B08-SOL_W912PF25QA015_Attachment4_Self Certification for Antimafia Communication.pdf

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Attached to
Custodial Services U. S. Army Garrison Darby Military Community (DMC) - Livorno
Solicitation number
W912PF25QA015
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This document is an Attachment 4 self-certification form for antimafia communication, a standard Italian legal declaration used in government contracting processes. The form is part of the solicitation W912PF25QA015 for Custodial Services at the U.S. Army Garrison Darby Military Community in Livorno, Italy. The document requires a potential contractor to declare under penalty of law that they do not have any disqualifying criminal associations that would prevent them from participating in a government contract, in compliance with Italian legal statutes (specifically D.P.R. n. 445 del 28.12.2000 and D.lgs. n. 159 del 06/09/2011). The form also includes a privacy consent statement acknowledging that personal data will be processed exclusively for the purposes of the contracting procedure.

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W912PF25QA015

ATTACHMENT 4

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 n.

Prov. di Via 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

DICHIARA

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.

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 .