Publications
| Practical operation documents | |
| Title | Annex C to the Special Commission Report of October 1994 |
| Year of publication | 1994 |
| Publisher | Hague Conference on Private International Law |
| Description (or download in PDF, if available) |
download in Word | download in PDF and complete online RECOMMENDED MODEL FORM CERTIFICATE OF CONFORMITY OF INTERCOUNTRY ADOPTION
Article 23 of the Hague Convention of 29 May 1993
1 -The undersigned authority: -The undersigned authority:
(Name and address of the competent authority of the State of adoption) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2 -Hereby certifies that the child: -Hereby certifies that the child:
Family name: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . First name(s): . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Sex: Male [ ] Female [ ] Date of birth: day . . . . month . . . . year . . . . Place of birth: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Habitual residence: . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3 -Was adopted according to the decision of the following authority: -Was adopted according to the decision of the following authority:. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Date of the decision: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Date at which the decision became final: . . . . . . . . . . . . . . . . . . .
(If the adoption was made otherwise than by a decision of an authority, please specify the equivalent details)
4 -By the following person(s): -By the following person(s):
a Family name of the adoptive father: . . . . . . . . . . . . . . . . . . . . Family name of the adoptive father: . . . . . . . . . . . . . . . . . . . .First name(s): . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Date of birth: day . . . . month . . . . year . . . . Place of birth: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Habitual residence at the time of the adoption: . . . . . . . . . . . . . .
b Family name of the adoptive mother: . . . . . . . . . . . . . . . . . . . . Family name of the adoptive mother: . . . . . . . . . . . . . . . . . . . .First name(s): . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Date of birth: day . . . . month . . . . year . . . . Place of birth: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Habitual residence at the time of the adoption: . . . . . . . . . . . . . .
5 -The undersigned authority certifies that the adoption was made in accordance with the Convention and that the agreements under Article 17, sub-paragraph c, were given by: -The undersigned authority certifies that the adoption was made in accordance with the Convention and that the agreements under Article 17, sub-paragraph c, were given by:a Name and address of the Central Authority of the State of origin: Name and address of the Central Authority of the State of origin:. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Date of the agreement: . . . . . . . . . . . . . . . . . . . . . . . . .
b Name and address of the Central Authority1 of the receiving State: Name and address of the Central Authority1 of the receiving State:. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Date of the agreement: . . . . . . . . . . . . . . . . . . . . . . . . .
6 -[ ]The adoption had the effect of terminating the pre-existing legal parent-child relationship. -[ ]The adoption had the effect of terminating the pre-existing legal parent-child relationship.[ ]The adoption did not have the effect of terminating the pre-existing legal parent-child relationship.
Done at . . . . . . . . . . . , on . . . . . . . . . .
Signature / Seal
(1)Or the public authority, body or person designated in accordance with Article 22(1) or (2) of the Convention. |