PTO: UniCredit Bank S.A.

Romania

CERTIFICATE REGARDING REVENUES OBTANIED FROM SALARY

No. _____________ Date ___/ ____/_______

The company ______________________, entity type ______________________, with registered offices in:
country ______________, address ____________________________________________________________ ,
registred at the Trade Registry with no. ______________________, represented by Mr./Mrs
_____________________________ as ____________________________hereby declare and confirm that:
1. The company is in liquidation, bankruptcy, insolvency  YES  NO
2. Mr./Mrs __________________________________ is our empolyee since ___/___/_____, in the position of
__________________________with a labour contract concluded on _________ for:
 Unlimited period
 a limited period until ____________________
3. The employee is under trial period according to the labour contract  YES  NO?
4. The employee is listed with ____ family members in his care;
5. The employee has work discontinuity in the last 24 months of ____ days;
6. The employee received the following income exclusively as salary type (including bonuses/ overtime/ other
assimilated income with a permanent character)

LAST YEAR CURRENT YEAR

MONTH NET SALARY INCOME* NET SALARY INCOME*
January
February
March
April
May
June
July
August
September
October
November
December
*Income currency __________
7. The income mentioned above has been declared to the Tax Authorities according to the legislation in place;
8. Currently, Mr./Mrs ______________________
 Is registered with monthly debts within our company in total amount of ______________ ;
 Other monthly commitements (e.g garnishments / installments, etc) in total amount of ___________________ ;
9. Salary repayment:  monthly on : ________or  advance on ________ and liquidation on ____________ in
the employee`s bank accont opened at _______________________;
10. By signing this statement, I confirm that all the above information is real and according to the acts and
documents issued and held by the Company

Name and first name …….......................................…………

Position………………...........................................…………..
Signature ……….............................................……………..
Company stamp