DECLARATION 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 (DPCM) issued on 3.12.2020 with regard to entry
into Italy, have established that:
Pursuant to Article 6, DPCM issued on 3.12.2020, it is prohibited travel to and from States and territories referred to in list E of Annex 20, as well as the entry
and transit in the Italian territory to persons who have transited or stayed in the States and territories referred to in the same list E in the previous fourteen days,
unless one or more of the following reasons occur, declared as provided for by to Article 7, paragraph 1: a) working needs; b) absolute urgency; c) health needs;
d) study needs; e) returning home, residence or usual dwelling place; f) entry into the Italian territory of citizens of E.U. member states, of the Schengen
Agreement signatory countries, of Andorra, of Principality of Monaco, of Republic of San Marino, of Vatican City State, of Great Britain and Northern Ireland;
g) entry into the Italian territory of family members of natural persons as referred to in letter f), as defined in articles 2 and 3 of Directive 2004-38/CE dated
April 29, 2004 of EU Parliament and Council on the right of citizens of the Union and their family members to move and reside freely within the territory of the
Member States amending Regulation (EEC)no 1612/68 and repealing Directives 64/221/EEC, 68/360/EEC, 73/148/EEC, 75/34/EEC, 75/35/EEC, 90/364/EEC,
90/365/EEC and 93/96/EEC; h) entry into the Italian territory of third-country nationals residing for a long period according to Directive 2003/109/EC issued on
25.11.2003 or of third-country nationals deriving the right of residence from other European provisions or from National legislation; i) entry into the Italian
territory of family members of natural persons as referred to in letter h) as defined in articles 2 and 3 of Directive 2004-38/CE dated April 29, 2004 of EU
Parliament and Council on the right of citizens of the Union and their family members to move and reside freely within the territory of the Member States
amending Regulation (EEC)no 1612/68 and repealing Directives 64/221/EEC, 68/360/EEC, 73/148/EEC, 75/34/EEC, 75/35/EEC, 90/364/EEC, 90/365/EEC and
93/96/EEC; l) entry into the Italian territory to join a person, as referred to in letters f) and h), at his/her dwell/home/residence, even if not cohabitant, with
whom there is a proven and stable affectionate relationship.
The limitations set for specific areas of the national territory pursuant to article 1 par.3 of decree 33/2020 as well as the limitations established in relation to the
origin from specific states or territories pursuant to art. 1 par 4 of decree 33/20
Pursuant to Article 7 of the aforementioned Decree, without prejudice to prohibitions and limitations of entry into Italy provided for by Article 6, anyone who
enters the Italian territory, regardless of the period of stay, from foreign states or territories referred to in lists B, C D, E of Annex 20 are required to submit to
the carrier upon boarding and to anyone in charge with control procedures a declaration made pursuant to articles 46 and 47 of the decree of the President of the
Republic of 28 December 2000, no. 445, giving clear and detailed indications, such as to allow the verifications, of:
a) foreign countries and territories in which the person stayed or transited in the 14 days prior to entering Italy;
b) reasons for travelling pursuant to art. 6, in the case of entry from States and territories referred to in lists E of the Annex 20
c) in case of stay/transit in States/territories referred to lett. D, E of the Annex 20 in the 14 days prior to entry into Italy:
1) address of the home/residence in Italy where the period of health surveillance/fiduciary isolation will be carried out;
2) private means of transport that will be used to reach the place referred to in number 1) or, exclusively in the event if entry into Italy by scheduled air transport,
the additional scheduled air transport that must be used to go to the final destination and ticket identification code;
3) phone number for due communications during the health surveillance and fiduciary isolation period;
4) circumstance/s as referred to in Article 8, paragraphs 7 and 8.
In the cases provided for by this decree and in other cases as established by the Health Authority pursuing safety protocols, it is mandatory to submit to the
carrier upon boarding and to anyone in charge with control procedures the certification of having undergone, in the 48 hours prior to entry into the Italian
territory, of a molecular or antigen test, carried out by means of a swab having negative result.
Persons, who have stayed or passed through, in the fourteen days prior to entering Italy, in states or territories referred to in lists C, D, E and F of Annex 20,
even if asymptomatic, are obliged to immediately communicate their entry into the Italian territory at the Department of prevention at the competent local health
unit (ASL).
In the event of the onset of COVID-19 symptoms, the obligation remains for anyone to report this situation promptly to the Health Authority and to undergo
isolation pending the consequent determinations of the Health Authority.
 Pursuant to Art. 8 of the aforementioned DCPM, persons who have stayed/transited, in the 14 days prior to entry into Italy, in states or territories referred to in
lists D, E of the Annex 20, even if asymptomatic, must comply with the following obligations:
a) to use exclusively a private vehicle to go from the place of entry into the Italian territory to the house or residence where the period of health
surveillance/fiduciary isolation will be carried out pursuant to Article 7, paragraph 1, lett. c), except in case of airport transit referred to in paragraph 3;
b) are subject to health surveillance and fiduciary isolation for a period of fourteen (14) days at the residence or house specified as provided for by Article 7,
paragraph 1, letter c).
Without prejudice to paragraph 1, lett. a), in the event of entry into the Italian territory by scheduled air flight, it is allowed to continue the journey to the final
destination indicated in the declaration referred to in art. 7, c. 1, lett. c), by other scheduled air flight, provided not to leave the airport specifically limited areas.
In the cases referred to in paragraphs 1 and 2, if, from the place of entry into the Italian territory or of disembarkation from transportation means used to enter
Italy, it is not possible to actually reach, by private vehicle, home or residence where health surveillance/fiduciary isolation will be carried out, without prejudice
to the assessment by the judicial authority regarding the possible falsity of the declaration made at the time of boarding pursuant to article 7, c. 1, lett. c), the
competent health authority for the territory immediately informs the Regional Civil Protection which, in coordination with the Civil Protection Department of the
Presidency of the Council of Ministers, determines how and where to carry out health surveillance/fiduciary isolation, with expenses borne exclusively by the
persons subject to the aforementioned measure. In the event of the onset of COVID-19 symptoms, the subjects referred to in the previous period are obliged to
report this situation promptly to the Health Authority.
Those who enter Italian territory that have stayed or transited in one or more countries in list C Annex 20 in the previous fourteen days are obliged to either:
a) submit to the carrier, upon boarding, and to anyone in charge of control procedures, certification that states to having undergone, in the 48 hours prior to
entering the Italian territory, a molecular or antigen test, by means of a swab and having a negative result; In case of no presentation of declaration named in this
letter, paragraphs from 1 to 5 apply
b) without prejudice to letter a) paragraphs 1 to 5 apply for people who, between December 21 st and January 6th, enter Italy from countries and territories named
in list C of annex 20 for any reasons differing from art. 6 paragraph 1.
Provided the absence of COVID-19 symptoms and without prejudice to the obligations pursuant to art. 7, the aforementioned do not apply:
a) crew and travel staff;
b) traveling employees;
c) to travels to and from the States and territories referred to in List A of Annex 20;
d) to entrances for work reasons regulated by special safety protocols, approved by the competent health authority
e) to entrance for non-deferrable reasons, including participation in sporting events at international level, subject to authorization by the Ministry of Health and
with the obligation to submit to the carrier upon boarding, and to anyone in charge with control procedures, the certification of having undergone, in the 48
hours prior to entry into Italy, a molecular or antigen test, carried out by means of a swab and having negative result;
f) to anyone who enters Italy for a period not exceeding 120 hours for proven work, health or absolute urgency needs, with the obligation, at the expiry of
this term, to leave the Italian territory immediately or, failing that, to start the period of surveillance/fiduciary isolation in accordance with paragraphs 1 to 5 of
art. 8;
g) anyone who transits, by private vehicle, in the Italian territory for a period not exceeding 36 hours, with the obligation, at the expiry of that term, to
immediately leave the Italian territory or, failing that, to start the surveillance period/fiduciary isolation;
h) citizens and residents of an EU State and of the other States/territories indicated in lists A, B, C and D of the Annex 20 who enter Italy for proven work
reasons, unless they have stayed/transited in the states/territories referred to in list C in the 14 days prior to entering Italy;
i) 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,
converted, with amendments, by law 24 April 2020, n. 27;
j) to cross-border workers entering and leaving Italian territory for proven work reasons and for returning to one's residence/home/dwell;
k) staff of companies with registered or secondary offices in Italy who travels abroad with proven working needs that doesn’t exceed 120 hours;
l) European Union or international organizations’ officials and agents, to diplomatic agents, to diplomatic administrative and technical staff to consular
officials and agents, Law Enforcement, Secret Services, fire fighters travelling for duty purposes;
m) pupils and students who attend a study courses in a State other than that of residence, home or dwell, to which they return every day or at least once a week;
n) entries with so called “Covid-tested” flights according to Ministry of Health Ordonnance dated November 23, 2020 and subsequent modifications.
 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

