DECLARATIE ANGAJAT

EMPLOYEE’s STATEMENT

Subsemnatul, _______________ , domiciliat* in ___________, strada _____________, nr. ____,

bl. _____, sc. _____, et. _____ ap. ______, sectorul/judet _____________-,
CNP_____________________, posesor al CI seria________, nr_________, telefon: _____________, email:
_____________ cunoscand faptul ca falsul in declaratii se pedepseste conform legii, declar urmatoarele:

Ms/Mr. __________, domiciled in __________, street, no. ___________________, block ______, _____ floor ____,
apartment ______, District _______________ having personal identification number __________________holder
of identity card series _____ no. _____________, telephone no.: _____________, email: ____________ knowing
that false statements are punishable by law , declare the following:

*) In cazul in care locuiti la o alta adresa, va rugam sa indicati si resedinta dumneavoastra:

*) If you live at a different address, please also indicate your residence address;

I. Am mai lucrat cu contract individual de munca*.

I. I have worked before with individual employment contract*.

I. Nu am mai lucrat cu contract individual de munca*.

I haven’t worked before with individual employment contract
*) Bifati varianta corecta.
*) Tick the correct version.

• Daca ati mai lucrat cu contract individual de munca, va rugam sa precizati ultima zi
lucrata_____________;
If you have worked before with individual employment contract, please indicate the last day worked
_______________;

II.In calitate de angajat al companiei……………………………………………………, mentionez

ca:
II.As an employee of the company________________, I mention the following:

• Voi avea functia de baza la societatea _________________.

My base function will be at __________________.

III. Intre data de 1 ale lunii si data angajarii*:

III. Between the 1st of the month and the employment starting date:

• Am mai lucrat cu contract individual de munca la un alt angajator;

I have worked before with individual employment contract to another employer.

• Nu am mai lucrat cu contract individual de munca la un alt angajator;

I haven’t worked before with individual employment contract to another employer.

* Prin semnarea acestui document, ati luat la cunostinta faptul ca datele dumneavoastra personale, vor
fi utilizate in raportarile catre autoritatile relevante (de ex: autoritatile de munca, fiscale etc.), in
conformitate cu prevederile legale.
* By signing this document, you acknowledge that your personal data will be used for reporting to
relevant authorities (e.g. labor authorities, tax, etc.), in accordance with the law.
*)Se completeaza daca data inceperii activitatii este diferita de data de 1 a lunii. Se va marca situatia
in care va incadrati.
*) Complete only if the activity start date is different from the 1st of the month. Thick the correct
version.

IV.Casa de sanatate la care sunteti asigurat/a este:

IV. Health house affiliation:
• Casa asigurarilor de sanatate a municipiului Bucuresti (Bucharest);
• Casa asigurarilor de sanatate a judetului (County Health House)_____________;
• Casa asigurarilor de sanatate a apararii, ordinii publice, sigurantei nationale si autoritatii
Judecatoresti (OPSNAJ).

V. Contul Iban agreat pentru viramentul salariului este:

V. Bank account number/Iban Code for the salary payment.
R O____________________________________________

VI. Persoana de contact care poate fi anuntata in cazul unui accident de munca este:
VI. Contact person in case of work accident:
• Nume si prenume (name/surname) ___________________________
• Adresa (address) _____________________________
• Telefon (Phone number) _______________________________

VII. In vederea stabilirii corecte a deducerii* in vederea calculului impozitului pe salariu, va

rugam sa precizati:
In order to determine the correct tax deduction *, please specify:

• nu solicit deduceri privind impozitul pe salariu (not requesting deduction on income tax).
• solicit deduceri privind impozitul pe salariu (requesting deduction on income tax )**.

*) Daca se va aplica;
If applicable;
*)) In cazul in care solicitati deduceri suplimentare, va rugam sa mentionati cate persoane aveti in
intretinere:
If you require additional deductions, please mention the dependent persons:

• Nume si prenume (Name/surname) ________________________,

• CNP (personal identification number )______________________
• Nume si prenume (name/surname) ________________________,
• CNP (personal identification number )_____________________

De asemenea, va rugam sa anexati prezentei urmatoarele documente aferente persoanei aflate in

intretinere :
Also, please attach the following documents required for dependent persons:

• copie carte de identitate (copy of the identity card);

• copie certificat de nastere (copy of the birth certificate);
• copie talon pensie (copy of the retirement certificate).
• adeverinta de la sotie/sot prin care se atesta ca nu se acorda deduceri acesteia/ acestuia (certificate
provided by the wife/husband stating that she/ he do not not benefit of deductions).

