12 | II Série A - Número: 036S1 | 27 de Novembro de 2014

Issued or certified by the Government of ……………………………..……………………………………………….
……………………………………………………………………………………………………………………………...

(Full designation of the State)

OR

The following text should be used when a State Party avails itself of Article 7 3) The present certificate is issued under the authority of the Government of ……………………………………… (Full designation of the State) by ………………………………………………………………………………………..………………………………… (Name of institution or organisation) At ……………………………..…………… On ………………………………..…………………………………..
(Place) ……………………………………………… (Date)…………………………………………………………

..………………………………………..
(Signature and title of issuing or certifying official)

Explanatory notes: 1 - If desired, the designation of the State may include a reference to the competent public authority of the country where the certificate is issued.
2 - If the total amount of security has been furnished by more then one source, the amount of each of them should be indicated.
3 - If security is furnished in several forms, these should be enumerated.
4 - The entry «Duration of security» must stipulate the date on which such security takes effect.
5 - The entry «Address» of the insurer(s) and/or guarantor(s) must indicate the principal place of business of the insurer(s) and/or guarantor(s). If appropriate, the place of business where the insurance or other security is established shall be indicated.