Fill and Sign the Hague Convention on International Child Abduction a Form

- 1 - REQUEST FOR RETURN Hague Convention of 25 October 1980 on the Civil Aspects of International Child Abduction_______________________________________Requesting Central Authority or Applicant _______________________________________ Requesting Authority Concerns the following child: __________________________ who will attain the age of 16 on __________________________, 20__. and __________________________ who will attain the age of 16 on __________________________, 20__. Note.--The following particulars should be completed insofar as possible.I --Identity of the Child and its Parents 1 Child Name and first names ____________________________________________________ Date and place of birth ____________________________________________________________________________________________________________________________ Passport or identity card No., if any ________________________________________ Description and photo, if possible (see annexes) ____________________________________________________________________________________________________________________________ Name and first names ____________________________________________________ Date and place of birth ____________________________________________________________________________________________________________________________ Passport or identity card No., if any _______________________________________ Description and photo, if possible (see annexes) ____________________________________________________________________________________________________________________________ 2 Parents - 2 - 2.1 Mother: Name and first names _____________________________________________ Date and place of birth ____________________________________________________________________________________________________________________________ Nationality ______________________________________________________ Occupation _______________________________________________________ Habitual-residence _______________________________________________ Passport or identity card No., if any ____________________________ 2.2 Father: Name and first names _____________________________________________ Date and place of birth ____________________________________________________________________________________________________________________________ Nationality ______________________________________________________ Occupation _______________________________________________________ Habitual residence _______________________________________________ Passport or identity card No., if any ____________________________ 2.3 Date and place of marriage _____________________________________________________________ II --Requesting individual or institution (who actually exercised custody before the removal or retention) 3 Name and first names ______________________________________________________________ Nationality of individual applicant _____________________________ Occupation of individual applicant ______________________________ Address _________________________________________________________ Passport or identity card No., if any ___________________________ Relation to the child ___________________________________________ Name and address of legal adviser, if any ____________________________________________________________________________________________________________________________ III --Place Where the Child is Thought To Be 4.1 Information concerning the person alleged to have removed or retained the child Name and first names ______________________________________________________________ Date and place of birth, if known - 3 - ______________________________________________________________ Nationality, if known ___________________________________________ Occupation ______________________________________________________ Last known address ______________________________________________________________ Passport or identity card No., if any ___________________________ Description and photo, if possible (see annexes) ____________________________________________________________________________________________________________________________ 4.2 Address of the child ______________________________________________________________4.3 Other persons who might be able to supply additional information relating to the whereabouts of the child ____________________________________________________________________________________________________________________________ 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: a. Name and first names _________________________________________ Date and place of birth ____________________________________________________________________________________________________________________________ Address __________________________________________________________ Telephone number _________________________________________________ b. Proposed arrangements for return of the child ________________________________________________________________________________ ____________________________________________________________________ - 4 - VIII—Other Remarks ________________________________________________________________________________ ________________________________ IX --List of Documents Attached ________________________________________________________________________________ _______________________________________________________________________________________ Date _____________________________________________________________ Place ____________________________________________________________ Signature and/or stamp of the requesting Central Authority or applicant_____________________________________________________