* Prin semnarea acestui document, ati luat la cunostinta faptul ca datele dumneavoastra personale, vor
fi utilizate in raportarile catre autoritatile relevante (de ex: autoritatile de munca, fiscale etc.), in
conformitate cu prevederile legale.
* By signing this document, you acknowledge that your personal data will be used for reporting to
relevant authorities (e.g. labor authorities, tax, etc.), in accordance with the law.
VIII. In cazul in care solicitati sa fie incluse si alte persoane in calitate de co-asigurat (pentru a
fi declarate in sistemul public de sanatate), va rugam sa mentionati urmatoarele informatii:
If your require to be included other persons as co-insured (for public health insurance
purposes), please mention the following information:

• Nume si prenume (Name/surname) ________________________,

• CNP (personal identification number )______________________

De asemenea, va rugam sa anexati urmatoarele documente aferente persoanei co-asigurate :

Also, please attach the following documents required for the co-insured persons request:

*cerere depusa de salariat prin care solicita acest lucru (the employee’s specific request);
*declaratie pe propria raspundere a salariatului prin care acesta declara ca are in intretinere persoana
coasigurata (the employee's statement in which he states that co-insured persons are also dependent
person).
*documente care sa ateste casatoria cu persoana asigurata, dupa caz (copy of the marriage certificate),
if the case;
*copie carte de identitate a persoanei co-asigurat (copy of the co-insured person identity card);
*declaratie pe propria raspundere a persoanei co-asigurate din care sa rezulte ca nu realizeaza venituri
proprii, respectiv adeverinta eliberata de ANAF din care sa rezulte faptul ca nu realizeaza venituri
(the co-insured person’s statement that does not obtain any income, respective the certificate issued by
the tax authorities stating that no income is obtained by the respective person).

IX. Detalii referitoare la studii - informatii necesare completarii declaratiei lunare catre
ANAF:

Studies details – information required to complete the monthly statement to ANAF:

1. Am studii superioare si vechime in munca de peste 1 an in domeniul studiilor superioare.
I have university degree and related work experience for over 1 year.

1.1 Nu am studii studii superioare sau am studii superioare dar vechime in munca sub 1 an in
domeniul studiilor superioare.
I don’t have university degree or I have university degree but related work experience less than 1
year.

X. Am cazier judiciar*.
I have criminal record.*

X. Nu am cazier judiciar*.
I do not have criminal record.*

*) Bifati varianta corecta.

*) Tick the correct version.

XI. Marimile echipamentului de protectie:

Safety equipement sizes:

Marime incaltaminte (35-45): ……………..

Shoe size (35-45): ……………

Marime imbracaminte (XS-XXXL): ………………

Clothing size (XS-XXXL):…………..
Marime casca de protectie (S-XXXL): ………………
Helmet size (S-XXXL): ……………

Marime Manusi (S-XXXL): ………………

Gloves size (S-XXXL): ……………

* Prin semnarea acestui document, ati luat la cunostinta faptul ca datele dumneavoastra personale, vor
fi utilizate in raportarile catre autoritatile relevante (de ex: autoritatile de munca, fiscale etc.), in
conformitate cu prevederile legale.
* By signing this document, you acknowledge that your personal data will be used for reporting to
relevant authorities (e.g. labor authorities, tax, etc.), in accordance with the law.

In cazul in care intervine o schimbare fata de cele mai sus mentionate, ma angajez sa le comunic
societatii/ angajatorului in termen de 5 zile.

In case of any modification, I undertake to notify the employer within 5 days.

Data:___________ Nume angajat/ Employee’s name

____________________________
Semnatura/ Signature
____________________________
* Prin semnarea acestui document, ati luat la cunostinta faptul ca datele dumneavoastra personale, vor
fi utilizate in raportarile catre autoritatile relevante (de ex: autoritatile de munca, fiscale etc.), in
conformitate cu prevederile legale.
* By signing this document, you acknowledge that your personal data will be used for reporting to
relevant authorities (e.g. labor authorities, tax, etc.), in accordance with the law.