Annex V - FORM FOR THE SUBMISSION OF STATEMENTS OF SUPPORT TO THE MEMBER STATES' COMPETENT AUTHORITIES

1. Full names, postal addresses and e-mail addresses of the contact persons (representative and substitute of the group of organisers) or of the legal entity managing the initiative and its representative:

2. Title of the initiative:

3. Commission registration number:

4. Date of registration:

5. Number of signatories who are nationals of (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 who are nationals of the relevant Member State.
If applicable, include the relevant certificate of conformity of the individual online collection system with Regulation (EU) 2019/788 of the European Parliament and of the Council of 17 April 2019 on the European 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 9 of Regulation (EU) 2019/788 of the European Parliament and of the Council of 17 April 2019 on the European citizens' initiative.

10. Date and signature of one of the contact persons (representative/substitute1) or of the representative of the legal entity:




Regulation on the European citizens’ initiative(pdf).
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