of the issuance of the Certificate (dd/mm/yyyy):

The Certificate is valid until (dd/mm/yyyy):

If additional sheets have been added, state the total number of pages:

Signature and/or stamp of the issuing authority:

CERTIFIED COPY

This certified copy of the European Certificate of Representation has been issued to:

Reference number of the copy:

Date of issue of the copy (dd/mm/yyyy):

Signature and/or stamp of the issuing authority:

For more information, please contact the issuing authority. 

INFORMATION BY THE CHOSEN AUTHORITIES ON THE EXERCISE OF THEIR JURISDICTION

(Article 6(2) of the Regulation (EU) 20XX/X)

To be used to inform the Central Authority of the Member State where an adult has his or her habitual residence that a measure directed to the protection of that adult has been taken in another Member State chosen by that adult. The choice should have been made in writing when the adult was still in position to protect his or her interests.

1.Authority which took the measure (‘Authority of origin’)

1.1 Member State

 Belgium  Bulgaria  Czech Republic  Germany  Estonia  Ireland  Greece

 Spain  France  Croatia  Italy  Cyprus  Latvia  Lithuania  Luxembourg

 Hungary  Malta  Netherlands  Austria  Poland  Portugal  Romania  Slovenia  Slovakia  Finland  Sweden

1.2 Name and designation of the authority:

1.3 Address

1.3.1 Street and number/PO box:

1.3.2 Place and postcode:

1.4 Contact details

1.3.1 Telephone:

1.3.2 E-mail:

2.Requested Central Authority

2.1 Member State of the Central Authority

 Belgium  Bulgaria  Czech Republic  Germany  Estonia  Ireland  Greece

 Spain  France  Croatia  Italy  Cyprus  Latvia  Lithuania  Luxembourg

 Hungary  Malta  Netherlands  Austria  Poland  Portugal  Romania  Slovenia

 Slovakia  Finland  Sweden

2.2 Name of the Central Authority: 

2.3 Address

2.3.1 Street and number/PO box:

2.3.2 Place and postcode:

2.3 Contact details

2.3.1 Telephone:

2.3.2 E-mail:

3.Adult concerned by the measure (‘Adult’)

3.1 Surname(s) and given name(s):

3.2 Surname(s) at birth (if different from point 3.1):

3.4 Date (dd/mm/yyyy) and place of birth:

3.5 Nationality

 Belgium  Bulgaria  Czech Republic  Germany  Estonia  Ireland  Greece

 Spain  France  Croatia  Italy  Cyprus  Latvia  Lithuania  Luxembourg

 Hungary  Malta  Netherlands  Austria  Poland  Portugal  Romania  Slovenia  Slovakia  Finland  Sweden

 Other (please specify ISO-code):

 Unknown

3.6 Identification number 33 :

3.6.1 National identity number:

3.6.2 Social security number:

3.6.3 Tax number:

3.6.4 Other (please specify):

3.7 Contact details

3.7.1 Telephone:

3.7.2 E-mail:

3.7.3 Other contact information:

4.Measure concerning the Adult

4.1 Date when the measure was taken (dd/mm/yyyy):

4.2 Date of expiration or renewal of the measure (dd/mm/yyyy):

4.3 The measure is registered in the register of the Member State of origin, please specify :

4.4 The measure was taken based on a choice of jurisdiction made by the Adult in writing on (dd/mm/yyyy):

4.5 The authority of origin has exercised its jurisdiction and verified that :

4.5.1 the Adult chose the authority when he or she was still in a position to protect his or her interests

4.5.2 the exercise of jurisdiction is in the interests of the Adult

4.5.3 the authorities having jurisdiction under Article 5 to 8 of the HCCH 2000 Protection of Adults Convention have not exercised their jurisdiction

5.Any additional information which might be relevant (including nature of the case, description of the measure and a brief statement of the facts, where appropriate):

Done at:

On (dd/mm/yyyy):

Signature and/or stamp of the competent authority issuing this communication form:

Reference number of the communication:

REQUEST FOR ASSISTANCE TO A CENTRAL AUTHORITY

(Chapter VI of Regulation (EU) 20XX/X)

To be used for the transmission, from the authorities of a Member State, to the Central Authority of another Member State, of an assistance request in a cross-border case.

For the purposes of the cooperation under Article 21 (placement) and 22 (designation of a representative abroad), the specific forms in Annex VI and VII shall be used.

