FORMAL STATEMENT TO THE PURPOSE OF ENTRY IN ITALY

In order to counter the spread of COVID-19 epidemic, the Decree of the President of the Council of Ministers issued on 13.10.2020 as well as the
Minister of Health Ordinances of 12 August 2020, 21 september 2020, with regard to entry into Italy, have established that:
➢ In the cases specifically provided for by this decree and in other cases in which the health authority, in the context of
the safety protocols provided for by this decree, it is compulsory show to the carrier upon boarding and to anyone in charge of control, a certificate
of having undergone, in the 72 hours prior to entry into the italian territory, a molecular or antigen test, carried out by means of a swab and having
negative result;
➢ All natural persons who in the 14 days prior to the entry into Italy, have stayed or passed through into states or territories
referred to in C, D, E and F lists, Annex 20, even if asymptomatic, are obliged to immediately communicate their entry in Italy to the Department
of prevention at the competent local health unit (ASL) of the entrance district, must comply with the following obligations: a) to use exclusively a
private vehicle to go from the place of entry into the italian territory or from the place of disembarkation of line transport means to the house or
residence where the period of health surveillance and fiduciary isolation will be carried out exept in case of airport transit; b) and are subject to
health surveillance and fiduciary isolation for a period of fourteen (14) days at their dwell or house as specified in this statement. In case of COVID-
19 symptoms onset, it is mandatory to report this situation immediately to the Health Authority through the pertinent telephone numbers;
➢ If it is not possible to reach dwell, house or residence indicated as the place where the surveillance period or fiduciary isolations should take
place, notwithstanding the assessment by the judicial authority regarding any falsity of the declaration made, the local Health Authority, which
informs immediately the Regional Civil Protection that, in coordination with the Department of Civil Protection of the Presidency of the Council
of Ministers, determine how and where to carry out surveillance health care and fiduciary isolation, with expenses borne exclusively by people
subjected to the aforementioned measures;
➢ in derogation from the provisions of the previous point, exclusively for proven working needs, absolute urgency or situations of necessity, health
reasons and for a maximum time not exceeding 120 hours; natural persons entering Italy, are obliged to immediately communicate their entry in
Italy to the Department of prevention at the competent local health unit (ASL) of the entrance district and must submit a formal statement to the
air company upon boarding, pursuant to Law art. 46, 47 of the Decree of the President of the Republic December 28, 2000, n. 445, specifying in
detail what the proven reason and duration of the permanence in Italy; dwell, house or residence address in Italy; private vehicle used to go from
the place of landing/arrival to the above mentioned address; telephone (eventually mobile) number to receive communications during the
permanence in Italy. At the end of such mentioned period, it is mandatory to leave Italian territory, otherwise sanitary surveillance and fiduciary
isolation must start and last for the next 14 days at the address declared, and in the event of COVID-19 symptoms’ onset, it is also obligatory to
report this situation immediately to the Department of prevention at the competent local health unit (ASL) through the pertinent telephone numbers
and start fiduciary isolation while health authorities are taking actions for the specific case;
➢ in case of land transport, transit in the Italian territory is authorized, also to the purpose of going to another State (EU or non-EU), by private or
personal vehicle, with the obligation to immediately communicate the entry in Italy to the Department of prevention at the competent local health
unit (ASL) relative to the entrance district, and, in the case of onset of COVID-19 symptoms, to report this situation promptly to the Health
Authority through the telephone numbers specifically dedicated. The maximum period of stay in Italy is 36 hours. In case of exceeding of this
period of stay, it is mandatory to communicate and submit health surveillance and fiduciary isolation.
➢ in case of air transport, passengers in transit with final destination in other EU or non-EU country are required to communicate to the air company
the reasons for the travel and length of stay in Italy, the last destination together with the identification code of the ticket and the vehicle used at
such purpose, as well as a phone (eventually mobile) number. In in the event of COVID-19 symptoms onset, it is mandatory to report it immediately
to the Department of prevention at the competent local health unit (ASL) through the pertinent telephone numbers and to submit isolation as for
the measures provided. The aforementioned passengers in any case must not move away from the airport areas specifically intended for them;
• The aforementioned provisions do not apply to:
a) crew and travel staff;
b) traveling employees;
c) to citizens and residents of the European Union member States and countries referred to in the A, B, C, D lists, Annex 20 who enter Italy for proven
work reasons, except those who in the previous 14 days have stayed or passed through the countries referred to in the C list;
d) health care personnel entering Italy to practice professional healthcare, including the temporary practice pursuant to Law art. 13 D.L. 17.03.2020,
n. 18;
e) to entrance for non-deferrable reasons, including participation in sporting events and exhibitions at international level, subject to authorization by
the Ministry of Health and with the obligation to present to the carrier upon boarding, and to anyone appointed to control procedures, the
certification of having undergone, in the 72 hours prior to entry into Italy, a molecular or antigen test, carried out by means of a swab and having
negative result;
f) cross-border workers entering and leaving the national territory for proven work reasons and the consequent return to their dwell, house or
residence;
g) staff of companies with registered or secondary offices in Italy who travels abroad with proven working needs that doesn’t exceed 120 hours;
h) movements to and from States in the A list, Annex 20;
i) European Union or international organizations’ officials and agents, to diplomatic agents, to diplomatic administrative and technical staff, to
consular officials and agents, Italian and foreign military and police personnel, fire fighters travelling for duty purposes;
j) pupils and students who attend a study course in a State other than that of residence, home or dwell, to which they return every day or at least once
a week.
• In any case it is allowed:
a) The entry into the national territory of citizens of the States referred to in art. 4, paragraph 1 letter f), of D.P.C.M. issued on 13 October 2020
and their family members as provided for by art. 2 and 3 of Directive 2004/38 / EC.
b) The entry into the national territory of third-country nationals residing for a long period according to Directive 2003/109 / EC as well as
third-country nationals who have the right of residence from other European provisions or national legislation as well as their respective
family members;
c) The entry into the Italian territory of third-country nationals residing in the countries referred to in list D, Annex 20;
d) entry to join a person to his/her dwell / home / residence as referred to in letters f) and h) of art. 4 co. 1 D.P.C.M. 13 October 2020, even if
not cohabiting, with whom there is a proven and stable affectionate relationship.

