If you ticked the box regarding ‘other measures’, please specify which measure is concerned by ticking the appropriate box(es): □ an obligation not to engage in specified activities in relation with the offence(s) allegedly committed, which may include involvement in a specified profession or field of employment; □ an obligation not to drive a vehicle; □ an obligation to deposit a certain sum of money or to give another type of guarantee, which may either be provided through a specified number of instalments or entirely at once; □ an obligation to undergo therapeutic treatment or treatment for addiction; □ an obligation to avoid contact with specific objects in relation with the offence(s) allegedly committed; □ other measure (please specify):
\nThe text of the decision is attached to the certificate.
\nSignature of the authority issuing the certificate and/or of its representative to confirm the accuracy of the content of the certificate:
\nName:
\nPosition (title/grade):
\nDate:
\nFile reference (if any): (Where appropriate) Official stamp:
\nANNEX II FORM referred to in Article 19 of Council Framework Decision 2009/829/JHA of 23 October 2009 on the application, between Member States of the European Union, of the principle of mutual recognition to decisions on supervision measures as an alternative to provisional detention REPORT OF A BREACH OF A SUPERVISION MEASURE AND/OR ANY OTHER FINDINGS WHICH COULD RESULT IN TAKING ANY SUBSEQUENT DECISION (a) Details of the identity of the person subject to supervision:
\nSurname:
\nForename(s):
\nMaiden name, where applicable:
\nAliases, where applicable:
\nSex:
\nNationality:
\nIdentity number or social security number (if any):
\nDate of birth:
\nPlace of birth:
\nAddress:
\nLanguage(s) understood (if known): (b) Details of the decision on supervision measure(s):
\nDecision issued on:
\nFile reference (if any):
\nAuthority which issued the decision Official name:
\nAddress:
\nCertificate issued on:
\nAuthority which issued the certificate:
\nFile reference (if any): (c) Details of the authority responsible for monitoring the supervision measure(s):
\nOfficial name of the authority:
\nName of the person to be contacted:
\nPosition (title/grade):
\nAddress:
\nTel. (country code) (area code) Fax (country code) (area code) E-mail:
\nLanguages that may be used for communication: (d) Breach of supervision measure(s) and/or other findings which could result in taking any subsequent decision:
\nThe person referred to in (a) is in breach of the following supervision measure(s): □ an obligation for the person to inform the competent authority in the executing State of any change of residence, in particular for the purpose of receiving a summons to attend a hearing or a trial in the course of criminal proceedings; □ an obligation not to enter certain localities, places or defined areas in the issuing or executing State; □ an obligation to remain at a specified place, where applicable during specified times; □ an obligation containing limitations on leaving the territory of the executing State; □ an obligation to report at specified times to a specific authority; □ an obligation to avoid contact with specific persons in relation with the offence(s) allegedly committed. □ other measures (please specify):
\nDescription of the breach(es) (place, date and specific circumstances): — other findings which could result in taking any subsequent decision Description of the findings: (e) Details of the person to be contacted if additional information is to be obtained concerning the breach:
\nSurname:
\nForename(s):
\nAddress:
\nTel. No: (country code) (area/city code) Fax No: (country code) (area/city code) E-mail:
\nLanguages that may be used for communication:
\nSignature of the authority issuing the form and/or its representative, to confirm that the contents of the form are correct:
\nName:
\nPosition (title/grade):
\nDate:
\nOfficial stamp (where applicable):
\n1 OJ L 294, 11.11.2009, p. 20 1 Opinion not yet published in the Official Journal.
\n2 OJ L 190, 18.7.2002, p. 1 3OJ L 350, 30.12.2008, p. 60.
\n4 OJ L 191, 7.7.1998, p. 4.
\n5 OJ C 316, 27.11.1995, p. 49.
\n6 OJ L 190, 18.7.2002, p. 1.
\n7 This certificate must be written in, or translated into, the official language or one of the official languages of the executing Member State, or any other official language of the Institutions of the European Union that is accepted by that State.
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