Space reserved for the witness
Name
Surname
Organisation
Title of witness
Address
Country
Witness:I,the undersigned,declare that this document was signed in my presence and that the signature above is that of the pensioner identified in the personal information section of this document,whose personal identity i hereby confirm.
Witness signature
Date:
The witness is hereby requested to keep a copy of this form on file as s/he may be contacted in regard to its contents. If you have any questions,if you have received any payments in error or to communicate the death of the recipient, please contact the citi inps pensioner support team at the contacts provided in the introductory letter.
Official stamp of the institution to which the public official,actihg as witness,belongs.