ANNEX I
Request for data entry into the exclusion database, its modification or removal by institutions other than the Commission and executive agencies
The request has to be sent in conformity with the procedure for classified information pursuant to the rules set by the institution. It has to be sent in a single closed envelope.
European Commission
Directorate-General Budget
Accounting Officer of the Commission
BRE2 13/505
B-1049 BRUXELLES
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- RESTRICTED EU -
(Place, date)
Request for registration, removal or modification of data concerning a third party in the exclusion database
Requesting institution: …
Name, first name of the person in charge of the contact point: …
I request
registration of an exclusion warning
removal of the warning ( 1 ) whose introduction was requested by note … dated …
modification of the warning (including renewal of a provisional registration) ( 2 ) whose introduction was requested by note … dated …
concerning the following entity in the exclusion database:
Name (and, where the person is a natural person, given name) of the entity: …
Legal form: …
Name, given name of the person(s) with powers of representation: …
Address (if legal person, address of the headquarter): street/nr/postcode/place/country …
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1. For registration of the entity in the Legal Entities File of the Commission, I attach a recent supporting document proving the legal existence of the entity:
Extract from the trade register or equivalent;
Copy of the VAT registration document;
Copy of the statutes, extract from the Official Journal or equivalent;
Copy of the identity card or passport (if natural person);
Other (give details): …
( 1 ) In this case do not fill in Sections 1 to 5.
( 2 ) Fill in all sections, not only the one concerned by the modification request.
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2. Indication of pertinent ground for exclusion pursuant to the Financial Regulation (FR):
Article 93(1)a FR (internal code NW5a2a)
Article 93(1)b FR (internal code NW5a2b)
Article 93(1)c FR (internal code NW5a30)
Article 93(1)d FR (internal code NW5a2d)
Article 93(1)e FR (internal code NW5a2e) (indicate below the type of conviction)
° Fraud
° Corruption
° Involvement in a criminal organisation
° Money laundering
Indicate the denomination of the court that rendered the judgment which has the force of res judicata:
Indicate the date of the judgment which has the force of res judicata: DD/MM/YYYY: …/…/…
Indicate the duration of the period of exclusion from procurement procedures (where applicable): Exclusion until DD/MM/YYYY: …/…/…
Article 93(1)f FR (= Article 96(1) FR) (internal code NW5a40)
Article 94 FR (internal code NW1d)
3. Short description of the exclusion situation ( 1 ):
4. Registration period:
Registration until DD/MM/YYYY ( 2 ): …
Automatic removal of the registration pursuant to Regulation (EC, Euratom) No …/… on the central exclusion database ( 3 ).
Provisional registration until DD/MM/YYYY (max. three months): …
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I certify that the information communicated was established and transmitted in accordance with the principles set out in Regulation (EC) No 45/2001 of the European Parliament and of the Council concerning the protection of personal data.
(Signature of person in charge of the contact point of the institution requesting introduction/removal/modification of the warning)
( 1 ) To be filled in one of the working languages of the Commission.
( 2 ) The duration of an exclusion pursuant to Article 93(1) points b, c, e, f of the Financial Regulation has to be decided by the institution.
( 3 ) Only for exclusions pursuant to Article 93(1) points a and d and Article 94 of the Financial Regulation.