Al Dipartimento di Ingegneria Industriale
Via Santa Marta 3
50139 Firenze						

DECLARATION

The undersigned ………………………….…………….……………………………….
born at …………………………………………..….……… the ………………………
living at ………………………………………….……………………………..……….
	                                                          (address)
with the title ……………………………………….……..…... having carried out the following activities ……………………………………….……..………………….….. at the Department of………………….……………………………………….. of the University of Florence in the course of research carried out at the said Department, and entitled to receive a total payment of € …………… of  which € …………… for seminars/fees and € ……….……for travel and/or hotel expenses. requests the application of the Agreement between Italy and ……………………… aimed at avoiding double taxation of salary and property and at avoiding evasion of taxes. (The Agreement was published in the Official Gazzette (Gazzetta Ufficiale) n. …………… of ……………….

To this end the undersigned declares under his/her personal responsability:
a) that he/she is eligible for the application of the above agreement and absolves the Department of  ……………………………………... of the University of Florence of all responsability in this regard;
b) that he/she is aware that the amount € …………………… must be added to his/her gross income for the year 20….. and subjected to taxation in the annual declaration of income presented to the appropriate agency of his/her country;
c) that he/she does not carry out professional activity with a permanent office in Italy, and that he/she regularly pays the appropriate taxes in his/her country for health insurance. for pension, and on income.

Florence ………………

									………………………………………
											(signature)
……………………………………
(number of passport or other ident)

					           		To be checked for authenticy of the signature
									         Department Director