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

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

…

born at (town) … in (country) …

on (date) …

holder of passport No … issued at …

on … and ID No …

and Social security No and competent authority (if applicable/where relevant)

…

hereby undertake to repay on demand to the Government of

…

in accordance with the national law of that Member State the equivalent of all costs as paid on my account or advanced to me by the consular officer

of the … Government at …

for the purpose of, or in connection with, the repatriation to …

of myself and the members of my family accompanying me, and to pay all appropriate consular fees in respect of the repatriation.

These are:

1. (i)Delete as appropriate: The Consular Officer and the applicant should initial each deletion in the margin.

   • Fares

   • Subsistence

   • Miscellaneous costs

   • LESS the contribution made by me

   • CONSULAR FEES:

     • Repatriation fee

     • Attendance fee

     • Passport/emergency fees

     • (… hours at … per hour …)

2. (ii)Delete as appropriate: The Consular Officer and the applicant should initial each deletion in the margin.

   All sums on my account for the purpose of, or in connection with, the repatriation of myself and the members of my family accompanying me which cannot be determined at the time this undertaking to repay is signed by me.

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

is: …

…

…

DATE … SIGNATURE …