SELF-CERTIFICATION PURSUANT TO ARTICLES 46 AND 47 OF PRESIDENTIAL DECREE
NO. 445/2020
I
the
undersigned..............................................................,
born
on........................in
...............................(Prov...........), domicile address................................................(Prov................), residence
address..................................(Prov.......) ID No..........................................................(specify type of
ID)..........................., issued by...........................................................................................................,
telephone number..............................................., fully cognizant that false statements made to a public
official are an offence, per the provisions of art 495 of the Criminal Code
HEREBY DECLARE, UNDER MY RESPONSIBILITY
that I am aware of the contagion containment measures per the provisions of art. 1 of Prime
Minister's Decree dated 11 March 2020; of art. 1 of Prime Minister's Decree dated 22 March
2020; of art. 1 of the Minister of Health Ordinance dated 20 March 2020 setting limitations to
the movement of individuals on the entire national territory;
that I am not quarantined and have not tested positive for the COVID-19 per article 1,
paragraph 1, letter c) of Prime Minister's Decree dated 8 March 2020;
that I am aware that, pursuant to the provisions of article 3, paragraph 4 of Law Decree No. 6
dated 23 February 2020 and of art. 4, paragraph 1 of Prime Minister's Decree dated 8 March
2020, failure to comply with the above containment measures is sanctioned in accordance with
the provision of art. 650 of the Criminal Code unless the offense constitutes a more serious crime;
that my journey started in ...............................................(specify departure address) with final
destination in .........................
due to
o
demonstrated work-related reasons;
o

extreme urgency ("for travel to other municipalities" per the provisions of
1,paragraph 1, letter b) of Prime Minister's Decree dated 22 March 2020;

art.

o

sheer necesity (for movement within the same municipality, per the provisions
of
art.1,
paragraph 1, letter a) of Prime Minister's Decree dated 8 March
2020 and art. 1 of Prime
Minister's Decree dated 9 March 2020;

o

health reasons .

In connection with the foregoing, I hereby declare that:
(I work for…...........…................, I have a medical appointment, I am returning from abroad…..................,
other special reason, etc.............................)
Date, place and time

The Declarant

The Police Officer