1.Reference number of the requesting Authority:

2.Reference number of the requested Central Authority (if known):

3.Requesting Authority

3.1 Member State

 Belgium  Bulgaria  Czech Republic  Germany  Estonia  Ireland  Greece

 Spain  France  Croatia  Italy  Cyprus  Latvia  Lithuania  Luxembourg

 Hungary  Malta  Netherlands  Austria  Poland  Portugal  Romania  Slovenia  Slovakia  Finland  Sweden

3.2 Name and designation of the requesting authority:

3.3 Address

3.3.1 Street and number/PO box:

3.3.2 Place and postcode:

3.4 Contact details

3.4.1 Telephone:

3.4.2 E-mail:

4.Requested Central Authority

4.1 Member State

 Belgium  Bulgaria  Czech Republic  Germany  Estonia  Ireland  Greece

 Spain  France  Croatia  Italy  Cyprus  Latvia  Lithuania  Luxembourg

 Hungary  Malta  Netherlands  Austria  Poland  Portugal  Romania  Slovenia  Slovakia  Finland  Sweden

4.2 Name of the Central Authority:

4.3 Address

4.3.1 Street and number/PO box:

4.3.2 Place and postcode:

4.4 Contact details

4.4.1 Telephone:

4.4.2 E-mail:

5.Adult concerned by the request (‘Adult’)

5.1 Surname(s) and given name(s):

5.2 Surname(s) at birth (if different from point 5.1):

5.3 Date (dd/mm/yyyy) and place of birth:

5.4 Nationality

 Belgium  Bulgaria  Czech Republic  Germany  Estonia  Ireland  Greece

 Spain  France  Croatia  Italy  Cyprus  Latvia  Lithuania  Luxembourg

 Hungary  Malta  Netherlands  Austria  Poland  Portugal  Romania  Slovenia  Slovakia  Finland  Sweden

 Other (please specify ISO-code):

 Unknown

5.5 Identification number 34 :

5.5.1 National identity number:

5.5.2 Social security number:

5.5.3 Tax number:

5.5.4 Other (please specify):

5.6. Address

5.6.1 Street and number/PO box:

5.6.2 Place and postcode:

5.6.3 Country

 Belgium  Bulgaria  Czech Republic  Germany  Estonia  Ireland  Greece

 Spain  France  Croatia  Italy  Cyprus  Latvia  Lithuania  Luxembourg

 Hungary  Malta  Netherlands  Austria  Poland  Portugal  Romania  Slovenia

 Slovakia  Finland  Sweden

 Other (please specify ISO-code):

5.7 Contact details

5.7.1 Telephone:

5.7.2 E-mail:

5.7.3 Other contact information:

6.Measure concerning the Adult

6.1  A measure has been taken by the requesting authority on (dd/mm/yyyy):

6.1.1 Date of expiration or renewal of the measure (dd/mm/yyyy):

6.1.2 The measure is registered in the register of the Member State of the requesting authority; please specify:

6.2  An application for a measure has been made and is being processed

6.3  A measure, confirmed powers of representation or other powers of representation concerning the Adult is/are registered in the register of the Member State of the requesting Authority

 Belgium  Bulgaria  Czech Republic  Germany  Estonia  Ireland  Greece

 Spain  France  Croatia  Italy  Cyprus  Latvia  Lithuania  Luxembourg

 Hungary  Malta  Netherlands  Austria  Poland  Portugal  Romania  Slovenia  Slovakia  Finland  Sweden

6.4 Nature of the case, description of the measure and a brief statement of the facts (in an attachment to this form, where appropriate):

7.Details of the assistance requested

7.1  Information on the laws of the requested Member State in matters of the protection of adults (please specify):

7.2  Information on specific procedures of the requested Member State in matters of the protection of adults (please specify):

7.3  Information on specific services in the requested Member State in matters of the protection of adults (please specify):

7.4  Other information that should be provided by the Central Authority of requested Member State on matters of the protection of adults (please specify):

7.5  Assistance in applying the Regulation (EU) 20XX/X with respect to:

7.5.1  establishing jurisdiction (please specify):

7.5.2  establishing applicable law (please specify):

7.5.3  recognising or enforcing a measure (please specify):

7.5.4  carrying out direct communication between authorities

7.5.5  Other (please specify):

7.6  Location of the Adult. Please specify the information justifying the assumption that the Adult is present in the requested Member State:

7.7  Location of a person who is likely to provide support to the Adult.

7.7.1 Information on the person who is likely to provide support to the Adult

7.7.1.1 Surname(s) and given name(s):

7.7.1.2 Surname(s) at birth (if different from point 7.7.1.1):

7.7.1.3 Date (dd/mm/yyyy) and place of birth:

7.7.1.4 Nationality

 Belgium  Bulgaria  Czech Republic  Germany  Estonia  Ireland

 Greece  Spain  France  Croatia  Italy  Cyprus  Latvia  Lithuania

 Luxembourg  Hungary  Malta  Netherlands  Austria  Poland  Portugal  Romania  Slovenia  Slovakia  Finland  Sweden

 Other (please specify ISO-code):

 Unknown

7.7.1.5 Identification number 35 :

7.7.1.5.1 National identity number:

7.7.1.5.2 Social security number:

7.7.1.5.3 Tax number:

7.7.1.5.4 Other (please specify):

7.7.2 Please specify the information justifying the assumption that the person is present in the requested Member State:

7.7.3 Please specify the relationship of the person with the Adult:

7.8  Provision of information when a measure is contemplated, in accordance with Article 25 of the Regulation (EU) 20XX/X (please specify):

7.9  Use of mediation or other means of alternative dispute resolution to achieve agreed solutions:

7.10  Request of legal aid in accordance to Article 33 of the Regulation (EU) 20XX/XX 36 with respect to:

 Recognition of a measure

 Enforcement of a measure

 Service of judicial or extrajudicial document in another Member State

 Other proceedings under Chapter VI of Regulation (EU) 20XX/X

7.10.1 The request of legal aid was made by: …

7.11  Other (please specify):

8.Any additional information which might be relevant:

Done at:

On (dd/mm/yyyy):

Signature and/or stamp of the requesting authority:

Reference number of the request:

INFORMATION FROM THE CENTRAL AUTHORITY CONCERNING THE REQUEST FOR ASSISTANCE

1.Reference number of the requesting Authority (if known):

2.Reference number of the requested Central Authority:

3.Requesting Authority

4.Central Authority of the requested State

4.1 Member State

 Belgium  Bulgaria  Czech Republic  Germany  Estonia  Ireland  Greece

 Spain  France  Croatia  Italy  Cyprus  Latvia  Lithuania  Luxembourg

 Hungary  Malta  Netherlands  Austria  Poland  Portugal  Romania  Slovenia  Slovakia  Finland  Sweden

4.2 Name of the Central Authority:

4.3 Address

4.2.1 Street and number/PO box:

4.2.2 Place and postcode:

4.4 Contact details

4.4.1 Telephone:

4.4.2 E-mail:

5.Reply by the Central Authority 37

5.1  Please find below the information requested:

5.2  The request does not contain all of the following necessary information (please specify the information):

5.3  The request is refused for the following reason(s):

If additional sheets have been added, state the total number of pages:

Done at:

On (dd/mm/yyyy):

Signature and/or stamp of the Central Authority:

Reference number of this communication:

REQUEST CONCERNING THE PLACEMENT OF AN ADULT IN ANOTHER MEMBER STATE

(Article 21(1) of Regulation (EU) 20XX/X)

To be used for the communication between the authority of a Member State contemplating the placement of an adult in another Member State, and the Central Authority of the requested Member State.

An answer shall be provided by the requested Central Authority no later than 6 weeks following the receipt of this request.

1.Reference number of the requesting authority:

2.Reference number of the requested Central Authority (if known):

3.Requesting Authority

3.1 Member State

 Belgium  Bulgaria  Czech Republic  Germany  Estonia  Ireland  Greece

 Spain  France  Croatia  Italy  Cyprus  Latvia  Lithuania  Luxembourg

 Hungary  Malta  Netherlands  Austria  Poland  Portugal  Romania  Slovenia  Slovakia  Finland  Sweden

3.2 Name of the requesting authority:

3.3 Address

3.3.1 Street and number/PO box:

3.3.2 Place and postcode:

3.4 Contact details

3.4.1 Telephone:

3.4.2 E-mail:

4.Central Authority of the requested State

4.1 Member State:

 Belgium  Bulgaria  Czech Republic  Germany  Estonia  Ireland  Greece

 Spain  France  Croatia  Italy  Cyprus  Latvia  Lithuania  Luxembourg

 Hungary  Malta  Netherlands  Austria  Poland  Portugal  Romania  Slovenia  Slovakia  Finland  Sweden

4.2 Name of the Central Authority:

4.3 Address

4.3.1 Street and number/PO box:

4.3.2 Place and postcode:

4.4 Contact details

4.4.1 Telephone:

4.4.2 E-mail:

5.Adult concerned by the placement (‘Adult’)

5.1 Surname(s) and given name(s):

5.2 Surname(s) at birth (if different from point 5.1):

5.3 Date (dd/mm/yyyy) and place of birth:

5.4 Nationality

 Belgium  Bulgaria  Czech Republic  Germany  Estonia  Ireland  Greece

 Spain  France  Croatia  Italy  Cyprus  Latvia  Lithuania  Luxembourg

 Hungary  Malta  Netherlands  Austria  Poland  Portugal  Romania  Slovenia  Slovakia  Finland  Sweden

 Other (please specify ISO-code): ………………………………………………………………

 Unknown

5.5 Identification number 38 :

5.5.1 National identity number:

5.5.2 Social security number:

5.5.3 Tax number:

5.5.4 Other (please specify):

5.6 Address

5.6.1 Street and number/PO box:

5.6.2 Place and postcode:

5.6.3 Country

 Belgium  Bulgaria  Czech Republic  Germany  Estonia  Ireland  Greece

 Spain  France  Croatia  Italy  Cyprus  Latvia  Lithuania  Luxembourg

 Hungary  Malta  Netherlands  Austria  Poland  Portugal  Romania  Slovenia

 Slovakia  Finland  Sweden

 Other (please specify ISO-code):