 not to be subjected to quarantine measures and to have not tested positive for COVID-19 virus (except when the movements are provided by health
Authorities);
 the travel started from (address) __________________________________________________ and the destination address is
_____________________________________________________;
o to have knowledge of the current contagion containment measures, and to have stayed in the last 14 days prior to entrance in Italy in the following
countries/territories_________________________________________________________________________________________________________
o to be aware of the sanctions provided for by D.L. n. 19, 23.03.2020 converted by law n°35 of 22.05.2020;
o to be (until December 9, 2020) citizen coming from or in transit in one of the countries or territories named in list C of annex 20:
 Belgium, France (including Guadeloupe, Martinique, Guyana, Réunion, Mayotte, and excluding other territories located outside the European
continent), The Netherlands (excluding territories located outside the European continent), Czech Republic, Romania, 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 48 hours prior to entering Italy;
o to be (from December 10, 2020) citizen coming from or in transit in one of the countries or territories named in list C of annex 20:
 Austria, Belgium, Bulgaria, Ciprus, Croatia, Danemark (including Far Oer islands and Greenland), Estonia, Finland, France, (including
Guadeloupe, Martinique, Guyana, Réunion, Mayotte, and excluding other territories located outside the European continent), Germany, Greece,
Ireland, Latvia, Lithuania, Luxembourg, Malta, The Netherlands (excluding territories located outside the European continent), Poland,
Portugal (including Azores and Madeira) Czech Republic, Romania, Slovakia, Slovenia, Spain (including territories on the African continent),
Sweden, Hungary, 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), Iceland, Norway, Liechtenstein, Switzerland, Andorra
and Principality of Monaco and will carry out the molecular/antigen test by means of a swab within 48 hours of entering Italy;
o to have undergone, in the last 48 hours, prior to entry into Italy the molecular/antigen test by means of a swab with a negative outcome. Otherwise
o I will carry out the fiduciary isolation/health surveillance period as provided by art. 8, par. from 1 to 5 of DPCM dated December 3rd, 2020 at
following address________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
 that the movement is due to:
□ working needs (as well as those regulated by special safety protocols, approved by the competent Health Authority - ex Art 8 par.7 lett e);
□ absolute urgency;
□ health needs;
□ study needs;
□ returning home, residence or usual dwelling place;
□ entry into Italy as citizen of E.U. member states, of the Schengen Agreement signatory countries, of Andorra, of Principality of Monaco, of
Republic of San Marino, of Vatican City State, of Great Britain and Northern Ireland;
□ entry into the Italian territory of family members of a citizen referred to in the previous point;
□ entry into the Italian territory as third-country national residing for a long period according to Directive 2003/109/EC issued on 25.11.2003 or
third-country national deriving the right of residence from other European provisions or from National legislation;
□ entry into the Italian territory as family member of third-country national residing for a long period according to Articles 2 and 3 of Directive
2004/38/EC, relating to the right of EU citizens and their family members to move/reside freely within the territory of the Member States;
□ entry into the Italian territory to join a citizen of an E.U. Member State, of the Schengen Agreement signatory countries, of Andorra, of
Principality of Monaco, of Republic of San Marino, of Vatican City State, of Great Britain and Northern Ireland at his/her dwell/home/residence,
even if not cohabitant, with whom there is a proven and stable affectionate relationship.
□ being European Union or international organizations’ officials and agents, to diplomatic agents, to diplomatic administrative and technical staff, to
consular officials and agents, Law Enforcement, Secret Services, fire fighters travelling for duty purposes;
□ non-deferrable reasons, including participation in sporting events at international level, subject to authorization by the Ministry of Health and with
the obligation to present to the carrier to present to the carrier upon boarding, and to anyone in charge with control procedures, the certification of
having undergone, in the 48 hours prior to entry into Italy, a molecular or antigen test, carried out by means of a swab and having negative result;

 from December 21st, 2020 till January 6th, 2021- (if arriving from one of the countries named in the list C of annex 20) as the movement is due to the
above-mentioned reasons:
 I carried out the molecular or antigen test within 48 hours before entering Italy by means of a swab and the result is negative. Otherwise
 I will carry out the fiduciary isolation/health surveillance period as provided by art. 8, par. from 1 to 5 of DPCM dated December 3rd, 2020
at following address.
 from December 21st, 2020 till January 6th, 2021- (if arriving from one of the countries named in the list C of annex 20) as the movement is not due to
the above-mentioned reasons:
□ I will carry out health surveillance and fiduciary as provided for by art. 8, par. from 1 to 5 of DPCM dated December 3rd, 2020 at following
address______________________________________________________________________________________________________________.

 Arriving from or transited in one of the countries named in the list D (Australia, Japan, New Zealand, Republic of Korea, Ruanda, Singapore,
Thailand, Uruguay) and list E (all other countries not mentioned in above lists) in the last 14 days, as the movement is not due to above mentioned
reasons:
□ I will carry out health surveillance and fiduciary as provided for by art. 8, par. from 1 to 5 of DPCM dated December 3rd, 2020 at following
address______________________________________________________________________________________________________________.

In this regard, the undersigned declares _______________________________________________________________________

_________________________________________________________________________________________________________________________

Check Date, Time and Place ____________________________________________

DECLARANT POLICE OFFICER