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ANNEX 1

DECLARATION OF RESIDENCE

ÿ Declaration of residence from another municipality. Indicate the municipality of

provenance

ÿ Declaration of residence coming from abroad. Indicate the foreign country of

provenance

ÿ Declaration of residence of Italian citizens enrolled in AIRE (Register of Italian residents

abroad) coming from abroad. Indicate the foreign country of origin and the municipality of AIRE registration

ÿ Declaration of change of residence within the same municipality

ÿ Registration for another reason

(specify the reason ……………………………………………………………………)

THE UNDERSIGNED

1) Surname*
*
First name* Date of birth
**
Birth place* Sex* Marital status
Citizenship* Tax ID code*
**
Position in occupation if employed:
Entrepreneur Executive Worker Worker
Freelancer ÿ 1 Clerk ÿ 2 self-employed ÿ 3 and similar ÿ 4 Assistant ÿ 5

Unprofessional Status: **
Housewife ÿ 1 Student ÿ 2 Unemployed/looking for first job ÿ 3
Retired / Retired from work ÿ 4 Other non-professional status ÿ 5
**
Education: No title/
Lic. Elementary ÿ 1 Bachelor ÿ 5 Doctorate ÿ Middle School ÿ 2 Diploma ÿ 3 Three-year degree ÿ 4
6

Type driving licence***

Number***
Release date***
Issuing body*** Province of***
Registration plates for vehicles Italy in as owner/co-owner,
registered in usufructuary/lessee***
Vehicles***
Trailers***
Motor vehicles***
mopeds***

Aware of the criminal liability for false declarations pursuant to articles 75 and 76 of Presidential Decree 445/2000 which
provide for the forfeiture of benefits and the obligation to report to the competent authority.

DECLARE

ÿ I have transferred my habitual residence to the following address :

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ANNEX 1

Common* Province*

Piazza way * House number*

Stairs Floor Internal

ÿ That the family members specified below have also moved to the house located at the new address :

2) Surname*
*
First name* Date of birth
**
Birth place* Sex* Marital status
Citizenship* Tax ID code*
*
Family relationship with the applicant
**
Position in occupation if employed:
Entrepreneur Executive Worker Self-
Freelancer ÿ 1 Clerk ÿ 2 employed worker ÿ 3 and similar ÿ 4 Adjuvant ÿ 5

Unprofessional Status: **
Housewife ÿ 1 Student ÿ 2 Unemployed/in looking for first job ÿ 3
Retired / Retired from work ÿ 4 Other non-professional status ÿ 5
**
Education: No title/
Lic. elementary ÿ 1 Lic. Media ÿ 2 Diploma ÿ 3 Three-year degree ÿ 4 Degree ÿ 5 Doctorate ÿ 6

Driving license***

Number***
Release date***
***
Issuing body*** province of
Registration plates for vehicles Italy in quality of owner/co-owner,
registered in usufructuary/lessee***
Vehicles***
Trailers***
Motor vehicles***
mopeds***

3) Surname*
*
First name* Date of birth
**
Birth place* Sex* Marital status
Citizenship* Tax ID code*
*
Family relationship with the applicant
**
Position in occupation if employed:
Entrepreneur Executive Worker Self-
Freelancer ÿ 1 Clerk ÿ 2 employed worker ÿ 3 and similar ÿ 4 Adjuvant ÿ 5

Unprofessional Status: **
Housewife ÿ 1 Student ÿ 2 Unemployed/in looking for first job ÿ 3
Retired / Retired from work ÿ 4 Other non-professional status ÿ 5
**
Education: No title/
Lic. elementary ÿ 1 Lic. Media ÿ 2 Diploma ÿ 3 Three-year degree ÿ 4 Degree ÿ 5 Doctorate ÿ 6

Type driving licence***

Number***
Release date***
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ANNEX 1

Issuing body*** Province of***

Registration plates for vehicles Italy in quality of owner/co-owner,
registered in usufructuary/lessee***
Vehicles***
Trailers***
Motor vehicles***
mopeds***

4) Surname*
*
First name* Date of birth
**
Birth place* Sex* Marital status
Citizenship* Tax ID code*
*
Family relationship with the applicant
**
Position in occupation if employed:
Entrepreneur Executive Self-employed Worker
Freelancer ÿ 1 Clerk ÿ 2 ÿ 3 and similar ÿ 4 Assistant ÿ 5