5.7 Contact details

5.7.1 Telephone:

5.7.2 E-mail:

5.7.3 Other contact information:

6.Protection measure concerning the Adult

6.1 A protection measure has been taken by the requesting authority on (dd/mm/yyyy):

6.1.1 Date of expiration or renewal of the measure (dd/mm/yyyy):

6.1.2 The measure is registered in the register of the requesting State, please specify

6.2  An application for a protection measure has been made and is being processed.

7.Details of the placement contemplated

7.1 The placement of the Adult is contemplated in a specific establishment or institution in the requested Member State

7.1.1 Name or designation of the place:

7.1.2 Address

7.1.2.1 Street and number/PO box:

7.1.2.2 Place and postcode:

7.1.3. Contact details of the place (where available)

7.1.3.1 Telephone:

7.1.3.2 e-mail:

7.2  Placement is contemplated in an establishment or an institution in the requested Member State without a specification of the establishment or the institution

7.2.1 Any specification of the placement (please indicate any criteria or details affecting the selection of the placement in the requested Member State):

7.2.2 Any other information or comment:

7.3  The placement and its condition of implementation will be decided by the requesting authority.

7.4  The placement will be authorised by the requesting authority and will be carried out with the support of the following person:

7.4.1 Surname(s) and given name(s):

7.4.2 Surname(s) at birth (if different from point 7.4.1):

7.4.4 Date (dd/mm/yyyy) and place of birth:

7.4.6 Identification number 39 :

7.4.6.1 National identity number:

7.4.6.2 Social security number:

7.4.6.3 Tax number:

7.4.6.4 Other (please specify):

7.5 The placement is temporary and will end

7.5.1  on (dd/mm/yyyy):

7.5.2  after a specific period of time (please specify):

7.6  The Adult has:

7.6.1  had the opportunity to be heard

7.6.2  refused to be heard

7.6.3  agreed with the contemplated placement

7.6.4  Other (please specify):

7.7  Due the following reasons the Adult was not given the opportunity to be heard

7.7.1  Urgency of the situation 40 (please specify):

7.7.2  Other (please specify):

8. Reasons for the placement contemplated: 

9.Any additional information which might be relevant:

Done at:

On (dd/mm/yyyy):

Signature and/or stamp of the requesting authority:

INFORMATION FROM THE CENTRAL AUTHORITY CONCERNING THE REQUEST FOR A PLACEMENT

To be used for the communication between a Central Authority of the Member State where a placement of an adult was requested and the authority of another Member State requesting the placement.

1.Reference number of the requesting authority:

2.Reference number of the requested Central Authority:

3.Requesting Authority:

4.Central Authority of the requested State

4.1 Member State

 Belgium  Bulgaria  Czech Republic  Germany  Estonia  Ireland  Greece

 Spain  France  Croatia  Italy  Cyprus  Latvia  Lithuania  Luxembourg

 Hungary  Malta  Netherlands  Austria  Poland  Portugal  Romania  Slovenia  Slovakia  Finland  Sweden

4.2 Name and designation of the Central Authority:

4.3 Address

4.2.1 Street and number/PO box:

4.2.2 Place and postcode:

4.4 Contact details

4.3.1 Telephone:

4.3.2 E-mail:

5.Information from the Central Authority of the requested Member State

5.1  Placement of the Adult in the requested Member State is accepted

5.1.1. Placement of the Adult is accepted in the following establishment or institution:

 the establishment or the institution proposed by the requesting authority

 an establishment or an institution corresponding to the specifications made by the requesting authority

 an establishment or an institution corresponding to these specifications made by the requesting authority (please specify):

 Other (please specify): 

5.2  Placement of the Adult in the requested Member State is accepted under (a) condition(s).

5.2.1  Placement is only authorised provided that the establishment or the institution specified in point 5.1.1 has free capacity

5.2.2  Other conditions (please specify):

5.3  Placement in the requested Member State is refused for the following reasons:

5.3.1  the request does not fall within the scope of Regulation (EU) 20XX/X.

5.3.2  the request does not contain all of the necessary information pursuant to Article 21 of Regulation (EU) 20XX/XX.

5.3.3  the placement contemplated is contrary to fundamental principles of law of the requested Member State (please specify):

5.3.4  Other (please specify):

6.Any additional information which might be relevant:

Done at:

On (dd/mm/yyyy):

Signature and/or stamp of the Central Authority of the requested Member State:

Reference number of the communication:

REQUEST FOR THE DESIGNATION OF A REPRESENTATIVE ABROAD

(Article 22(1) of the Regulation (EU) 20XX/X)

To be used by authorities of one Member State to request the designation of a representative in another Member State with a view to protect the interests of the adult in that other Member State.

1.Reference number of the requesting authority:

2.Reference number of the requested Central Authority:

3.Requesting Authority

3.4 Member State

 Belgium  Bulgaria  Czech Republic  Germany  Estonia  Ireland  Greece

 Spain  France  Croatia  Italy  Cyprus  Latvia  Lithuania  Luxembourg

 Hungary  Malta  Netherlands  Austria  Poland  Portugal  Romania  Slovenia  Slovakia  Finland  Sweden

3.1 Name:

3.2 Address

3.2.1 Street and number/PO box:

3.2.2 Place and postcode:

3.3 Contact details

3.3.1 Telephone:

3.3.2 E-mail:

4.Central Authority of the requested Member State

4.4 Member State

 Belgium  Bulgaria  Czech Republic  Germany  Estonia  Ireland  Greece

 Spain  France  Croatia  Italy  Cyprus  Latvia  Lithuania  Luxembourg

 Hungary  Malta  Netherlands  Austria  Poland  Portugal  Romania  Slovenia  Slovakia  Finland  Sweden

4.1 Name and designation of the Central Authority:

4.2 Address

4.2.1 Street and number/PO box:

4.2.2 Place and postcode:

4.3 Contact details

4.3.1 Telephone:

4.3.2 E-mail:

5.Adult concerned by the measure (‘Adult’)

5.1 Surname(s) and given name(s):

5.2 Surname(s) at birth (if different from point 5.1.):

5.4 Date (dd/mm/yyyy) and place of birth:

5.5 Nationality

 Belgium  Bulgaria  Czech Republic  Germany  Estonia  Ireland  Greece

 Spain  France  Croatia  Italy  Cyprus  Latvia  Lithuania  Luxembourg

 Hungary  Malta  Netherlands  Austria  Poland  Portugal  Romania  Slovenia  Slovakia  Finland  Sweden

 Other (please specify ISO-code):

 Unknown

5.6 Identification number 41 :

5.6.1 National identity number:

5.6.2 Social security number:

5.6.3 Tax number:

5.6.4 Other (please specify):

5.7 The Adult benefits/has benefitted from legal aid or from exemption from costs and expenses, (please specify):

6.Protection measure concerning the Adult

6.1  A protection measure has been taken by the requesting authority on (dd/mm/yyyy)

6.2 Date of expiration or renewal of the measure (dd/mm/yyyy):

6.3  An application for a protection measure has been made and is being processed

6.4.  The measure is registered in the register of the Member State of origin, please specify

6.5  A representative is appointed in the Member State of origin

6.5.1 Surname(s) and given name(s):

6.5.2 Surname(s) at birth (if different from point 6.5.1):

6.5.4 Date (dd/mm/yyyy) and place of birth:

6.5.6 Identification number 42 :

6.5.6.1 National identity number:

6.5.6.2 Social security number:

6.5.6.3 Tax number:

6.5.6.4 Other (please specify):

6.1.1.Brief description of the tasks of the representative

6.5.7.1.  Management of financial assets

6.5.7.2  Management of immovable property (please specify the address):

6.5.7.3  Support concerning the Adult’s welfare or health.

6.5.7.4  Other (please describe shortly):

7.Details of the designation contemplated

7.1 The representative whom designation is contemplated :

7.1.1  is known by the requested authority

7.1.1.1 Surname(s) and given name(s):

7.1.1.2 Surname(s) at birth (if different from point 7.1.1.1.):

7.1.1.3 Date (dd/mm/yyyy) and place of birth:

7.1.1.4 Identification number 43 :

7.1.1.4.1 National identity number:

7.1.1.4.2 Social security number:

7.1.1.4.3 Tax number:

7.1.1.4.4 Other (please specify):

7.1.1.5 Address

7.1.1.5.1 Street and number/PO box:

7.1.1.5.2 Place and postcode:

7.1.1.5.3 Country

 Belgium  Bulgaria  Czech Republic  Germany  Estonia  Ireland

 Greece  Spain  France  Croatia  Italy  Cyprus  Latvia  Lithuania

 Luxembourg  Hungary  Malta  Netherlands  Austria  Poland  Portugal

 Romania  Slovenia  Slovakia  Finland  Sweden

 Other (please specify ISO-code):

 7.1.2 shall be chosen by the requested authority

7.2 Description of the case and the reasons why a representative shall be designated in the requested Member State:

7.3 The representative will support or replace the Adult in :

7.3.1  Management of financial assets

7.3.1.1 nature of the financial assets (please specify):

7.3.1.2 contact details of the financial institution (please specify):

7.3.2  Management of immovable property (please specify the address):

7.3.2  Support concerning the Adult’s welfare or health.

7.3.2  Other (please specify):

7.4 The representative should accomplish the following specific tasks, under the supervision of the requesting authority:

7.7  The assistance of the requested authority is necessary for the supervision of the representative, please specify:

7.5.  The designation is temporary and will end

7.5.1  on (dd/mm/yyyy):

7.5.2  after a specific period of time (please specify):

7.6  The Adult had the opportunity to be heard and:

7.6.1  has refused to be heard

7.6.2  has agreed with the contemplated designation

7.6.3  Other (please specify):

7.6  Due the following reasons the Adult was not given the opportunity to be heard

7.6.1  Urgency 44 of the situation (please specify):

7.6.2  Other (please specify):

8.Any additional information which might be relevant:

