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1594
Uluslararası Adli İşbirliği
ANNEX No. 3
CERTIFICATE
(a)
* Issuing State: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . …………………
* Executing State: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(b) The authority which issued the decision imposing the financial penalty:
Official name. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Address. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . .. . . . . . ………
File reference: . . . . . . . . . . . . . . . . .. . . . .. . . . . . . . . . . . . . . . . . . . . ………
Tel. No: (country code) (area/city code) . . . . . . . . . .. . . . . . . . . ………
Fax No (country code) (area/city code) . . . . . . . . . .. . . . . . . . . . . . . . ………
E-mail (when available. . . . . …………….. . . . . . . . . . . . . . . . . . . . . . ………
Languages in which it is possible to communicate with the issuing authority. . . . . . . . . . . . . . . .
. . . . . . . . . . . .. . .
Contact details for person(s) to contact to obtain additional information for the purpose of
the enforcement of the decision or, where applicable, for the purpose of the transfer to the issu-
ing State of monies obtained from the enforcement (name, title/grade, tel. No., fax No., and, when
available,
E-mail) .. . . . . . . . . . . . . ………………………………………. . . . . . . . . . . .
(c) The authority competent for the enforcement of the decision imposing the financial pe-
nalty in the issuing State (if the authority is different from the authority under point (b)):
Official name:. . . . . . . . . . . . . . . . …………………………………………………..
Address:. . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Tel. No: (country code) (area/
city code)... . . . . . . . . . . . . . .. . .. . . . .
Fax No (country code) (area/city code). . . . . . . . …………. . . . . . . ………
E-mail (when available).. . . . . . . . . . . . . .. . . . . . . . . . . . . . . ………
Languages in which it is possible to communicate with the authority competent for the en-
forcement ........................
Contact details for person(s) to contact to obtain additional information for the purpose of
the enforcement of the decision or, where applicable, for the purpose of the transfer to the issu-
ing State of monies obtained from the enforcement (name, title/grade, tel. No., fax No., and, when
available, E-mail): . . . . . . . . . . . . . . . . . . . . . . . …………………………………………
(d) Where a central authority has been made responsible for the administrative transmission
of decisions imposing financial penalties in the issuing State: