€ 2. 00 revenue stamp
ONLY for remuneration and/or reimbursement of expenses exceeding € 77.47

OCCASIONAL EMPLOYMENT 		
    RECORD OF THE SERVICES PROVIDED 
FOR A SEMINAR/CONFERENCE/
SINGLE TEACHING ASSIGNMENT/CASE STUDY						

The undersigned _____________________________________________________________________
place of birth ______________________________________________ date of birth ______________
resident in	 _______________________________________________________ prov. ______ address _________________________________________________________________ no. ______ postcode _____________  tax identification Code_________________________________ 
 VAT identification n. _________________________________ following the conferment of the assignment and provision of services of __________________ to carry out the seminar/conference/single teaching assignment/case study described as follows: __________________________________________________________________________________
___________________________________________________________________________________
option 1) for which the payment of the total amount of € _______________ gross of withholding tax paid by the recipient has been agreed
option 2) for which the payment of the total amount of € _______________ gross of withholding tax paid by the recipient in addition to the following expenses* □ travel      □ board    □ accommodation has been ag
option 3) for which only the reimbursement of the following expenses*   □ travel     □ board 
□ accommodation has been agreed
declares
that the above mentioned occasional service has been carried out as agreed, autonomously defining the method of procedure,
and requests
(option 1) the payment of the agreed fee of € _____________ gross of withholding tax paid by the recipient.
or
(option 2) the payment of the agreed fee of € _______________ as well as reimbursement of the following expenses:
Travel expenses for a total amount of € _______________
relative to trips by [specify the vehicle] ____________________ [if travelling using your own vehicle please specify the type of vehicle, brand, model and fuel, as well as the kilometres travelled. The eligible expense merely refers to the cost of fuel resulting from the receipts supplied and re-measured according to the kilometres based on ACI tables]:

date ____________ from __________________ to _________________ and return journey € ________ 
date____________ from __________________ to _________________ and return journey € ________ 
Board expenses for a total amount of € ______________
meal (date) _______________ € _________________ c/o _____________________________________
meal (date)    _______________ € _________________ c/o _____________________________________
Accommodation expenses for a total amount of € __________________
no. nights _____ from _____________ to ____________ c/o hotel _____________________________ + tourist tax   € _____
for a total amount (fee + expenses) of € gross of withholding tax paid by the recipient
or
(option 3) the reimbursement of the following expenses:
Travel expenses for a total amount of € _______________ 
relative to trips by [specify the vehicle] ____________________ [if travelling using your own vehicle please specify the type of vehicle, brand, model and fuel, as well as the kilometres travelled. The eligible expense merely refers to the cost of fuel resulting from the receipts supplied and re-measured according to the kilometres based on ACI tables]:
date ____________ from __________________ to ________________ and return journey € ________ 
date____________ from __________________ to _________________ and return journey € ________ 
Board expenses for a total amount of € ______________
meal (date) _______________ € _________________ c/o _____________________________________
meal (date)    _______________ € _________________ c/o _____________________________________
Accommodation expenses for a total amount of € __________________
no. nights _____ from _____________ to ____________ c/o hotel _____________________________ + tourist tax   € _____
for a total amount of € _______________
The undersigned declares under his/her responsibility,
□	that he/she has not received nor will receive as such any other reimbursement of the above reported expenses.

The undersigned attaches to the present declaration the relevant documentation providing evidence of the expenses.
Florence, date ________________				   The contractor
				_________________________________
* Expenses as well as fee are taxed pursuant to art. 25 D.P.R. no. 600 of 1973. See also resolution no. 49/E of 11 July 2013 – taxation of expense reimbursements by the Italian Revenue Agency.

For Office use only

The reimbursement of the expenses incurred for an amount of € _____________ gross of withholding tax paid by the recipient is approved (€ ____________________inclusive of charges borne by the Administration).

 HEAD OF THE DEPARTMENT			FUNDS ASSIGNEE
________________________________	Proj. ___________________________

Prof. ___________________________	Prof.  ___________________________