Division FORM E

Reference No of the transmitting agency:

Reference No of the receiving agency:

Addressee:

1. 1..

   The request cannot be executed without the following additional information:

   1. 1.1.

      Addressee’s identity^f2:

   2. 1.2.

      Date of birth :

   3. 1.3.

      Identification number/social security number/organisation number/or equivalent :

   4. 1.4.

      Other (please specify):

2. 2..

   The request cannot be executed without the following documents:

   1. 2.1.

      Documents to be served :

   2. 2.2.

      Proof of payment :

   3. 2.3.

      Other (please specify):

Done at:

Date:

Signature and/or stamp or electronic signature and/or electronic seal: