STANDARD FORM FOR DETERMINING THE MEMBER STATE (1) RESPONSIBLE FOR EXAMINING AN APPLICATION FOR INTERNATIONAL PROTECTION

Request for taking charge presented on the basis of the following Article of Regulation (EU) No 604/2013:

Article 8 (unaccompanied minor):

Article 9 (family member resident in the Member State as a beneficiary of international protection):

Article 10 (family member applying for international protection in a Member State):

Article 11 (keeping family groups together):

Article 12(1) or (3) (valid residence document):

Article 12(2) or (3) (valid visa):

VIS No (where applicable) …

Article 12(4) (residence document which expired less than two years previously or visa which expired less than six months previously):

Article 13(1) (illegal entry at external frontier less than 12 months ago):

Article 13(2) (residence of at least 5 months in the Member State):

Article 14(1) (visa requirement waived for entry):

Article 16 (keeping an applicant together with a dependent relative)

Article 17(2) (sovereignty clause or humanitarian grounds):

Eurodac data:

Eurodac No: …

Reply requested urgently:

No later than: …

Reason for urgency: Article 28 (detention)

Article 21(2) (other reasons)

File number

Personal particulars of applicant

1. Surname (*)

Maiden name

2. Forename(s)

3. Does the applicant use/has he/she used other names?

What are/were they?

Yes

No

4. Date of birth

5. Place of birth

District/region

Country

6. Nationality(ies)

(indicate all)

a) current

b) previous

c) none/stateless

7. Sex

Male

Female

8. Name of father

9. Name of mother

Photo

(*) In block capitals.

10. Marital status

Single

Married

Widowed

Divorced

Cohabitee

11. Language(s) of origin

Personal particulars of family members

12. Spouse:

Surname (*), maiden name, forename(s), sex, date of birth, place of birth, place of residence (if the spouse is seeking international protection a separate form should be completed; in this case include the reference number of the other member of the couple on all forms).

Reference number of spouse (if necessary): …

13. Children:

Surname (*), forename(s), sex, date of birth, place of birth, place of residence (indicate all children; a separate form should be completed for children over 18 years of age if international protection is sought)

a) …

b) …

c) …

d) …

e) …

14. Place and date of the application for international protection in the country of residence: …

Previous asylum procedures

15. Has the applicant ever previously applied for international protection or recognition of refugee or subsidiary protection status in the country of residence or in another country?

Yes

No

When and where?

Was any decision taken on the application?

No

Don’t know

Yes, application rejected

When was the decision taken?

Identity papers

16. National passport

Number

Issued on

By

Valid until

Yes

No

17. Document replacing passport

Number

Issued on

By

Valid until

Yes

No

18. Other document

Number

Issued on

By

Valid until

Yes

No

19. In the absence of documents:

(specify whether they may have contained a valid visa or residence permit and, if so, indicate the issuing authority and date of issue as well as the period of validity)

Left without documents

Documents lost

Documents stolen

(When? where?

…)

Other reasons

(Please specify …)

Residence documents/visas

20. Does the applicant possess a residence document/visa for the country of residence?

Yes

No

Type of document

Residence permit

Entry visa

Transit visa

Issued on

By

Valid until

21. Does the applicant possess a residence document/visa for another EU Member State? (2)

Yes

No

Which State?

Type of document

Residence permit

Entry visa

Transit visa

Issued on

By

Valid until

Travel route

22. Country in which the journey was begun

(country of origin or of provenance)

Route followed from country where journey was begun to point of entry into country in which international protection is requested

Dates and times of travel

Crossed border on

At the authorised crossing point

or

Avoided border controls (entered illegally)

Means of transport used

Public transport (what form? …)

Own vehicle

Other means (how? …)

23. Did the applicant enter via another European Union Member State? (3)

Yes

No

Which was the first EU Member State entered?

Crossed border at authorised crossing point,

or

Avoided border controls at

When?

Residence in another EU Member State (4)

24. Residence in another EU Member State or States after leaving country in which journey was begun (country of origin/provenance)

Yes

No

In which State or States?

