Attachment 4 - F 4.15.2 Self declaration.pdf

F 4.15.2 Rev. 21 Oct 2025

F 4.15.2 Declaration in lieu of the affidavit

Companies and Self-Employed Workers Rev. 21 October 2025

INSTRUCTIONS:

To be completed by CONTRACTORS or SELF-EMPLOYED WORKERS Fill in only one of the two forms, depending on the applicable case:

Form A1 – Companies:

• Complete all fields with company information

• Fill in the checklist items with the required information in the grey boxes (letters d), e))

• Attach all documents listed at the bottom of the form

• Indicate place and date

• Apply company stamp and signature

• Return this self-certification to the Contracting Office (31 CONS) or to the requester of the work or service (Client).

Form A2 – Self-Employed workers:

• Complete all fields with company information

• Attach all documents listed at the bottom of the form

• Indicate place and date

• Apply stamp and signature

• Return this self-certification to the Contracting Office (31 CONS) or to the requester of the work or service (Client).

For clarification:

31 FW/CCPP, Prevention and Protection Office [Safety and Occupational Health – FN requirements, D.Lgs 81/08]

Email: 31FW.CCPP.DUVRI@us.af.mil Comm. +39 0434 307722 Hours: Mon-Fri 8.30-12.30/13.30 -17.30 Aviano Air Base, Bldg. 1472 mailto:31FW.CCPP.DUVRI@us.af.mil

A1 – COMPANY

DECLARATION IN LIEU OF THE AFFIDAVIT

(D.P.R. 28.12.2000, n. 445 – S.O. n. 30 alla G.U. n. 42 del 20.02.2001)

The undersigned in quality of Employer of the Company address phone VAT/ P.IVA Pec Fiscal Code/ CF INPS Assurance Position/s PAT INAIL Emplyment Contract / Contratto Collettivo Nazionale di Lavoro (C.C.N.L.) applied aware of the criminal penalties applicable in the event of false statements, pursuant to Articles 47 and 76 of Presidential Decree 28 December 2000, No. 445, and Article 11, paragraph 3 of Presidential Decree 20 October 1998, No. 403, having regard to Articles 26 (paragraph 1) and 90 (paragraph 9), and Annex XVII of Legislative Decree No. 81/2008, DECLARES

a) That the company is duly registered in the Business Register (Registro delle Imprese), with a Corporate Purpose relevant and appropriate to the type of work assigned.

b) That all obligations regarding occupational health and safety, as required by Legislative Decree No. 81/08 and subsequent amendments, have been fulfilled.

c) That the Risk Assessment Document (DVR) has been prepared.

d) That the Responsible of the Prevention and Protection Service (RSPP) has been appointed.

e) That the Occupational Health Physician has been appointed (Medico Competente).

f) That Fire Safety and Emergency Response Personnel, as well as First Aid Personnel, have been appointed and have received the required initial training and subsequent refresher training.

g) That Safety Monitors (Preposti) have been identified and have received the required initial training and subsequent refresher training.

h) That the workers have elected or designated the Workers’ Safety Representative (RLS), and that the RLS has received the mandatory initial training and subsequent refresher training.

i) That all machinery, equipment, and temporary works to be used during the performance of the activities comply with the provisions of

Legislative Decree No. 81/08, are accompanied by conformity documentation, and are subject to scheduled maintenance by competent personnel as well as legally required periodic inspections.

j) That all workers employed during the performance of the activities are duly registered in the company’s employment records and have been medically certified as fit for their assigned tasks.

k) That all workers are provided with adequate Personal Protective Equipment (PPE) necessary to safely perform their duties.

l) That all workers have received appropriate information, training, and instruction for their role and tasks, including general and specific safety training, qualification for the use of work equipment, and authorization for operating machinery.

m) That all workers are provided with an identification badge with photograph, containing their personal details (surname, name, date of birth, role or task), as well as the Employer’s details (company name, VAT number).

n) That the company is compliant with all legal tax, wage, and social security obligations.

o) That the company is not subject to any suspension or prohibition measures under Art. 14, paragraph 1 of Legislative Decree No. 81/2008.

p) That the company possesses all the required technical and professional suitability requirements (pursuant to Article 26, paragraph 1, letter a), point 2, and for construction sites, pursuant to Article 90, paragraph 9 of Legislative Decree No. 81/2008) and/or holds SOA certification where required.

q) That the company complies with the points-based license system (“Patente a Punti”) required under Article 27 of Legislative Decree No.

