17. Declaration.docx

APPROVED

by Order of the

Minister of Finance

no. 145 of 24 November 2020

DECLARATION

regarding the confirmation of the identity of beneficial owners and their non-inclusion in the situation of having been convicted for participation in the activities of a criminal organisation or group, for corruption, fraud and/or money laundering.

The undersigned, _________________________ authorised representative of _____________ (name of the Company) acting as tenderer/associated tenderer designated as winner in the public procurement procedure No. ocds-b3wdp1-MD-1781161220358 of __/__/___, hereby declare on my own responsibility, under the sanctions applicable to the offence of falsification of public documents, that the beneficial owner(s) of the Company have not, within the last 5 years, been convicted by a final court judgment for participation in the activities of a criminal organisation or group, for corruption, fraud and/or money laundering.

Date of completion: ___________________

Signed: _____________________________

Name/Surname: ______________________

Position: ____________________________

Name of the Company: ________________

IDNO of the Company: ________________