Unprofessional Status: **
ÿ 1 Student
Housewife ÿ 2 Unemployed/looking for first job ÿ 3
Retired / Retired from work ÿ 4 Other non-professional status ÿ 5
**
Degree:
No Title/Lic. elementary ÿ 1 Lic. Media ÿ 2 Diploma ÿ 3 Three-year degree ÿ 4 Degree ÿ 5 Doctorate ÿ 6 Type
driving licence*** Number***

Release date***
Issuing body*** Province of***
Registration plates for vehicles Italy in quality of owner/co-owner,
registered in usufructuary/lessee***
Vehicles***
Trailers***
Motor vehicles***
mopeds***

ÿ That the following people are already registered in the home located at the new address (è

it is sufficient to specify the personal details of a member of the family):

*
Surname * First name
* *
Place Date of birth
*
Signature Identification document details (attach
photocopy)*

ÿ There are no relationships of marriage, kinship, ÿ The following constraint exists with respect to the
affinity, adoption, guardianship or emotional aforementioned family member who is already resident:
ties with members of the already resident family.

The following documents are attached:

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ANNEX 1

To legitimately occupy the house on the basis of the title described below, aware that, pursuant to art. 5 of Legislative
Decree No. 47 of 28.3.2014 (converted into Law No. 80 of 23.5.2014), in the event of a false declaration, the registration
in the registry office will be void, by express provision of the law, with effect from the date of the declaration itself.

1 I am the owner of the house identified by the following cadastral details:

Section ________; sheet _________; parcel or map ____________; subordinate ___________

2 That I am the holder of the lease contract duly registered with the Revenue Agency on
_______________ ___________ at no. _________________

3 That I am the holder of a lease contract relating to a Public Residential Building (attach a copy of the
contract or the property delivery report).

4 To be the borrower with a free loan agreement duly registered with the Revenue Agency of dated
__________________ _________ at no. _____

5 To be a usufructuary, by virtue of the following constitutional title:

indicate useful data to allow verification by the Registry Office

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

6 To legitimately occupy the house on the basis of the title described below:

Indicate useful data to allow verification by the Registry Office

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

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ANNEX 1

All communications relating to this declaration must be sent to the following addresses:

Common Province
Piazza way House number
Telephone Mobile phone

Fax e-mail/pec

Date ………………. Applicant's signature

………………………………

Signature of the other adult members of the family

Surname and name ………………………………..

Surname and name ………………………………..

Presentation mode

This form must be completed, signed and presented at the registry office of the municipality where the applicant intends
to establish his residence, or sent to the addresses published on the institutional website of the municipality by
registered mail, fax or electronically.
The latter possibility is permitted under one of the following conditions: a) that the
declaration is signed with a digital signature; b) that the author is identified
by the computer system with the use of the electronic identity card, the national services card, or in any case with
tools that allow the identification of the subject making the declaration; c) that the declaration is sent to the
certified e-mail box of

applicant.
d) that the copy of the declaration bearing the applicant's handwritten signature is acquired
by scanner and sent by simple e-mail.
The declaration must be accompanied by a copy of the identity document of the applicant and of the persons
transferring residence together with the applicant who, if of age, must sign the form.

For the purpose of registering the kinship relationship with other family members in the registry office, the citizen from a
foreign country must attach the relative documentation, in compliance with the provisions on the subject of translation and
legalization of documents.
The citizen of a State not belonging to the European Union must attach the documentation indicated in attachment A).

The citizen of a State belonging to the European Union must attach the documentation indicated in attachment B).

The applicant must complete the form for himself and for the persons over whom he exercises authority or guardianship.

_______________________________
*
Mandatory data. Failure to fill in the fields relating to mandatory data will result in the inadmissibility of the
application.
** Data of statistical interest.
***
Interesting data from the Ministry of Infrastructure and Transport – Department for land transport (art.116, paragraph 11, of
the CdS).
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ANNEX 1

Declaration of residence - Attachment A: documentation necessary for the registration

of citizens of non-European Union countries.

