HAGUE CONFERENCE ON PRIVATE INTERNATIONAL LAW
                                (Revised 4.2.93)

                                 STANDARD FORM
                      FOR REPORTING OF CASES DECIDED UNDER
      THE CONVENTION ON THE CIVIL ASPECTS OF INTERNATIONAL CHILD ABDUCTION
         [Annex to the Report of the 2nd Special Commission Meeting, 18-21
         Jan 1993]

         Please submit this form, together with a copy of the court's
         opinion and, if this is available, a summary in English or French,
         to:

         Permanent Bureau of the
         Hague Conference on private international law
         6, Scheveningseweg
         2517 KT The Hague
         The Netherlands

         ESSENTIAL INFORMATION

         1     Date of decision:        ____________________

         2     Name of court:           ____________________

         3     Location of court:
                  (City)                ____________________
                  (Province or State)   ____________________
                  (Country)             ____________________

         4     Docket number or other identification number:
               __________________

         5     Names of parties or other case name (if permitted by law):
               _________________________
               _________________________
               _________________________

         6     The decision is (strike out what is not applicable):
                  A-     Interim Measure / Final Decision
                  B-     At First Instance / On Appeal
                  C-     Subject to Appeal / Not Subject to Appeal

         7     Articles of the Convention mentioned by the court:
               _____________________________________________

         8     Article upon which disposition of the case was based:
               _____________________________________________

         9     If return of a child was sought, was return ordered?
               _____________________________________________

         10    If access to the child was sought, was access ordered?
               _____________________________________________

         11    If return of the child was denied, was access ordered?
               _____________________________________________

         12    Where can an interested court, lawyer or other jurist obtain
               a copy of the full decision?

                  Name:                      ____________________
                  Address:                   ____________________
                  Telefax no:                ____________________
                  Cost of copy (if any):     ____________________

         OPTIONAL INFORMATION

         13    Issues under Article 3 mentioned by the court (Check each
               box which is appropriate):
                  [ ] rights of custody
                  [ ] joint custody
                  [ ] actual exercise of custody
                  [ ] habitual residence of the child

         14    Issues under Article 5 mentioned by the court:
                  [ ] definition of "rights of custody"
                  [ ] definition of "rights of access"

         15    Issues under Article 12 mentioned by the court:
                  [ ] date of "commencement of the proceedings"
                  [ ] date of "wrongful removal or retention"
                  [ ] whether or not the child was "settled in its new
                      environment"

         16    Issues under Article 13 mentioned by the court:

                  *13a Whether the person having the care of the child:
                  [ ] was not actually exercising the custody rights
                  [ ] consented to the removal or retention
                  [ ] acquiesced in the removal or retention

                  *13b Whether there was a grave risk that return would
                       expose the child to:
                  [ ]  physical harm
                  [ ]  psychological harm
                  [ ]  an otherwise intolerable situation

                  *13, 2nd para. Whether the child:
                  [ ]  objected to being returned
                  [ ]  had attained an age and degree of maturity at which
                       it was appropriate to take account of its views

         17    Were any of the following sanctions ordered in case the
               child was not returned:
                  [ ]  fine?
                  [ ]  imprisorunent?
                  [ ]  direct action by police or other authorities to pick
                       up the child?

         18    Was the person who removed or retained the child ordered to
               pay the costs of:
                  [ ]  return of the child (e.g. airline tickets)? legal
                       counsel for the applicant?
                  [ ]  travel and other expenses of the applicant?

         19    If return of the child was ordered, was it to:
                  [ ]  the parent left behind?
                  [ ]  the habitual residence of the child? (for example,
                       if the abductor accompanied the child on the way
                       back)
                  [ ]  the (temporary) care of a court, or other authority
                       (such as a juvenile authority) in the country of
                       habitual residence?

         20    Any other interesting information (if necessary, attach
               additional sheet):
               ___________________________________________________________
               ___________________________________________________________
               ___________________________________________________________
               ___________________________________________________________
               ___________________________________________________________
               ___________________________________________________________
               ___________________________________________________________
               ___________________________________________________________