Division

1. ☐

   I hereby request that the court, based on my application, issue a Preservation Order against the debtor.

2. ☐

   I declare that the information provided in this application is true and complete to the best of my knowledge and that I am aware that any deliberately false or incomplete statements may lead to legal consequences under the law of the Member State in which the application is lodged or to liability pursuant to Article 13 of Regulation (EU) No 655/2014.

3. ☐

   I hereby request that debtor's account information be obtained (please tick this box only if you are making a request for the obtaining of account information and have therefore filled in section 7 of this form).

If additional sheets have been added, please state the total number of pages and number each page:

Done at:

Date:

(dd/mm/yyyy)

Name, signature and/or stamp: