EN   EN 
 
 
 EUROPEAN  
COMMISSION   
Brussels, XXX  
[…](2018) XXX  draft  
ANNEXES 1 to 6  
 
ANNEXES  
to the  
COMMISSION IMPLEMENTING REGULATION (EU) …/...  
on the templates for ‘EC’ declarations and certificates for railway interoperability 
constituents and subsystems, on the model of declaration of conformity to an authorised 
railway vehicle type and on the ‘EC’ verification procedures for subsystem in 
accor dance with Directive (EU) 2016/797 of the European Parliament and of the Council 
and repealing Regulation (EU) 201/2011    
EN 1  EN ANNEX I 
 
TEMPLATE FOR  ‘EC’ DECLARATION OF CONFORMITY OR SUITABILITY  
FOR  USE OF INTEROPERABILITY CONSTITUENTS  
‘EC’ declaration identification number  – [ERADIS ID]1 
 
We, Manufacturer or Authorised representative  
[Business name]  
[Complete postal address]  
 
Declare under our sole responsibility that the following interoperability constituent:  
[Name/short description of interoperability constituent/type]  
 
to which this declaration refers complies with the relevant Union law:  
[Title(s) of the Directive(s); Title(s) of the TSI(s); Title(s) of European Specifications]  
 
has been assessed by the following Notified Body:  
[Business name]  
[Regist ration number]  
[Full address]  
 
In accordance with the following approval(s) and/or certificate(s):  
[Approval(s), date of issue]  
[Certificate number(s), date of issue]  
 
The following restrictions or conditions of use apply2: 
[List or reference to the list o f conditions of use and other restrictions]  
 
The following procedures have been followed in order to declare conformity:  
[The modules chosen by manufacturer for the assessment of the interoperability 
constituent]  
 
List of Annexes  
[Titles of the Annexes (Technical documentation or technical file  accompanying the 
‘EC’ declaration of conformity or suitability for use )] 
 
Done on:  
[Date DD/MM/YYYY]  
Signature of Manufacturer/Authorised representative  
[First Name , Surname]   
                                                 
1  The information in square brackets [ ] is provided to support the user in correctly and exhaustively compiling the 
template .  
2  When a reference  to a list of conditions and limits of use  is made, such list shall be accessible to the authorising entity.   
EN 2  EN ANNEX II 
 
TEMPLATE FOR ‘EC’ DECLARATION OF VERIFICATION OF SUBSYSTEM    
 
‘EC’ declaration of verification of s ubsystem  
‘EC’ declaration identification number  [ERADIS ID]1  
 
We, Applicant:  
[Business name]  
[Complete postal address]  
 
Declare under our sole responsibility that the following subsystem:  
[Name/short description of the subsystem  Identification of the subsystem]  
 
to which this declaration refers has been subject to the relevant verification procedures and 
complies with the r elevant Union law and any relevant national rules :    
[Reference to: the Directive(s); TSI(s); Relevant national rules;]  
 
has been assessed by the following conformity assessment bodies:  
 
Notified Body:  
Business name  
Registration number  
Full address  Designated Body:  
Business name  
Identification number  
Full address  Assessment body [Risk 
assessment]:  
Business name  
Identification  number  
Full address  
 
 
In accordance with the following certificate(s) and or report(s):  
[Certificate(s) number(s), report(s) number(s), date(s) of issue]  
 
The following conditions of use and other restrictions apply2: 
[List or reference to the list of conditions of use and other restrictions ] 
 
The following procedures have been followed in order to declare conformity:  
[The modules chosen by applicant for the verification of the subsystem]  
                                                 
1  The informa tion in square brackets [ ] is provided to support the user in correctly and exhaustively compil ing the 
template.  
2  When a reference  to a list of conditions and limits of use  is made, such list shall be accessible to the authorising entity.   
EN 3  EN  
Identification of the technical file accompanying this declaration  
[Reference to the technical file accompanying the ‘EC’ declaration of verification of 
subsystem  in accordance with Article 15(4) of Directive (EU) 2016/797 ] 
 
Reference to former ‘EC’  declaration of verification  (where applicable)   
[Yes/No]  
 
Done on:  
[date DD/MM/YYYY]  
 
Signature of Applicant  
First Name , Surname     
EN 4  EN ANNEX III 
 
TEMPLATE FOR  ‘EC’ DECLARATION OF VERIFICATION FOR  SUBSYSTEM 
INITIALLY PLACED IN SERVICE WITHOUT AN ‘EC’ DECLARATION  
 
‘EC’ declaration of v erification of subsystem  
‘EC’ declaration identification number  [ERADIS ID]1  
 
We, Applicant:  
[Business name]  
[Complete postal address]  
 
Declare under our sole responsibility that  for the subsystem  to which this declaration refers :  
[Name/short description of the subsystem  Identification of the subsystem]  
 
The changed part of the subsystem : 
[Name/short description of the parts of the subsystem]  
 
has been subject to the relevant verification procedures and complies with the relevant Union 
law and any relevant national rules :    
[Reference to: the Directive(s); TSI(s); Relevant national rules;]  
 
has been assessed by the following conformity assessment bodies:  
 
Notified Body:  
Business name  
Registration number  
Full address  Designated Body:  
Business name  
Identification number  
Full address  Assessment body [Risk 
assessment ]:  
Business name  
Identification  number  
Full address  
 
In accordance with the following certificate(s) and or report(s):  
[Certificate(s) number(s), report(s) number(s), date(s) of issue]  
 
The unchanged part of the subsystem t o which this declaration refers  has been approved to be 
used in the railway system and has been in use since  the date of approval until the date of the 
establishing the ‘EC’  declaration of verification . 
 
                                                 
1  The informa tion in square brackets [ ] is provided to support the user in correctly and exhaustively compil ing the 
template.   
EN 5  EN The following conditions of use and other restrictions apply2: 
[List or reference to  the list of conditions of use and other restrictions ] 
 
The following procedures have been followed in order to declare conformity:  
[The modules chosen by applicant for the verification of the subsystem]  
 
Identification of the technical file accompanying t his declaration  
[Reference to the technical file accompanying the ‘EC’ declaration of verification of 
subsystem  in accordance with  Article 15(4) of Directive (EU) 2016/797 ] 
 
Reference to former ‘EC’  declaration of verification  (where applicable)   
[Yes/No]  
 
Done on:  
[date DD/MM/YYYY]  
 
Signature of Applicant  
First Name , Surname    
                                                 
2  When a reference  to a list of conditions and limits of use  is made, such list shall be accessible to the authorising entity.   
EN 6  EN ANNEX IV 
 
TEMPLATE FOR  INTERMEDIATE STATEMENT OF VERIFICATION   
 
Intermediate Statement of Verification  
Number [unique ISV identification number]1 
 
Object of Assessment:  
[Unique Identification of the subsystem or of the part of the subsystem: identification of whole or of the part of the 
subsystem, and stages of verification in accordance with Annex IV – Section 2.2.3 of Directive (EU) 2016/7972] 
 
Applicant, wh ere applicable also Manufacturer and Manufacturing l ocations:  
[Name(s), Address(es)]  
 
Assessment Requirements:  
[Reference to: the Directive(s), the TSI(s), the non -application of TSI(s), the relevant 
National Rules, European specifications, other Acceptable Means of Compliance]  
 
Module(s) applied:  
[The modules as chosen by the applicant for the assessment of the subsystem or of a 
part of the subsystem, and stages of verification]  
 
Assessment/Audit result:  
[Including reference to the assessment/audi t report]  
 
The following conditions and limits of use apply3: 
[List or reference to the list of conditions and limits of use]  
 
Annex of ISV4 (where applicable)     
[Yes/No]  
 
Documentation accompanying this ISV:  
[reference to accompanying documents; list or  file of documents used for the 
assessment]  
 
 
                                                 
1  The i nformation in square brackets [ ] is provided t o support the user  in compiling the template.  
2  Directive (EU) 2016/797 of the European Parliament and of the Council of 11 May 2016 on the interoperability of the 
rail system within the European Union (recast) (OJ L 138, 26.5.2016, P. 44 202) . 
3  When  a reference  to a list of conditions and limits of use  is made, such list shall be a ccessible  to the authorising entity . 
4  It is good practice to issue ISV as a single page document; if the relevant information for the ISV does not fit all on one 
page, the Annex provides sufficient space for any other relevant information to be considered.   
EN 7  EN Validity:  
[Time and conditions of validity of ISV]  
 
Done on:  
[date DD/MM/YYYY]  
 
Notified Body  
Signature  
First Name, Surname   
[OR]   
 
 
 
 
Page 1[/nn]  Designated Body  
Signature  
First Name, Surname  
Business name  Business name  
Registration number  Identification number  
Complete postal 
address  Complete postal 
address  
 
Annex to Intermediate Statement of Verification [ where applicable ] 
Number [unique ISV identification number]  
 
Object of Assessment:  
[Unique Identification of the subsystem or of the part of the subsystem: identification 
of whole or of the part of the subsystem, and stages of verification in accordance with 
Annex IV – Section 2.2.3 of Directive (EU) 2016/7975] 
 
Done on:  
[date DD/MM/YYYY]  
 
Notif ied Body  
Signature  
First Name, Surname   
[OR]  Designated Body  
Signature  
First Name, Surname  
Business name  Business name  
Registration number  Identification number  
Complete postal 
address  Complete postal address  
Page n/nn  
                                                 
5   Directive (EU) 2016/797 of the European Parliament and of the Council of 11 May 2016 on the interoperability of the 
rail system within the European Union (recast) (OJ L 138, 26.5.201 6, P. 44 202) .  
EN 8  EN ANNEX V 
 
TEMPLATE FOR  CERTIFICATE  
 
 [‘EU’]1 Certificate  of [conformity / suitability for use /verification ] 
Number [ unique  certificate identification number ]2 
 
Object of Assessment:  
[Unique Identification of the Interoperability Constituent or of the Subsystem]  
 
Applicant, where applicable also Manufacturer and manufacturing locations:  
[Name(s), Address(es)]  
 
Assessment Requirements:  
[Reference to: the Directive(s), the TSI(s), the relevant National Rules, European 
specifications, other Acceptable Means of Complia nce] 
 
Module(s) applied:  
[The module(s) as chosen by the applicant for the assessment of the Interoperability Constituent or of 
the Subsystem]  
 
Assessment/Audit result:  
[Including reference to the assessment/audit report]  
 
The following conditions and limi ts of use apply3: 
[List or reference to the list of conditions and limits of use]  
 
Annex4   (where  applicable):  
[Yes/No]  
 
Documentation accompanying this [ ‘EU’ ]1 Certificate:  
[reference to accompanying documents; list or file of documents used for the assessment]  
 
Validity:  
[Time and conditions of validity of certificate]  
                                                 
1  ‘EU’ applies only to  NoBo Certificates, to be omitted on DeBo Certificates . 
2  The information in square brackets [ ] is just provided to support the user in correctly and exhaustively compil ing the 
template.  
3  When a reference  to a list of conditions and limits of use  is made, such list shall be accessible to the authorising entity.  
4  It is good practice to issue certificates as a single page document; if the relevant information for the certificate does not  
fit all on one page, th e Annex provides sufficient space for any other relevant information to be considered.   
EN 9  EN  
Done on:  
[date DD/MM/YYYY]  
 
Notified Body  
Signature  
First Name, Surname   
[OR]  Designated Body  
Signature  
First Name, Surname  
Business name  Business name  
Registration number  Identification number  
Complete postal address  Complete postal address  
 
page 1[/nn]   
 
Annex to the [ ‘EU’] 5  certificate [ where  applicable65] 
Number [ unique  certificate identification number ] 
 
 
Object of Assessment:  
[Unique Identification of the Interoperability Constituent or of the Subsystem]  
 
 
 
Done on:  
[date DD/MM/YYYY]  
 
Notified Body  
Signature  
First Name, Surname   
[OR]  Designated Body  
Signature  
First Name, Surname  
Business name  Business name  
Registration number  Identification number  
Complete postal address  Complete postal address  
 
 
page n/nn  
                                                 
5   ‘EU’ applies only to  NoBo Certificates, to be omitted on DeBo Certificates.  
6   It is good practice to issue certificates as a single page document ; if the relevant information for the certificate does not 
fit all on one page, the Annex provides sufficient space for any other relevant information to be considered.   
EN 10  EN ANNEX VI 
 
MODEL OF DECLARATION OF CONFORMITY TO AN AUTHORISED  VEHICLE 
TYPE  
Declaration of conformity to an authorised vehicle type  
 
We,  
Applicant  
 
[Business name] 1 
[Full address]  
 
Declare under our sole responsibility that vehicle [reserved  Vehicle Number] 2  to 
which this declaration refers  
- conforms to authorised vehicle type [ERATV identification of the 
type/version/variant of vehicle]  
-  complies with the relevant Union law and relevant national rules, as indicated in the 
annexes to this declaration,  
-  has undergone all verification procedures necessary for establishing this declaration.  
List of annexes3  
[Titles of the annexes]  
Signed for and on behalf of [name of the applicant]  
Done at [place] , [date DD/MM/YYYY]  
[name, function] [signature]  
 
European Vehicle Number  allocated to the vehicle4: [EVN]  
                                                 
1  The information in square brackets [ ] is to support the user in correctly and exhaus tively compil ing the template.  
2  If at the moment of establishing this declaration the vehicle has not yet been assigned a reserved  Vehicle Number, the 
vehicle shall be identified by another identification system agreed by the applicant and the authorisin g entity. In this 
case, when an EVN has been assigned to the vehicle, the authorising entity shall fill in the field reserved for this 
purpose.  
3  Annexes shall include copies of EC declaration(s) of verification of subsystem(s) . 
4  The applicant  shall fil l in th is field when the EVN is assigned .