• Upon entry into Italy from the countries referred to in the C, D, E and F lists, Annex 20 subsists the obligation of health surveillance and fiduciary
isolation as referred to in article 6, D.P.C.M issued on 13.10.2020.
• Those who intend to enter Italian territory and who have stayed or transited in one or more countries in list C Annex 20 in the previous fourteen days
are obliged to either:
a) show to the carrier during boarding and to anyone in charge of control, certification that states to having undergone, in the 72 hours prior to entering
the national territory, a molecular or antigen test, by means of a swab and having a negative result;
b) or undergo molecular or antigen tests, by means of a swab, upon arrival at the airport, if possible, or within 48 hours of entering the national territory,
at the local health unit, with the obligation of fiduciary isolation at home or dwelling while waiting to undergo the test.

FORMAL STATEMENT PURSUANT TO LAW DPR N. 445/2000 ART. 46, 47

Being aware of the aforementioned information, the undersigned (surname name) ________________________________________, born on
___/___/_____, in _____________________________________ residence (city, address) ___________________________
__________________, living in (city, address)_______________________________, identification document and number _______________-
___________, issued by ____________, on ___/___/_____, phone number ____________________, and also aware of criminal consequences
in case of false information given to a Police Officer as provided by Criminal Law (art. 495 C.P.)

HEREBY DECLARES UNDER ITS OWN LIABILITY

• to be not subjected to quarantine measures and to have not tested positive for COVID-19 virus (except when the movements are provided by
health Authorities);
• the movement started from (address) __________________________________________________ and the destination address is
_____________________________________________________;
• to have knowledge of the current contagion containment measures, and not to have stayed or transited in the 14 days prior to entry into Italy
in Armenia, Bahrain, Bangladesh, Bosnia and Herzegovina, Brazil, Chile, Kosovo, Kuwait, Macedonia Northern, Moldova, Montenegro,
Oman, Panama, Peru, Dominican Rep., Colombia;
• to be aware of the sanctions provided for by D.L. n. 19, 23.03.2020, art. 4, law n°35 22.05.2020;
• I declare to be:
-coming or in transit from Belgium, France (including Guadeloupe, Martinique, Guyana, Réunion, Mayotte, and excluding other territories
located outside the European continent), Netherlands (excluding territories located outside the European continent), Czech Republic, Spain
(including territories on the African continent), United Kingdom of Great Britain and Northern Ireland (including Channel Islands, Gibraltar,
Isle of Man and British bases on the Island of Cyprus and excluding territories outside the European continent), being negative for the molecular
/ antigen test already carried out by means of a swab in the 72 hours prior to entering Italy;
-coming from or in transit from Belgium, France, (including Guadeloupe, Martinique, Guyana, Réunion, Mayotte, and excluding other territories
located outside the European continent), Netherlands (excluding territories located outside the European continent), Czech Republic, Spain
(including territories on the African continent), United Kingdom of Great Britain and Northern Ireland (including Channel Islands, Gibraltar,
Isle of Man and British bases on the Island of Cyprus and excluding territories outside the European continent) and will carry out the molecular
/ antigen test by means of a swab within 48 hours of entering Italy and, while waiting for this test to be carried out at the local health unit,
undergoing fiduciary isolation at the residence / dwelling located in___________________________________________________________
• that the movement is due to:
• working needs;
• absolute urgency;
• health needs;
• study needs;
• returning home, residence or usual dwelling place;
• family of residents of E.U., of signatory countries of the Schengen Agreement, of Andorra, of Principality of Monaco, of Republic of
San Marino, of Vatican City State, of Great Britain and Northern Ireland UE and third-country nationals residing for a long period
according to Directive 2003/109 / EC or of those who derive the right of residence from other European provisions or from National
legislation.
• entry to join a person to his/her dwell / home / residence as referred to in letters f) and h) of art. 4 co. 1 D.P.C.M. 13 October 2020, even
if not cohabiting, with whom there is a proven and stable affectionate relationship.

In this regard, the undersigned declares _______________________________________________________________________

Check Date, Time and Place ____________________________________________

DECLARANT POLICE OFFICER