ANNEX IV
TEMPLATE FOR INTERMEDIATE STATEMENT OF VERIFICATION
Intermediate Statement of Verification
Number [unique ISV identification number ensuring traceability of the document]
( 1 )
Object of Assessment ( 2 ) :
[Unique Identification of the subsystem or of the part of the subsystem: identification of whole or of the part of the subsystem, and stages of verification in accordance with point 2.2.3 of Annex IV to Directive (EU) 2016/797]
Applicant, where applicable also Manufacturer and Manufacturing locations:
[Name(s), Address(es)]
Assessment Requirements:
[Reference to: the Directive(s), the TSI(s), the non-application of TSI(s), the relevant National Rules, European specifications, other Acceptable Means of Compliance]
Module(s) applied:
[The modules as chosen by the applicant for the assessment of the subsystem or of a part of the subsystem, and stages of verification]
Assessment/Audit result:
[Including reference to the assessment/audit report]
The following conditions and limits of use apply ( 3 ) :
[List or reference to the list of conditions and limits of use]
Annex of ISV ( 4 ) (where applicable)
[Yes/No]
Documentation accompanying this ISV:
[reference to accompanying documents; list or file of documents used for the assessment]
Validity:
[Time and conditions of validity of ISV]
Done on:
[date DD/MM/YYYY]
Notified Body
Signature
First Name, Surname
[OR]
Designated Body
Signature
First Name, Surname
Business name
Business name
Registration number
Identification number
Complete postal address
Complete postal address
Page 1[/nn]
Annex to Intermediate Statement of Verification [where applicable]
Number [unique ISV identification number]
Object of Assessment:
[Unique Identification of the subsystem or of the part of the subsystem: identification of whole or of the part of the subsystem, and stages of verification in accordance with point 2.2.3 of Annex IV to Directive (EU) 2016/797]
Done on:
[date DD/MM/YYYY]
Notified Body
Signature
First Name, Surname
[OR]
Designated Body
Signature
First Name, Surname
Business name
Business name
Registration number
Identification number
Complete postal address
Complete postal address
Page n/nn
( 1 ) The information in square brackets [ ] is provided to support the user in compiling the template.
( 2 ) The description of the subsystem or part of the subsystem shall enable unique identification and allow for traceability.
( 3 ) When a reference to a list of conditions of use and other restrictions is made, such list shall be accessible to the authorising entity.
( 4 ) It is good practice to issue ISV as a single page document; if the relevant information for the ISV does not fit all on one page, the Annex provides sufficient space for any other relevant information to be considered.