Done at:

On (dd/mm/yyyy):

Signature and/or stamp of the requesting authority:

Reference number of the communication: 

INFORMATION FROM THE CENTRAL AUTHORITY CONCERNING THE REQUEST FOR DESIGNATION OF A REPRESENTATIVE ABROAD

1.Reference number of the requesting authority:

2.Reference number of the requested Central Authority:

3.Requesting Authority:

4.Requested Central Authority

4.1 Name and designation of the Central Authority::

4.2 Address

4.2.1. Street and number/PO box:

4.2.2. Place and postcode:

4.3 Contact details

4.3.1. Telephone:

4.3.2. E-mail:

4.4. Member State

 Belgium  Bulgaria  Czech Republic  Germany  Estonia  Ireland  Greece

 Spain  France  Croatia  Italy  Cyprus  Latvia  Lithuania  Luxembourg

 Hungary  Malta  Netherlands  Austria  Poland  Portugal  Romania  Slovenia  Slovakia  Finland  Sweden

5.Information from the Central Authority

5.1  Request executed

5.1.1  The authority has designated the following representative

5.1.1.1 Surname(s) and given name(s):

5.1.1.2 Surname(s) at birth (if different from point 5.1.1.1.):

5.1.1.4 Date (dd/mm/yyyy) and place of birth:

5.1.1.6 Identification number 45 :

5.1.1.6.1 National identity number:

5.1.1.6.2 Social security number:

5.1.1.6.3 Tax number:

5.1.1.6.4 Other (please specify):

5.1.1.6.5 Contact details

5.1.1.6.5.1 Telephone:

5.1.1.6.5.2 E-mail:

5.1.2  The requested authority will assist with the supervision of the representative in accordance with the request, please specify:

5.1.3  The documents regarding the designation of the representative, including the decision or the measure, are attached.

5.2  Designation of the representative abroad cannot be granted for the following reason(s):

5.2.1  The following conditions are not met:

5.2.2  Designation of the representative requires the following advance payment

5.2.2.1 Amount of the payment requested:

5.2.2.2 Details of the bank account:

5.3.2  The request does not contain all of the necessary information. Please specify the information missing:

5.3  Designation of the representative abroad is refused for the following reason(s):

5.3.1  A deposit or advance was asked for on (dd/mm/yyyy): in accordance with Article 22(3) of Regulation (EU) 20XX/XX and has not been made.

5.3.2  The requesting authority has not complied with the request for additional information from the requested authority dated (dd/mm/yyyy):

5.3.3 The request does not fall within the scope of Regulation (EU) 20XX/XX

5.3.4 The designation or the assistance requested is not allowed under the law of the requested authority (please specify):

Done at:

On (dd/mm/yyyy):

Signature and/or stamp of the Central Authority:

Reference number of the communication:

COMMUNICATION BETWEEN AUTHORITIES

(Article 27(3) of the Regulation (EU) 20XX/X, and Article 8 of the HCCH 2000 Protection of Adults Convention)

To be used for the communication between the authorities of a Member State where the adult has his or her habitual residence and the authorities of another Member State.

The authority of a Member State may use this form to transfer its jurisdiction to the authorities of another Member State with which the adult has substantial connections, doing so either by its own motion or upon request of another competent authority.

REQUEST

1. Reference number of the requesting authority:

2. Reference number of the requested authority (if known):

3. Requesting Authority

3.1 Member State

□ Belgium □ Bulgaria □ Czech Republic □ Germany □ Estonia □ Ireland □ Greece □ Spain

□ France□ Croatia □ Italy □ Cyprus □ Latvia □ Lithuania □ Luxembourg □ Hungary □ Malta

□ Netherlands □ Austria □ Poland □ Portugal □ Romania □ Slovenia □ Slovakia □ Finland □ Sweden

3.2 Name of the requesting Authority:

3.3 Address:

3.3.1 Street and number/PO box:

3.3.2 Place and postcode:

3.4 Contact details

3.4.1 Telephone:

3.4.2 Email:

4. Requested Authority

4.1 Member State

□ Belgium □ Bulgaria □ Czech Republic □ Germany □ Estonia □ Ireland □ Greece □ Spain

□ France□ Croatia □ Italy □ Cyprus □ Latvia □ Lithuania □ Luxembourg □ Hungary □ Malta

□ Netherlands □ Austria □ Poland □ Portugal □ Romania □ Slovenia □ Slovakia □ Finland □ Sweden

4.2 Name of the requested Authority:

4.3 Address:

3.3.1 Street and number/PO box:

3.3.2 Place and postcode:

4.4 Contact details

3.4.1 Telephone:

4.4.2 Email:

5. Adult concerned by the measure (‘Adult’)

5.1 Surname(s) and given name(s):

5.2 Surname(s) at birth (if different from point 5.1):

5.3 Date (dd/mm/yyyy) and place of birth:

5.4 Nationality

 Belgium  Bulgaria  Czech Republic  Germany  Estonia  Ireland  Greece

 Spain  France  Croatia  Italy  Cyprus  Latvia  Lithuania  Luxembourg

 Hungary  Malta  Netherlands  Austria  Poland  Portugal  Romania  Slovenia

 Slovakia  Finland  Sweden

 Other (please specify ISO-code):

 Unknown

5.5 Identification number 46 :

5.5.1 National identity number:

5.5.2 Social security number:

5.5.3 Tax number:

5.5.4 Other (please specify):

5.6 Address

5.6.1 Street and number/PO box:

5.6.2 Place and postcode:

5.6.3 Country

 Belgium  Bulgaria  Czech Republic  Germany  Estonia  Ireland  Greece

 Spain  France  Croatia  Italy  Cyprus  Latvia  Lithuania  Luxembourg

 Hungary  Malta  Netherlands  Austria  Poland  Portugal  Romania  Slovenia

 Slovakia  Finland  Sweden

 Other (please specify ISO-code):

5.7 Contact details

5.7.1 Telephone:

5.7.2 E-mail:

5.7.3 Other contact information:

6. Origin of the request

6.1  made by the requesting authority on its own motion

6.2  from the following competent authority (please specify):

7. Nature of the measure to be taken by the requested authority:

7.1  relating to the Adult’s person (please specify) :

7.2  relating to the Adult’s property (please specify):

8. Justification of the request for the transfer of jurisdiction

8.1 Request is made in accordance with the following letter of Article 8(2) of the HCCH 2000 Protection of Adults Convention:

 letter a)

 letter b)

 letter c)

 letter d)

 letter e)

 letter f)

8.2 Justification of the request:

9.Any additional information which might be relevant:

Done at:

On (dd/mm/yyyy):

Signature and/or stamp of the requesting authority:

Reference number of the request:

INFORMATION FROM THE REQUESTED AUTHORITY

1. Reference number of the requesting authority (if known):

2. Reference number of the requested authority

3. Information from the requested authority

3.1  Jurisdiction is accepted

3.2  Jurisdiction is not accepted

3.3 The following relevant documents are attached to the reply:

3.3.1  The decision or the measure taken by the requested authority

3.3.2  Explanation why jurisdiction is not accepted

3.3.3  Other (please specify):

Done at:

On (dd/mm/yyyy):

Signature and/or stamp of the requested authority:

Reference number of the communication:

INFORMATION OR REQUEST BY AUTHORITIES OF ONE MEMBER STATE TO AUTHORITIES OF ANOTHER MEMBER STATE

(Article 27(4) of Regulation (EU) 20XX/X and Articles 7, 10 and 11 of the HCCH 2000 Protection of Adults Convention)

To be used by the authorities of a Member State for the transmission to the authorities of another Member State of information or a request relating to the exercise of their jurisdiction.

1.    Reference number of the requesting authority:

2.    Reference number of the requested authority:

3.    Requesting authority

3.1 Member State

□ Belgium □ Bulgaria □ Czech Republic □ Germany □ Estonia □ Ireland □ Greece □ Spain

□ France □ Croatia □ Italy □ Cyprus □ Latvia □ Lithuania □ Luxembourg □ Hungary □ Malta

□ Netherlands □ Austria □ Poland □ Portugal □ Romania □ Slovenia □ Slovakia □ Finland

□ Sweden

3.2 Name of the authority:

3.3 Address:

3.3.1 Street and number/PO box:

3.3.2 Place and postcode:

3.4 Contact details

3.4.1 Telephone:

3.4.2 Email:

4.    Requested authority

4.1 Member State

□ Belgium □ Bulgaria □ Czech Republic □ Germany □ Estonia □ Ireland □ Greece □ Spain

□ France □ Croatia □ Italy □ Cyprus □ Latvia □ Lithuania □ Luxembourg □ Hungary □ Malta

□ Netherlands □ Austria □ Poland □ Portugal □ Romania □ Slovenia □ Slovakia □ Finland

□ Sweden

4.2 Name of the authority:

4.3 Address:

4.3.1 Street and number/PO box:

4.3.2 Place and postcode:

4.4 Contact details

4.4.1 Telephone:

4.4.2 Email:

5. Adult concerned by a measure (‘Adult’)

5.1 Surname(s) and given name(s):

5.2 Surname(s) at birth (if different from point 5.1):

5.3 Date (dd/mm/yyyy) and place of birth:

5.4 Nationality

 Belgium  Bulgaria  Czech Republic  Germany  Estonia  Ireland  Greece

 Spain  France  Croatia  Italy  Cyprus  Latvia  Lithuania  Luxembourg

 Hungary  Malta  Netherlands  Austria  Poland  Portugal  Romania  Slovenia  Slovakia  Finland  Sweden

 Other (please specify ISO-code):

 Unknown

5.5 Identification number 47 :

5.5.1 National identity number:

5.5.2 Social security number:

5.5.3 Tax number:

5.5.4 Other (please specify):

5.6 Address

5.6.1 Street and number/PO box:

5.6.2 Place and postcode:

5.6.3 Country

 Belgium  Bulgaria  Czech Republic  Germany  Estonia  Ireland  Greece

 Spain  France  Croatia  Italy  Cyprus  Latvia  Lithuania  Luxembourg

 Hungary  Malta  Netherlands  Austria  Poland  Portugal  Romania  Slovenia

 Slovakia  Finland  Sweden

 Other (please specify ISO-code):

5.7 Contact details

5.7.1 Telephone:

5.7.2 E-mail:

5.7.3 Other contact information:

6. Details concerning the information or the request

6.1  A protection measure is contemplated:

6.1.1  concerning the person of the Adult

6.1.1.1  Under Article 7 of the HCCH 2000 Protection of Adults Convention

6.1.1.2  Under Article 11 of the HCCH 2000 Protection of Adults Convention

6.1.2  concerning the property of the Adult (Article 7 of the HCCH 2000 Protection of Adults Convention)

6.2  A protection measure has been taken:

6.2.1  Under Article 7 of the HCCH 2000 Protection of Adults Convention

6.2.2  Under Article 10 of the HCCH 2000 Protection of Adults Convention

6.3.  A decision has been made that no measures are to be taken (Article 7 of the HCCH 2000 Protection of Adults Convention).

6.4  Proceedings are pending concerning the protection of the Adult (Article 7 of the HCCH 2000 Protection of Adults Convention).

6.5  urgency measures of protection have been taken (Article 10 of the HCCH 2000 Protection of Adults Convention) (please specify):

6.6  measures of protection required by the situation have been taken, (Article 11(2) of the HCCH 2000 Protection of Adults Convention) (please specify):

7. Other information

7.1  Copies of the relevant decisions or measures are attached (please specify):

7.2  Other (please specify):

8.  For further information, please contact 

8.1  the requesting authority.

8.2  another authority which has taken the decision.

8.2.1 Name of the authority:

8.2.2 Address:

8.2.2.1 Street and number/PO box:

8.2.2.2 Place and postcode:

8.2.3 Contact details

8.2.3 1 Telephone:

8.2.3 2 Email:

Done at:

On (dd/mm/yyyy):

Signature and/or stamp of the authority:

Reference number of the communication:

ACKNOWLEDGEMENT OF RECEIPT OF A REQUEST OR INFORMATION

(Article 32 of Regulation (EU) 20XX/X and Articles 7, 10 and 11 of the HCCH 2000 Protection of Adults Convention)

1.    Reference number of the requesting competent or Central authority (if known):

2.    Reference number of the requested Authority or Central Authority (if known):

3.    Name of the requesting competent or Central Authority

4.    Requested competent or Central Authority

4.1 Member State

□ Belgium □ Bulgaria □ Czech Republic □ Germany □ Estonia □ Ireland □ Greece □ Spain □ France

□ Croatia □ Italy □ Cyprus □ Latvia □ Lithuania □ Luxembourg □ Hungary □ Malta □ Netherlands

□ Austria □ Poland □ Portugal □ Romania □ Slovenia □ Slovakia □ Finland □ Sweden

4.2 Name and designation of the requested competent or Central Authority:

4.3 Address

4.3.1 Street and number/PO box:

4.3.2 Place and postcode:

4.4 Contact details

4.4.1 Telephone:

4.4.2 E-mail:

5. Adult concerned by the measure (‘Adult’)

5.1 Surname(s) and given name(s):

5.2 Surname(s) at birth (if different from point 5.1):

5.3 Date (dd/mm/yyyy) and place of birth:

5.4 Nationality

□ Belgium □ Bulgaria □ Czech Republic □ Germany □ Estonia □ Ireland □ Greece □ Spain

□ France □ Croatia □ Italy □ Cyprus □ Latvia □ Lithuania □ Luxembourg □ Hungary □ Malta

□ Netherlands □ Austria □ Poland □ Portugal □ Romania □ Slovenia □ Slovakia □ Finland

□ Sweden

□ Other (please specify ISO-code):

□ Unknown

5.6 Identification number 48

5.6.1 National identity number:

5.6.2 Social security number:

5.6.3 Tax number:

5.6.4 Other (please specify):

6. The request or information was received on (dd/mm/yyyy) by the requested competent or Central Authority indicated in point 4:

7. The request cannot be dealt with or the information cannot be provided because:

7.1  The language used to complete the form is not accepted

7.1.1 Please use (one of) the following language(s):

7.2  The document is not legible

7.3  The request is not complete and the following necessary information is missing:

7.4 Other reason (please specify):

Done at:

On (dd/mm/yyyy):

Signature and/or stamp of the competent or Central Authority:

Reference number of this communication: