District No.

In the matter of Council Regulation (EC) 4/2009 on jurisdiction, applicable law, recognition and enforcement of decisions and cooperation in matters relating to maintenance obligations (the “Maintenance Regulation”) and the European Communities (Maintenance) Regulations 2011 (S.I. No. 274 of 2011).

and ........ of ........ Maintenance Debtor

Record number:

I, ........ , the District Court Clerk assigned to the above Court area, HEREBY CERTIFY that the sums payable to the District Court Clerk assigned to the above Court area by the above maintenance debtor now residing at ...... for transmission to the above maintenance creditor, domiciled at ....... under a maintenance order *(made) *(as varied) on the ...... day of ........ 20.... by ‡........

*and in respect of which an enforcement order was made by the Master of the High Court on the ...... day of ........ 20....,

*and which is a decision recognised within the meaning of Article 17.1 of the Maintenance Regulation,

*[have not been paid in full and that there is according to the best of my information and belief, in arrears the sum of €...... being the amount of weekly payments which have become due and payable up to and including the ...... day of ........ 20.... (together with the sum of €....... for costs and expenses, making in all the total sum of €.....)].

*[have been paid in full up to and including the ...... day of ........ 20.... and that there are no such sums in arrears at the date of this certificate.]

Dated this ...... day of ........ 20....

Signed ........

District Court Clerk assigned to the above District Court area,

District Court Office at........

IRELAND

*Delete where inapplicable

‡name of Court which made order