STATEMENT OF SUPPORT FORM — PART A (1)

(for Member States that do not require the provision of a personal identification number/personal identification document number)

Unless stated otherwise, all fields on this form are mandatory.

TO BE PRE-COMPLETED BY THE ORGANISERS:

1. All signatories on this form are

Please mark only one Member State per list.

residents in:

IE

UK

residents in or citizens of:

EE

NL

SK

FI

residents in or citizens of (citizens living abroad only if they have informed their national authorities about their place of residence):

BE

DK

DE

LU

2. European Commission registration number:

3. Date of registration:

4. Web address of this proposed citizens’ initiative in the European Commission’s register:

5. Title of this proposed citizens’ initiative:

6. Subject matter:

7. Main objectives:

8. Names and email addresses of registered contact persons:

9. Names of the other registered organisers:

10. Website of this proposed citizens’ initiative (if any):

TO BE COMPLETED BY THE SIGNATORIES IN CAPITAL LETTERS:

‘I hereby certify that the information that I have provided in this form is correct and that I have not already supported this proposed citizens’ initiative.’

FULL FIRST NAMES

FAMILY NAMES (2)

RESIDENCE (street, number, postal code, city, country) (3)

DATE AND PLACE (4) OF BIRTH

NATIONALITY

DATE AND SIGNATURE (5)

(1) The form shall be printed on one sheet. Organisers may use a double-sided sheet.

(2) For the Netherlands and Slovakia, please also state the name at birth.

(3) For Finland, please only state the country of permanent residence.

(4) For Ireland, Finland and the United Kingdom, please only state the date of birth.

(5) Signature is not mandatory if the form is submitted electronically via an online collection system as referred to in Article 6 of Regulation (EU) No 211/2011.

Privacy statement: in accordance with Article 10 of Directive 95/46/EC of the European Parliament and of the Council of 24 October 1995 on the protection of individuals with regard to the processing of personal data and on the free movement of such data, the personal data provided on this form to the organisers of the proposed initiative will only be made available to the competent authorities for the purpose of verification and certification of the number of valid statements of support received for this proposed citizens’ initiative (see Article 8 of Regulation (EU) No 211/2011 of the European Parliament and of the Council of 16 February 2011 on the citizens’ initiative) and, if necessary, further processed for the purpose of administrative or legal proceedings relating to this proposed citizens’ initiative (see Article 12 of Regulation (EU) No 211/2011). The data may not be used for any other purpose. Data subjects are entitled to obtain access to their personal data. All statements of support will be destroyed at the latest 18 months after the date of registration of the proposed citizens’ initiative, or, in the case of administrative or legal proceedings, at the latest one week after the date of conclusion of the said proceedings.

STATEMENT OF SUPPORT FORM — PART B (1)

(for Member States that require the provision of a personal identification number/personal identification document number)

Unless stated otherwise, all fields on this form are mandatory.

TO BE PRE-COMPLETED BY THE ORGANISERS:

1. All signatories on this form hold personal identification numbers/personal identification document numbers of:

Please mark only one Member State per list.

BG

CZ

EL

ES

FR

HR

IT

CY

LV

LT

HU

MT

AT

PL

PT

RO

SI

SE

See Part C for personal identification numbers/personal identification document numbers one of which must be provided.

2. European Commission registration number:

3. Date of registration:

4. Web address of this proposed citizens’ initiative in the European Commission’s register:

5. Title of this proposed citizens’ initiative:

6. Subject matter:

7. Main objectives:

8. Names and email addresses of registered contact persons:

9. Names of the other registered organisers:

10. Website of this proposed citizens’ initiative (if any):

TO BE COMPLETED BY THE SIGNATORIES IN CAPITAL LETTERS:

‘I hereby certify that the information that I have provided in this form is correct and that I have not already supported this proposed citizens’ initiative.’

FULL FIRST NAMES

FAMILY NAMES (2)

RESIDENCE (street, number, postal code, city, country) (3)

DATE AND PLACE OF BIRTH (4)

NATIONALITY

PERSONAL IDENTIFICATION NUMBER/PERSONAL IDENTIFICATION DOCUMENT TYPE AND NUMBER (5)

DATE AND SIGNATURE (6)

(1) The form shall be printed on one sheet. Organisers may use a double-sided sheet.

