TEMPLATE FOR THE AFFADAVIT/DECLARATION
Affidavit/Declaration on own responsibility
The undersigned ______________________________, currently residing in, county / sector_________________, at street _____________________________________________, number _______, building _______, floor _______, apartment _______, and identified with,
CNP / Passport / ID number: ________________________________ / Serial Number:______________________,
Being an actual resident in the locality of1: Country:_______________________________________,
street: _________________________________, number _______, building _______, floor _______, city _________________, state: __________________.
Being aware of the provisions of art. 326 on the false statement2, and of art. 352 on hindering the
combating of diseases, as stipulated by the new Criminal Code, I nearby declare my own responsibility of
the fact that I travel on personal/professional grounds, between the hours of _____:_____ and _____:_____
for3: □ Travel between home and work venue, when the professional activity is essential and cannot beorganized remotely, or travel for professional grounds that cannot be postponed;
□ Health check that cannot be postponed;
□ Travel for shopping of good, covering the basic needs of persons, at a commercial area located near the residing area;
□ Travel to provide assistance to the elderly, vulnerable people or for accompanying children;
□ Short travel, around the residing area, for outdoor individual physical activity, excluding any form of collective sporting activity;
□ Short travel, around the residing area, for needs related to pets
□ Travel for solving the following urgent situation:
I hereby declare and sign that the above information is accurate:
Date: ______/______/_______ Signature: ________________________________
1. Must be declared when the person does not live at the address stated on the identity document.
2. Declaring a situation that does not correspond to the real one, expressed in front of a person of those provided for in art. 175 or another person when, according to the law or circumstances, has authority to request this declaration, is punishable with 3 months, to 2 years imprisonment or with a fine.
3. To indicate the reason for travel