1. Citizen in possession of a valid residence permit

Documentation to be attached
*
1) copy of valid passport or equivalent document. 2) copy of the valid
residence permit.* 3) copy of the original documents,
translated and legalized, proving the marital status and the composition of the
family.**

2. Citizen in possession of a residence permit being renewed

Documentation to be attached
1) copy of passport or equivalent valid document.* 2) copy of expired
residence permit.* 3) receipt of the request
for renewal of the residence permit.* 4) copy of the original
documents translated and legalized, proving marital status and composition of the
family.**

3. Citizen awaiting the issuance of the first residence permit for work
subordinate

Documentation to be attached
1) copy of passport or valid document; 2) copy of the
*
residence contract at the Sportello Unico for immigration;* 3) receipt issued by the
post office certifying the presentation of the residence permit request;*

4) application for issue of the residence permit for subordinate work presented at the Sportello
Unique; *
5) copy of the original documents, translated and legalized, proving the civil status and the composition of the
family **

4. Citizen awaiting the issuance of the residence permit for reunification

familiar

Documentation to be attached
1) copy of passport or valid document;* 2) receipt issued by
the post office certifying the presentation of the permit request;* 3) non-authenticated photocopy of the no
impediment document issued by the Sportello unico;* 4 ) copy of the original
documents, translated and legalized, proving the civil status and the composition of the
family. **

_______________________________________

*
mandatory documentation;
**
documentation necessary for registration in the registry office of the relationship and for the issue of the certification.
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ANNEX 1

Declaration of residence — Annex B: documentation necessary for the registration of

citizens of countries belonging to the European Union.

1. Employed or self-employed citizen 1

Documentation to be submitted

1) copy of a valid identity document for expatriation issued by the competent authorities of
the country of which you are a citizen;* 2) documentation proving
your status as an employed or self-employed worker;* 3) copy of the original
documents , translated and legalized, proving marital status and composition
of the family.**

2. Citizen with sufficient economic resources to stay (non-worker)

Documentation to be submitted

1) copy of a valid identity document for expatriation issued by the competent authorities of
the country of which you are a citizen;* 2) self-declaration of
possession of sufficient economic resources not to become a burden on the assistance
social state. The reference sum corresponds to the amount of the social allowance
which, for 2012, is Euro 5,577.00 gross per year. For the purpose of registering in
the personal data, the overall personal situation of the interested party is also assessed;*

3) copy of health insurance covering health risks on the national territory, valid for at least
one year, or copy of one of the following forms issued by the country of origin: E106,
E120, E121 (or E 33), E109 (or E 37);* The EHIC (European health
insurance card) can be used by anyone who does not intend to transfer their residence
to Italy and allows for enrollment in the temporary population register.

4) copy of the original documents translated and legalized, proving the civil status and
family composition. **

___________________

1 Article 7 paragraph 3 of Legislative

Decree no. 30/2007 The citizen of the Union, formerly an employed or self-employed worker on the
national territory, retains the right to stay referred
to in paragraph 1, letter a) when : a) he is temporarily unable to work following an
illness or an accident ; b) is in a state of involuntary unemployment duly proven after having exercised
a working activity for over a year in the national territory and is registered with the Employment Centre,
or has made the declaration, referred to in article 2, paragraph 1 , of the legislative decree 21 April
2000, n. 181, as replaced by article 3 of legislative decree 19 December 2002, n. 297, which certifies
the immediate availability to carry out work activities;
c) is in a duly proven state of involuntary unemployment at the end of an employment contract
with a fixed duration of less than one year, or was in this state during the first twelve months of stay in
the national territory, is registered with the Center for employment or has made the declaration, referred to in
article 2, paragraph 1, of the legislative decree of 21 April 2000, n. 181, as replaced by article 3 of
legislative decree 19 December 2002, n. 297, which certifies the immediate availability to carry out work
activities. In this case, the interested party retains the status of subordinate worker for a period of one year;

d) follows a professional training course. Except in the case of involuntary unemployment, the
maintaining the quality of subordinate worker presupposes that there is a link between the professional
activity previously carried out and the training course followed.

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ANNEX 1

3. Student citizen (non-worker)

Documentation to be submitted

1) copy of a valid identity document for expatriation issued by the competent authorities of the country of which
the citizen is held; *
2) documentation certifying enrollment in an educational or training institute
professional; *
3) self-declaration of possession of sufficient economic resources not to become a burden on the State's social
assistance. The reference sum corresponds to the amount of the social allowance which, for 2015, is Euro
5,830.76 gross per year. For the purpose of enrollment in the registry office, the overall personal situation
of the person concerned is also assessed;* 4) coverage of health risks:* for the student requesting enrollment
in the registry office
of the resident population:

copy of health insurance covering health risks on the national territory and valid for at least one year or at
least equal to the course of study or professional training, if less than the year or community form;

for the student requesting enrollment in the temporary population register: TEAM issued by the country
of origin or
community form;
5) copy of the original documents, translated and legalized, proving the civil status and composition
of the family. **

4. EU family member 2 of the citizen referred to in the previous points

Documentation to be presented: 1) copy

of a valid identity document for expatriation issued by the competent authorities
authority of the country of which you are a citizen;*
2) copy of the original documents, in compliance with the rules on translation and legalization, of residence (e.g. marriage
certificate for the spouse, birth certificate with paternity and maternity status for the ascendant or descendant);* The
registration of the family member
assumes that the Union citizen is a worker or has sufficient economic resources for himself and his family members for the
stay according to the criteria set out in art. 29, co.3, lett. b), of Legislative Decree 25 July 1998, n. 286, reassessed annually.

Example table
Income limit Number of components

€5,830.76 Applicant only

€8,746.14 Applicant + a family member

€11,661.52 Applicant + two family members

€14,576.90 Applicant + three family members

€17,492.28 Applicant + four family members

€11,661.52 Applicant + two or + children under 14 years of age

€14,576.90 Applicant + two or more children under 14 and a family

member

2
By family member of a citizen of the European Union we mean: the spouse; direct descendants under the age of 21 or dependents and those of the
spouse; dependent direct ascendants and those of the spouse (Article 2 of Legislative Decree No. 30/2007).

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ANNEX 1

For all ascendants and descendants over 21 years of age, declaration of dependent living made by the citizen of
the Union in possession of autonomous residence requirements.*

5. Citizen of a non-EU state, family member of a citizen of the European Union

Documentation to be submitted 1)
copy of passport;* 2) residence
card of a family member of an EU citizen, or receipt of the request for the issue of a residence card.*

*
mandatory documentation;
**
documentation necessary for registration in the registry office of the relationship and for the issue of the certification.

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PRIVACY DISCLAIMER
Regulation 679/2016/EU
Data Subject Disclosure - Demographic, registry, civil status and cemetery services
Pursuant to and for the purposes of articles 13 and 14 of Regulation 679/2016/EU "General Data Protection Regulation", we inform you
that Roma Capitale processes the personal data you provide and freely communicated. Roma Capitale guarantees that your personal data
will be processed in compliance with your fundamental rights and freedoms, as well as your dignity, with particular reference to
confidentiality, personal identity and the right to protection of personal data.
1. Purpose of the processing of personal data (Art. 13.1.c Regulation 679/2016/EU)
All personal data of the interested parties, and possibly those belonging to particular categories pursuant to art. 9 of the EU Regulation or
relating to criminal convictions and offenses pursuant to art. 10 of the EU Regulation, are processed by the Data Controller on the basis of
one or more of the following conditions of lawfulness:
• fulfill the obligations established by laws, regulations, community legislation and for the performance of
institutional functions (article 6.1.c Regulation 679/2016/EU);
• perform a task in the public interest connected to the exercise of public authority (article 6.1.e, article 9.2.g
Regulation 679/2016/EU).
Listed are the purposes for which the personal data of the interested party will be processed:

• inclusion in the personal data and in the Capitoline computer databases; •

management and maintenance of the personal data bank currently in
use; • management of activities related to demographic, registry and civil status services; •
management and keeping of civil status deeds and registers, of the registry office and issue of certifications, issue of
identification documents; issuing
• of cemetery concessions and clearances for the cremation, assignment and dispersion of ashes;
• release of the authorization for burial and burial and release of the authorization for the so-called privileged burial and of the
mortuary passports; • completion of the
mortuary police activities of competence; • management and keeping of the
lists of popular judges; • management and maintenance of
military service; • correspondence management;
• elaboration of internal statistics; • fulfill
your specific requests.

2. Methods of processing personal data

The processing of your personal data takes place at the headquarters and offices of the Data Controller or, if necessary, at the subjects
indicated in paragraph 4, using both paper and computerized supports, by telephone and telematics, also through automated tools suitable
for memorizing, manage and transmit the data, with the observance of all precautionary measures, which guarantee their security and
confidentiality.
The treatment will be developed in such a way as to minimize the risk of destruction or loss, of unauthorized access, of treatment that does
not comply with the purposes of collecting the data. Your personal data are processed:

• in compliance with the minimization principle, pursuant to articles 5.1.c and 25.2 of Regulation 679/2016/EU;
• lawfully and fairly.