(2) For Bulgaria and Greece, please also state the father’s name. For Greece, please also state the name at birth.

(3) Only for France, Croatia, Italy, Austria, Poland and Romania.

(4) For Greece, Spain, Malta, Portugal and Romania, please only state the date of birth. For France, Italy, Austria, Slovenia, please state both the date and place of birth. For the other Member States, do not state anything.

(5) For Italian identification documents, please also state the issuing authority.

(6) Signature is not mandatory if the form is submitted electronically via an online collection system as referred to in Article 6 of Regulation (EU) No 211/2011.

Privacy statement: in accordance with Article 10 of Directive 95/46/EC of the European Parliament and of the Council of 24 October 1995 on the protection of individuals with regard to the processing of personal data and on the free movement of such data, the personal data provided on this form to the organisers of the proposed initiative will only be made available to the competent authorities for the purpose of verification and certification of the number of valid statements of support received for this proposed citizens’ initiative (see Article 8 of Regulation (EU) No 211/2011 of the European Parliament and of the Council of 16 February 2011 on the citizens’ initiative) and, if necessary, further processed for the purpose of administrative or legal proceedings relating to this proposed citizens’ initiative (see Article 12 of Regulation (EU) No 211/2011). The data may not be used for any other purpose. Data subjects are entitled to obtain access to their personal data. All statements of support will be destroyed at the latest 18 months after the date of registration of the proposed citizens’ initiative, or, in the case of administrative or legal proceedings, at the latest one week after the date of conclusion of the said proceedings.

1. Full names, postal addresses and email addresses of the contact persons (representative and substitute of the citizens’ committee):

2. Title of proposed citizens’ initiative:

3. Commission registration number:

4. Date of registration:

5. Number of signatories coming from (name of Member State):

6. Total number of collected statements of support:

7. Number of Member States where the threshold has been reached:

8. Annexes:

(Include all statements of support from signatories to be verified by the relevant Member State.

If applicable, include the relevant certificate(s) of conformity of the online collection system with Regulation (EU) No 211/2011 of the European Parliament and of the Council of 16 February 2011 on the citizens’ initiative.)

9. I hereby declare that the information provided in this form is correct and that the statements of support have been collected in accordance with Article 5 of Regulation (EU) No 211/2011.

10. Date and signature of one of the contact persons (representative/substitute (1)):

(1) Delete as appropriate

1. Title of citizens’ initiative:

2. Commission registration number:

3. Date of registration:

4. Number of valid statements of support received (must be at least one million):

5. Number of signatories certified by Member States:

BE

BG

CZ

DK

DE

EE

IE

EL

ES

FR

HR

IT

CY

LV

LT

LU

Number of signatories

HU

MT

NL

AT

PL

PT

RO

SI

SK

FI

SE

UK

TOTAL

Number of signatories

6. Full names, postal addresses and email addresses of the contact persons (representative and substitute of the citizens’ committee) (1).

7. Indicate all sources of support and funding received for the initiative, including the amount of financial support at the time of submission (1):

8. I hereby declare that the information provided in this form is correct and that all relevant procedures and conditions set out in Regulation (EU) No 211/2011 of the European Parliament and of the Council of 16 February 2011 on the citizens’ initiative have been complied with.

Date and signature of one of the contact persons (representative/substitute (2)):

9. Annexes:

(Include all certificates)

(1) Privacy statement: in accordance with Article 11 of Regulation (EC) No 45/2001 of the European Parliament and of the Council of 18 December 2000 on the protection of individuals with regard to the processing of personal data by the Community institutions and bodies and on the free movement of such data, data subjects are informed that these personal data are compiled by the Commission for the purpose of the procedure in respect of the citizens’ initiative. Only the full names of the organisers, the email addresses of the contact persons and information relating to the sources of support and funding will be made available to the public on the Commission’s online register. Data subjects are entitled to object to the publication of their personal data on compelling legitimate grounds relating to their particular situation, and to request the rectification of that data at any time and its removal from the Commission’s online register after the expiry of a period of two years from the date of registration of the proposed citizens’ initiative.

(2) Delete as appropriate