From – to

Place/exact address

Residence was

Authorised

Unauthorised

Period of validity of residence permit

Purpose of residence

Particulars of family members living in EU Member States (5)

25. a) Is any family member residing in a Member State?

Yes

No

Name of family member

Date of birth

Marital status

Single

Married

Widowed

Divorced

Relationship

spouse

father

mother

child

brother

sister

guardian

other (please specify)

Member State

Address in that State

Residence status

recognised beneficiary

resident

applicant

illegal

b) Do any of those concerned object to the examination of the application in that Member State?

Yes

No

Other useful information

(1) NB: The words ‘Member States’ include Iceland, Norway, Switzerland and Liechtenstein.

(2) Including Iceland, Norway, Switzerland and Liechtenstein.

(3) Including Iceland, Norway, Switzerland and Liechtenstein.

(4) Including Iceland, Norway, Switzerland and Liechtenstein.

(5) Including Iceland, Norway, Switzerland and Liechtenstein.

STANDARD FORM FOR REQUEST FOR TAKING BACK

Request for taking back presented on the basis of the following Article of Regulation (EU) No 604/2013:

Article 20(5) (process of determining the Member State responsible is under way in the Member State where the application was lodged):

Article 18(1)(b) (applicant made an application in another Member State or is in another Member State without a residence document, while application is under examination in the Member State responsible):

Article 18(1)(c) (third country national or stateless person has made an application or is in another Member State without a residence document after withdrawing his/her application in the Member State responsible):

Article 18(1)(d) (third country national or stateless person has made an application or is in the Member State without a residence document and his application has been rejected in the Member State responsible):

Eurodac data:

Eurodac No: …

Reply requested urgently:

No later than: …

Reason for urgency: …

File number

Personal particulars of applicant

1. Surname (*)

Maiden name

2. Forename(s)

3. Does the applicant use/has he/she used other names?

Yes

No

What are/were they?

4. Date of birth

5. Place of birth

District/region

Country

6. Nationality(ies)

(indicate all)

a) current

b) previous

c) none/stateless

7. Sex

Male

Female

8. Name of father

9. Name of mother

10. Marital status

Single

Married

Widowed

Divorced

Cohabitee

(*) In block capitals

Photo

11. Date of the application in the requesting country, of the Eurodac hit, or on which the requesting Member State became aware that the requested Member State may be responsible for the person concerned, as applicable

Previous procedures

12. Has the applicant ever previously applied for international protection or recognition of refugee status in the country of residence or in another country?

Yes

No

When and where?

Was any decision taken on the application?

No

Don’t know

Yes, application rejected

When was the decision taken

13. Does the applicant state that he left the territory of the Member States?

Yes

No

If yes:

Date of departure: …

Date of return: …

Which country(ies) did he go to?

Travel route:

14. Documents submitted by the applicant

Please enclose a list:

Other useful information:

Specimen laissez-passer for transfer of applicants for international protection

LAISSEZ-PASSER

Reference No (*):

Issued pursuant to Article 29(1) of Regulation (EU) No 604/2013 establishing the criteria and mechanisms for determining the Member State responsible for examining an application for international protection lodged in one of the Member States (1) by a third-country national or stateless person.

Valid only for transfer from … (2) to … (3), with the applicant required to present him/herself at … (4) by … (5)

Issued at: …

SURNAME: …

FORENAMES: …

PLACE AND DATE OF BIRTH: …

NATIONALITY: …

Date of issue …

For the Ministry for the Interior: …

SEAL

The bearer of this laissez-passer has been identified by the authorities … (6) (7).

This document is issued pursuant to Article 29(1) of Regulation (EU) No 604/2013 only and cannot under any circumstances be regarded as equivalent to a travel document permitting the external frontier to be crossed or to a document proving the individual’s identity.

(*) Reference number to be given by the country from which the transfer takes place.

(1) NB: The words ‘Member States’ include Iceland, Norway, Switzerland and Liechtenstein.

(2) Member State from which transferred.

(3) Member State to which transferred.

(4) Place where the applicant has to present him/herself upon arrival in the Member State responsible.

(5) Deadline by which the applicant has to present him/herself upon arrival in the Member State responsible.

(6) On the basis of the following travel or identity documents presented to the authorities.

