Attachment 5 Self Certification for Antimafia Communication.pdf
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- Attached to
- Family Advocacy Program at DMC
- Solicitation number
- W912PF26QA054
About this file
This is a self-certification form for Antimafia communication required as Attachment 10 to the Combined Synopsis Solicitation W912PF25QA065. The form is a declaration substitute for certification (Dichiarazione sostitutiva di certificazione) under Italian law (D.P.R. n. 445 del 28.12.2000) and serves as a template for respondents to complete.
The form requires the declarant to provide personal identification information including full name, tax identification number (Codice Fiscale), birthplace, province, date of birth, and current residence address. The declarant must also identify their position within the company and provide the company's name, tax identification number, and registered office address including province and street information. Under penalty of false declaration and resulting loss of any benefits obtained, the signatory declares that no grounds exist for prohibition, forfeiture, or suspension as specified in Article 67 of Italian Legislative Decree No. 159 of September 6, 2011. The form includes a notice regarding personal data protection under Italian Legislative Decree No. 196/2003, stating that collected personal data will be processed exclusively within the scope of the procurement procedure for which the declaration is made. The document requires the declarant's readable signature and date at the bottom.
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Attachment 10
Combined Synopsis Solicitation W912PF25QA065
Self-certification for Antimafia communication
Autocertificazione della comunicazione antimafia
Dichiarazione sostitutiva di certificazione (D.P.R. n. 445 del 28.12.2000)
Il/la sottoscritto/a (nome e cognome) _______________________________ C.F._________________ nato/a
_______________________________ Prov. _________ il ______________ residente a
________________________ Prov. _____ in via/piazza ____________________
_______________________________ n. ____, in qualità di (carica ricoperta) ___________ dell’impresa (indicare la denominazione) _______________________________________________ C.F. __________________ avente la sede in _________________________ Prov. di __________ Via ___________________________ n. ______ consapevole delle sanzioni penali in caso di dichiarazioni false e della conseguente decadenza dai benefici eventualmente conseguiti (ai sensi degli artt. 75 e 76 D.P.R. 445/2000) sotto la propria responsabilità che nei propri confronti non sussistono le cause di divieto, di decadenza o di sospensione di cui all’art. 67 del D.lgs. n. 159 del 06/09/2011.
DICHIARA
Il/la sottoscritto/a dichiara inoltre di essere informato/a, ai sensi del D.Lgs. n. 196/2003 (codice in materia di protezione di dati personali) che i dati personali raccolti saranno trattati, anche con strumenti informatici, esclusivamente nell’ambito del procedimento per il quale la presente dichiarazione viene resa.
data firma leggibile del dichiarante (2)
File details come from the government source that posted it. Updated .