District No.

In the matter of

*Regulation (EC) No 1215/2012 on Jurisdiction and the Recognition and Enforcement of Judgments in Civil and Commercial Matters (the “Jurisdiction Regulation”)

*The Brussels Convention of the European Communities on Jurisdiction and the Enforcement of Judgments in Civil and Commercial Matters, 1968 (the “Brussels Convention”)

*The Lugano Convention on Jurisdiction and the Enforcement of Judgments in Civil and Commercial Matters Between Member States of the European Communities and the European Free Trade Association, 2007 (the “Lugano Convention”)

*Council Regulation (EC) 4/2009 of 18 December 2008 on Jurisdiction, Applicable Law, Recognition and Enforcement of Decisions and Cooperation in Matters relating to Maintenance Obligations (the “Maintenance Regulation”)

*The Rome Convention Between the Member States of the European Communities on the Simplification of Procedures for the Recovery of Maintenance Payments (the “Rome Convention”) and the Maintenance Act 1994

*The New York Convention on the Recovery Abroad of Maintenance (the “New York Convention”) and the Maintenance Act 1994

Record number:

of ................ Claimant

and .............

of ............. Respondent

I ..............*(solicitor for) the above claimant hereby certify:

1 That the claim(s) made in the document beginning the above proceedings which was lodged with this certificate *is a claim/*are claims which under the *(Jurisdiction Regulation) *(Jurisdiction of Courts and Enforcement of Judgments (European Communities) Act 1998) *(Maintenance Regulation), the Court has power to hear and determine by virtue of the provisions of Article(s)...... of *(the Jurisdiction Regulation) *(the Brussels Convention) *(the Lugano Convention) *(the Maintenance Regulation),

2 That the claim(s) brought by the claimant *is a claim/*are claims which the Court has jurisdiction to hear and determine by reason of the fact(s) that **.....

3 That no proceedings involving the same cause of action are pending between the parties in another *Member State *Contracting State.

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

Signed ....................

*(Solicitor for the) claimant

*delete where inapplicable

**for examples of clauses which might be inserted here see below

• The respondent is domiciled in the above District Court Area within the jurisdiction of the Honourable Court
• The claim against the respondent arises out of a contract and the place for performance of the obligations under the contract is within the jurisdiction of the Honourable Court and therefore, by virtue of *(Article 7.1 of the Jurisdiction Regulation) *(Article 5.1 of the Brussels Convention) *(Article 5.1 of the Lugano Convention) above-named, the Court has jurisdiction.
• The claim against the respondent is a claim in tort and the harmful event giving rise to the cause of action occurred in the above District Court Area within the jurisdiction of the Honourable Court.
• The claim against the respondent relates to and/or arises out of the operation of a branch, agency or other establishment of the respondent which said branch, agency or establishment is situated in the above District Court Area within the jurisdiction of the Honourable Court.
• The claim against the respondent is a claim in which the claimant is a policy holder under a policy of insurance and it is therefore a claim to which *(Article 11 of the Jurisdiction Regulation) *(Article 9 of the Lugano Convention) *(Article 8.2 of the Brussels Convention) applies. The Plaintiff is ordinarily resident/carries on a profession, business or occupation in the above District Court Area within the jurisdiction of the Honourable Court.
• The claim against the respondent is brought by the claimant in his/her capacity as a consumer in relation to a consumer contract to which *(Article 18 of the Jurisdiction Regulation) *(Article 16 of the Lugano Convention) *(Article 14 of the Brussels Convention) applies. The claimant is ordinarily resident/carries on a profession, business or occupation in the above District Court Area within the jurisdiction of the Honourable Court.
• The claim against the respondent is a claim to which *(Article 24 of the Jurisdiction Regulation) *(Article 22 of the Lugano Convention) *(Article 16 of the Brussels Convention) (relating to exclusive jurisdiction) applies and the Honourable Court has exclusive jurisdiction to hear and determine the claim because (give details as in relevant provisions of Article 24/Article 22/Article 16)
• The claim against the respondent arises out of a contract/agreement made between the claimant and the respondent which provided, inter alia, that the Honourable Court was to have jurisdiction in relation to matters arising out of the contract/agreement and, by virtue of *(Article 25 of the Jurisdiction Regulation) *(Article 23 of the Lugano Convention) *(Article 17 of the Brussels Convention), the Honourable Court is entitled to assume jurisdiction.
• The claimant’s claim is a claim relating to maintenance obligations and the claimant is habitually resident in the District Court Area above-named and the claim is within the jurisdiction of the Honourable Court by virtue of Article 3(b) of the Maintenance Regulation.
• The claimant’s claim is a claim relating to maintenance obligations and the claim is ancillary to proceedings concerning the status of a person (specify the proceedings concerned) which proceedings are within the jurisdiction of the Honourable Court by virtue of (specify the basis of the Court’s jurisdiction) and accordingly the claim relating to maintenance obligations is within the jurisdiction of the Honourable Court by virtue of Article 3(c) of the Maintenance Regulation.
• The claimant’s claim is a claim relating to maintenance obligations and the said claim is ancillary to proceedings concerning parental responsibility (specify the proceedings concerned) which proceedings are within the jurisdiction of the Honourable Court by virtue of (specify the basis of the Court’s jurisdiction) and accordingly the claim relating to maintenance obligations is within the jurisdiction of the Honourable Court by virtue of Article 3(d) of the Maintenance Regulation.
• The claimant’s claim is a claim relating to maintenance obligations and the parties have agreed in accordance with Article 4 of the Maintenance Regulation the Honourable Court shall have jurisdiction to settle any disputes in matters relating to a maintenance obligation which have arisen or may arise between them, and the Court is a court mentioned in Article 4.1*(a)*(b)*(c) of the Maintenance Regulation.