(7) On the basis of a statement by the asylum applicant or of documents other than a travel or identity document.

Photo

REQUEST FOR INFORMATION PURSUANT TO ARTICLE 34 OF REGULATION (EU) No 604/2013

Date: / /

Reference No: …

Individual concerned:

Surname: …

Forename: …

Date of birth: …

Place of birth: …

Nationality: …

Indicative evidence enclosed:

Yes:

No:

(please specify)

This request for information concerns:

residence document:

appeal:

travel document:

decision:

visa:

expulsion:

application for international protection:

other:

Details: …

STANDARD FORM FOR THE TRANSFER OF DATA PRIOR TO A TRANSFER PURSUANT TO ARTICLE 31(4) OF REGULATION (EU) No 604/2013

Date (DD/MM/YY):

Transferring Member State:

Ref. number in the transferring Member State:

Responsible Member State:

Ref. number in the responsible Member State:

Data identifying the person to be transferred:

Family name: (if different in the responsible Member State please specify )

First name: (if different in the responsible Member State please specify )

Alias: (if different in the responsible Member State please specify )

Date and place of birth:

Nationality(ies):

Sex: M/F

Timeframe regarding the transfer:

Within six months of acceptance of the request;

Within six months of a decision on an appeal with suspensive effect; please indicate the date when the final decision on appeal or review was issued

Within one year of acceptance of the request, due to imprisonment of the person;

Within 18 months of acceptance of the request, due to absconding of the person.

Data regarding the transfer:

Type of transfer:

Voluntary transfer

By supervised departure

Under escort ; if possible, please provide details of the escort (name, function etc.)

Proposed date of the transfer (DD/MM/YY):

Means used to transfer the person to the responsible Member State:

By car (please provide specific details )

By train (please provide specific details )

By plane (please provide specific details )

Other (please mention which and provide specific details)

Location on the territory (1) of the responsible Member State where the person will be reporting to or handed over to the authorities:

(1) The expression “on the territory” covers both border points and internal territory, and both situations of escorted transfers (which may be limited to the border point) and situations of voluntary transfers (where the person is reporting to the asylum authorities inside the territory as well). The rules on the division of costs between the sending and receiving Member States are those stipulated in Regulation (EU) No 604/2013, Article 30.

Foreseen date and time of arrival in the responsible Member State:

The person to be transferred will be in possession of:

a laissez-passer;

other travel document; please indicate type and reference number

Documents the person will be carrying:

Other data regarding the person to be transferred:

Where the person travels with family:

Spouse; please provide name, age and reference numbers, if applicable

Children; please provide name, age and reference numbers, if applicable

Any other relative; please specify the relation, and provide the name, age and reference numbers, if applicable

Assistance needed upon arrival, other than health-related:

Contact details of family members, relatives and other family relations in the responsible Member State:

Languages spoken by the person(s) transferred:

If accompanying minors, provide, where possible, information on the level of education of the minors:

Health condition of the person(s) to be transferred:

All persons to be transferred appear fit to travel;

One or more persons to be transferred has/have health related concerns; in this case, please provide the name(s) and reference numbers of that/those person(s) and specify if corresponding health certificate(s) is/are attached:

yes;

no, the person is physically or legally incapable of giving consent and no vital interests of the applicant or of another person can be affected;

no, the person refused to consent to transmitting his/her health data.

Any other relevant information on the person(s) to be transferred:

STANDARD FORM FOR EXCHANGE OF INFORMATION ON THE CHILD, SIBLING OR PARENT OF AN APPLICANT IN SITUATIONS OF DEPENDENCY PURSUANT TO ARTICLE 16(4) OF REGULATION (EU) No 604/2013

PART A

DATA TO BE FILLED BY THE REQUESTING MEMBER STATE

Date (DD/MM/YY):

Ref. number:

Requesting Member State:

Requested Member State(s):

Data regarding the applicant:

Family name:

First name:

Date and place of birth (declared or documented by the applicant):

In the absence of that, age declared by the applicant:

Nationality(ies):

Sex: M/F

Proposed date for receiving a reply:

Information allowing to identify and locate the person possibly found on the territory of the requested Member State:

presumed relationship with the applicant:

child

sibling

parent

personal details of the child, sibling or parent:

Family name:

First name:

Date and place of birth:

Nationality(ies) (present and former):

Sex: M /F

Address in the requested Member State:

Please attach any photographic evidence which might be helpful in identifying the child, sibling or parent.