Your data is collected:

• for specified explicit and legitimate purposes;

• accurate and if necessary updated;
• relevant, complete and not excessive in relation to the purposes of the processing.
3. Nature of collection and consequences of failure to provide personal data (Art. 13.2.e
Regulation 679/2016/EU)
The provision of your personal data is mandatory for the purposes set out in paragraph 1. Failure to provide them involves the failure to
provide the requested service, its correct performance and any legal obligations.
Your data is stored in the offices and services of Rome Capital and external conservators. If necessary, your data may also be kept by the
other subjects indicated in paragraph 4.

Privacy information - Demographic, registry, civil status and cemetery services_vers.1

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4. Communication and dissemination of personal data (Art. 13.1.e Regulation 679/2016/EU)

Your personal data, if necessary, may be communicated (by this term meaning giving knowledge to one or more specific subjects) to:

• subjects whose right to access data is recognized by provisions of the law, secondary and community legislation; collaborators,
• employees and consultants of Roma Capitale, in the context of their duties and/or any contractual obligations; suppliers,
including the
• Data Processors designated pursuant to Article 28 of EU Regulation 2016/679, who act on behalf of Roma Capitale;

• natural and/or legal persons, public and/or private, when the communication is necessary or functional for the performance of the
activity of Roma Capitale in the ways and for the purposes illustrated above.
Your personal data will not be disseminated under any circumstances, with this term meaning giving knowledge of it in any way to a
plurality of unspecified subjects, without prejudice to legal obligations.
5. Personal data controller (Art. 13.1.a Regulation 679/2016/EU)
The Data Controller of personal data is Roma Capitale. As of today, all information concerning the Controller, together with the updated
list of Managers and designated system Administrators, can be found at Palazzo Senatorio, via del Campidoglio 1, 00186 Rome; PEC:
protocol.gabinettosindaco@pec.comune.roma.it.
6. Data Protection Officer (DPO) / Data Protection Officer (RPD) (Art. 13.1.b Regulation
679/2016/EU)

The Data Protection Officer/Data Protection Manager identified by the entity is the following subject:

DPO VAT number Piazza way POSTAL CODE Common Callsign

LTA Srl 14243311009 Via della Conciliazione, 10 00193 Rome Luigi Recovery

The person responsible for the protection of personal data (Data Protection Officer - "DPO") of Rome Capital can be reached at the
following e-mail address: rpd@comune.roma.it
7. Criteria used to determine the retention period (Art. 13.2.a Regulation 679/2016/EU)
The Data Controller declares that the personal data of the interested party being processed will be kept for the period necessary to comply
with the conservation terms established by the Conservation Plan of the Italian Municipalities (ANCI 2005) and in any case in accordance
with the regulations in force on the matter.
8. Rights of the interested party (Art. 13.2.b Regulation 679/2016/EU)
We inform you that, at any time, the interested party can exercise:

• right to ask the Data Controller, pursuant to Article 15 of Reg. 679/2016/EU, to be able to access your personal data; right to
ask the
• Data Controller, pursuant to Article 16 of Reg. 679/2016/EU, to be able to rectify one's personal data, where the latter does not
conflict with current legislation on data retention; right to ask the Data Controller, pursuant to Article 17
• of Reg. 679/2016/EU, to be able to cancel one's personal data, where the latter does not conflict with current legislation on data
retention; right to ask the Data Controller, pursuant to Article 18 of Reg. 679/2016/EU, to be able to
• limit the processing of your personal data; right to object to the processing, pursuant to Article 21 of Reg. 679/2016/EU.

•
9. Right to lodge a complaint (Art. 13.2.d Regulation 679/2016/EU)
The interested party is informed that he has the right to lodge a complaint with a supervisory authority (in particular with the Italian Data
Protection Authority www.garanteprivacy.it).
10.Source from which the data originate (Article 14 of Regulation 679/2016/EU)
Personal data that have not been obtained from the interested party are acquired automatically from Rome Capital or from other PAs or
third parties.

Privacy information - Demographic, registry, civil status and cemetery services_vers.1