To fill in and return to the relevant Department/Center/Office

FORM FOR THE REIMBURSEMENT OF EXPENSES INCURRED DURING FREE
OCCASIONAL OR SPORADIC EMPLOYMENT (RISOLUZIONE 49/E/2013)-NOT RESIDENT

Substitute statement issued in accordance with articles. 46-47 of the DPR n. 445/2000, in compliance with art. 76 of the same DPR 445/2000 on penal sanctions for falsification of documents and false statements

I, First Name           _______________________________  Surname _______________________________
Middle Name	_______________________________   Sex     M  F 
Place of birth - Country______________________________  Town_______________________________
Date of birth 	_______________________________  Citizenship _____________________________
Telephone no. - Home_________________  Office ____________________Mobile___________________  
Email  ________________________________________________________
Passport no.	   _______________________________   Valid until ______________________________

Residency (for tax purposes)  Address  _______________________________________________________
		       Town      _________________________________ ZIP/Post Code __________
		       Country   _______________________________________________________
Foreign taxpayer reference/identification number _____________________________
Italian taxpayer identification no.- Codice Fiscale (If you have one) 
I DECLARE that for the professional service provided here I will not ask for any fee but only for the reimbursement of expenses I have incurred

I ASK to have the reimbursement paid into:

Bank: _________________________________________________________________________________
Account no. (with myself as beneficiary)______________________________________________________
IBAN ________________________________________________________
Routing _______________________________________________________________________________
Bic/Swift ______________________________________________________________________________

Declaration

The information I have given in this form is correct and complete to the best of my knowledge and belief.
I must inform Università degli Studi di Padova immediately of any changes to the information that I provided.

Date: _________________			Signature:___________________________________

Privacy and Data Protection

I consent to the use of the above information in accordance to D.Lgs. 30 June 2003 no. 196 as modified by D.Lgs. 101/18 for the purpose of fulfilling the obligations arising from the contract between myself and Uni-versità degli Studi di Padova.

Date: _________________			Signature:_________________________________

Attention. Please enclose a copy of your document of identification.