81/2008 for activities carried out in temporary or mobile construction sites (where applicable).

r) That, in the event of subcontracting, the technical and professional suitability of the subcontracted companies has been verified, and that cooperation has been ensured by providing the Client with all information necessary for the assessment of interference risks.

s) That an RCO (Employer’s Liability) and RCT (Third-Party Liability) insurance policy has been duly taken out.

Please, Attach the following:

• Copy of the Employer’s Identity Card (valid)

• Copy of the Certificate of Registration with the Chamber of Commerce, Industry and Crafts (recent copy)

• Single Insurance Contribution Compliance Certificate – DURC (valid)

• Single Tax Compliance Certificate – DURF (valid)

The Company authorized the processing of their data pursuant to EU Regulation 2016/679 (GDPR) and Legislative Decree 196/2003.

Place and date Stamp Employer Signature

A2 – SELF-EMPLOYED WORKER

DECLARATION IN LIEU OF THE AFFIDAVIT

(D.P.R. 28.12.2000, n. 445 – S.O. n. 30 alla G.U. n. 42 del 20.02.2001)

The undersigned in quality of Self-employed worker addess

Phone VAT / P.IVA Pec /e-mail Fiscal Code /CF aware of the criminal penalties applicable in the event of false statements, pursuant to Articles 47 and 76 of Presidential Decree 28 December 2000, No. 445, and Article 11, paragraph 3 of Presidential Decree 20 October 1998, No. 403, having regard to Articles 26 (paragraph 1) and 90 (paragraph 9), and Annex XVII of Legislative Decree No. 81/2008, DECLARES

Under their own responsibility:

a) That they are duly registered in the Business Register (Registro delle Imprese), with a Corporate Purpose relevant and appropriate to the type of work assigned.

b) That they have fulfilled all obligations regarding occupational health and safety as required by Legislative Decree No. 81/08 and subsequent amendments.

c) That all machinery, equipment, and temporary works to be used during the performance of the activities comply with the provisions of Legislative Decree No. 81/08, are accompanied by conformity documentation, and are subject to scheduled maintenance by competent personnel as well as legally required periodic inspections.

d) That they are equipped with adequate Personal Protective Equipment (PPE) necessary to safely perform their tasks.

e) That they have received appropriate occupational health and safety training for their role and tasks, including qualification for the use of work equipment and operation of machinery.

f) That they possess valid medical fitness certification, where expressly required (Articles 21 and 26 of Legislative Decree

81/2008).

g) That they are provided with an identification badge with photograph, containing their personal details (surname, name, date of birth, role or task), as well as the Employer’s details (company name, VAT number).

h) That they are compliant with all legal tax, wage, and social security obligations.

i) That they are not subject to any suspension or prohibition measures under Article 14, paragraph 1 of Legislative Decree No.

81/2008.

j) That they possess all required technical and professional suitability requirements (pursuant to Article 26, paragraph 1, letter a), point 2, and for construction sites, pursuant to Article 90, paragraph 9 of Legislative Decree No. 81/2008) and/or hold SOA certification where required.

k) That they comply with the points-based license system (“patente a punti”) required under Article 27 of Legislative Decree No. 81/2008 for activities carried out in temporary or mobile construction sites (where applicable).

l) That, in the event of subcontracting, they have verified the technical and professional suitability of the subcontracted companies and have cooperated by providing the Client with all information necessary for the assessment of interference risks.

m) That they have taken out an RCO (Employer’s Liability) and RCT (Third-Party Liability) insurance policy.

Please, Attach the following:

• Copy of the Declarant’s Identity Card (valid)

• Copy of the Certificate of Registration with the Chamber of Commerce, Industry and Crafts (recent copy)

• List of Personal Protective Equipment (PPE) provided

• Training Certificates

• Single Insurance Contribution Compliance Certificate – DURC (valid)

• Single Tax Compliance Certificate – DURF (valid)

The Company authorized the processing of their data pursuant to EU Regulation 2016/679 (GDPR) and Legislative Decree 196/2003.

Place and date Stamp Signature