Declaration of authenticity of personal data

I, the undersigned:

name:
postal address:

I declare that:

my identity card number/date of birth:
my nationality:

I declare that the information provided they correspond to reality.

Date:

Declarant's signature

(If the Declarant certifies the document using the AVDH procedure, there is no need for witnesses or for the document to be signed by hand.)

Witness 1.	Witness 2.
Name:	Name:
Address:	Address:

Signature:	Signature: