CITTA' METROPOLITANA DI FIRENZE
  
U.O.C SERVIZI EDUCATIVI E ISTRUZIONE
ALLEGATO C

MODULO DI DOMANDA DI MANIFESTAZIONE DI INTERESSE	
ALLA CONCESSIONE IN COMODATO D’USO GRATUITO DI UN DEAMBULATORE PEDIATRICO NON PIÙ UTILIZZATO DALL’ENTE

Il/la sottoscritto/a __________________________________________________________________
nato/a a ________________________________________________ il //________
residente a ________________________________________________ Cap __________________
in qualità di legale rappresentante dell’Ente del Terzo Settore
Denominazione ente __________________________________________________________________
Codice Fiscale / Partita IVA ___________________________________________________________
Iscritto al RUNTS al n. ________________________ del //________
Sede legale ________________________________________________________________________
Sede operativa (se diversa) __________________________________________________________
Recapito telefonico ______________________________
E-mail ________________________________________
PEC __________________________________________
CHIEDE
di essere ammesso/a alla procedura comparativa per la concessione in comodato d’uso gratuito del deambulatore pediatrico oggetto dell’avviso pubblico del Comune di Empoli del 28 novembre 2025.
DICHIARA SOTTO LA PROPRIA RESPONSABILITÀ (ai sensi degli artt. 46 e 47 D.P.R. 445/2000)
1.  che l’Ente è iscritto al Registro Unico Nazionale del Terzo Settore (RUNTS) da almeno 6 mesi alla data di pubblicazione dell’avviso;
2.  che l’oggetto sociale/statutario dell’Ente prevede espressamente attività di assistenza socio-sanitaria, educazione, istruzione, riabilitazione o tutela dei diritti in favore di minori e/o persone con disabilità (allegare statuto aggiornato e visura RUNTS);
3.  di aver preso completa visione dell’avviso pubblico e di accettarne integralmente tutte le condizioni;
4.  di impegnarsi, in caso di assegnazione, a:
	•  ritirare il bene a proprie cure e spese…
	•  sostenere integralmente tutte le spese di trasporto…
	•  effettuare la manutenzione ordinaria; la manutenzione straordinaria sarà a carico del Comune salvo uso improprio;
	•  utilizzare il deambulatore esclusivamente a favore di minori con disabilità motoria;
	•  trasmettere entro il 31 gennaio di ogni anno una breve relazione…
	•  restituire immediatamente il bene…
	•  risarcire eventuali danni o perimento per dolo, colpa grave o uso improprio in misura pari al valore di acquisto (€ 3.285,00 + IVA);
RELATIVAMENTE ALL’AVVISO AL FINE DI CONSENTIRE AL CONUNE DI EMPOLI DI VALUTARE L’ISTANZA RIMESSA
DICHIARA 

A) Tipologia di struttura e intensità dell’assistenza prestata
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B) N. minori con disabilità motoria attualmente seguiti dall’ente 
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C) Compatibilità immediata e necessità dell’ausilio 
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D) Prossimità logistica 
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							Il Legale rappresentante dell’ETS 
								(firma digitale)