Division UNDERTAKING TO REPAY COSTS OF CONSULAR PROTECTION (FINANCIAL ASSISTANCE) — (Article 14(1) of Directive (EU) 2015/637)

I, (Mr/Ms) (full name in block capitals)

…

holder of passport No … issued at …

hereby acknowledge receipt from the Embassy/Consulate of …

… at …

of the sum of …

as an advance for the purpose of …

… (including any applicable fee)

and/or undertake and promise to repay on demand to the Ministry of Foreign Affairs/Government of [Member State of nationality] …

in accordance with the national law of that Member State the equivalent of that sum or the equivalent of all costs as paid on my account or advanced to me, including costs incurred by the member(s) of my family accompanying me, in (currency) …

at the rate of exchange prevailing on the day on which the advance was made or the costs were paid.

My address^f1 (in block capitals) (country) …

is: …

…

…

DATE … SIGNATURE …