Photographic evidence annexed (if any).

claimed relationship of dependence:

the applicant claims to be dependent on the person;

the person claims to be dependent on the applicant.

type of dependence:

pregnancy

new-born child

serious illness

severe disability

old age

Any other comments:

PART B

DATA TO BE FILLED BY THE REQUESTED MEMBER STATE

Ref. number:

Information requested:

Concerning the presence of the person on the territory of the requested Member State, please specify:

Person was not found;

If the person mentioned above is legally resident in the requested Member State:

Yes

No

in an on-going procedure for obtaining legal residence (additional information: )

Any other situation (please mention which):

Where the person was identified and/or located, please provide:

First name:

Family name:

Date and place of birth:

Nationality:

Contact details: address, telephone number, etc.:

Any other information enabling to identify or locate the person (photographs, statements, administrative information, etc.)

In situations where a child, sibling or parent is (are) identified as legally resident(s) in the requested Member State:

Declared relationship with the applicant:

Please specify, following inquiry, the presumed nature of the relationship of the person identified with the applicant:

Please provide information on the type of data used to establish the relation (e.g. administrative certificates or other types of official documents found in the possession of the person)

Where applicable, presumed capacity of the person to take care of the applicant:

The person does not seem capable of taking care of the applicant

The person seems capable of taking care of the applicant

In the latter case, please provide preliminary information concerning any or all of the following aspects:

Basic evidence of material capacity to take care of the applicant (financial information, employment information, social security information, etc.) — please attach documentation;

Evidence of capacity to take care of the applicant (the person expresses desire in writing to take care of the applicant, the person seems socially and psychologically appropriate to take care of the applicant, the person already took care of the applicant in the past, etc.) — please attach written consent.

If applicable, name and contact details of public authority, representative services, NGO or IGO who were involved in identifying and locating the person, assessing the degree of relationship or in evaluating the capacity to take care of the applicant and that could be contacted by medical/social services in the requesting Member State

Any other comments:

STANDARD FORM FOR THE EXCHANGE OF INFORMATION ON THE FAMILY, SIBLINGS OR RELATIVES OF AN UNACCOMPANIED CHILD IN A DUBLIN PROCEDURE PURSUANT TO ARTICLE 6(5) OF REGULATION (EU) No 604/2013

PART A

DATA TO BE FILLED BY THE REQUESTING MEMBER STATE

Date (DD/MM/YY):

Ref. number:

Requesting Member State:

Requested Member State(s):

Data regarding the child:

Family name:

First name:

Date of birth as documented:

In the absence of that, age declared by the child:

Place of birth:

Age assessment made by the requesting MS:

Yes; please specify the method used for the assessment and the result;

No

Nationality(ies) or country of habitual residence, if considered stateless:

Sex: M /F

Proposed date for receiving a reply (1):

Reasons for the request for information (please tick any of the following boxes, as appropriate):

Information provided by the child: (please indicate briefly the content of the information helpful for the identification of the parent, sibling or relative)

The views of the child, [with regard to future care], in line with Article 6 of the Regulation

Information provided by another person traveling with the child: (please indicate the nature of the relation of this person to the child and briefly describe the content of the information helpful for the identification of the parent, sibling or relative);

Information provided through the representative: (please indicate briefly the content of the information helpful for the identification of the parent, sibling or relative);

Information provided via child protection channels/Red Cross/UNHCR/ICRC/other NGO or IGO: (please indicate which organisation and briefly describe the content of the information helpful for the identification of the parent, sibling or relative).

Concerning the identity of the following person possibly found on the territory of the requested Member State:

Family name:

First name:

Nationality(ies)

Sex: M /F

Contact details, if known (address, telephone number, as applicable):

Any other information allowing to locate the person in the requested Member State:

(1) The four weeks proposed deadline will be included in the relevant article of the implementing regulation.

Presumed relationship with the child:

parent

adult responsible

sibling

aunt/uncle

grandparent

any other family relation, not defined by the Regulation (please specify: )

Please attach any photographic evidence provided, which might be helpful in identifying the person concerned.

Photographic evidence annexed

Any other comments:

PART B

DATA TO BE FILLED BY THE REQUESTED MEMBER STATE

Ref. number:

Concerning the presence of the person on the territory of the requested Member State, please specify:

Person was not found;

Person was found; in this case, please provide:

Family name:

First name:

Date and place of birth:

Nationality:

Contact details, if known (address, telephone number, as applicable):

Any other information locating the person:

If the person mentioned above is legally present on the territory of the requested Member State:

Yes

No

in an on-going procedure for obtaining legal residence (additional information: )

Any other situation (please mention which):

If “yes”, under which status (please tick one or more of the following boxes, as applicable):

applicant for international protection

beneficiary of international protection

with short term visa

with residence permit or long stay visa

in a procedure for obtaining a residence permit

In prison (please specify the reason for this, the start of and length of imprisonment )

any other legal status (please specify )

If the person is present on the territory of the requested Member State with an irregular status:

In a return procedure

In prison (please specify the reason, the start of and length of imprisonment )

In detention (please specify the start of and length of detention period )

Any other situation (please mention which):

If the person is no longer present on the territory of the requested Member State:

Date of departure

(please provide date of return DD/MM/YY)

Person absconded

(please provide approximate date of absconding DD/MM/YY )

Any other situation (please specify)

If possible, in case whereabouts of the person are known, please provide contact details: address, telephone number, etc.

Any other information enabling to identify or locate the person (photographs, statements, administrative information, etc.)

If the requested Member State is or has been aware of the presence of family members or relatives, but no longer is aware of its whereabouts, please specify the circumstances of this presence

In situations where the person/persons mentioned above is/are present on the territory of the requested Member State:

Relationship of the person with the child:

Please specify, following inquiry, the presumed nature of the relationship of the person identified with the child:

Please provide information on the type of data used to establish the relation (e.g. administrative certificates or other types of official documents found in the possession of the person)

Presumed capacity of the person to take care of the child:

The person does not seem capable of taking care of the child

The person seems capable of taking care of the child

In the latter case, please provide preliminary indication concerning any or all of the following aspects:

Material evidence of capacity to take care of the child (financial information, employment information, social security information, etc.)

Evidence of capacity to take care of the child (the person wishes to take care of the child, the person seems socially and psychologically apt to take care of the child, the person already took care of the child in the past, etc.)

If applicable, name and contact details of public authority, representative services, NGO or IGO who were involved in identifying and locating the person, assessing the degree of relationship or in evaluating the capacity to take care of the child and that could be contacted by similar services in the requesting Member State

Any other comments or relevant information:

Attachments (where appropriate):

STANDARD FORM FOR EXCHANGE OF HEALTH DATA PRIOR TO A DUBLIN TRANSFER PURSUANT TO ARTICLE 32(1) OF REGULATION (EU) No 604/2013

(Common health certificate)

Date (DD/MM/YY):

Transferring Member State:

Ref. number in the transferring Member State:

Responsible Member State:

Ref. number in the responsible Member State:

Data identifying the person transferred:

Family name:

First name:

Date and place of birth:

Nationality(ies):

Sex: M /F

Information regarding the transfer:

Type of transfer:

Voluntary transfer;

By supervised departure;

Under escort.

Means used to transfer the person to the responsible Member State:

By car

By train

By plane

Other (please mention which and provide specific details )

I. Information provided by the transferring Member State

General evaluation of the person’s health:

Disabled

Elderly

Pregnant

Minor

Victim of torture or other form of physical violence

Victim of rape or other form of sexual violence

Victim of psychological violence

Suffering from a psychiatric condition

Suffering from any other condition that requires medical help

Please specify whether the evaluation was based on the person’s self-assessment or provided by a medical staff:

Medical diagnosis (if applicable):

If applicable, specify the treatment: and medication used

Duration of treatment (where known): from ; to

Specify whether treatment needs to continue upon arrival in the responsible Member State: until

Type of medical follow-up needed in the future (if known and considered necessary)