IZJAVA / IZJAVA

Ja, ______________________________ , ro|en-a ___________________ , u/u __________________

/ime i prezime / ime i prezime /

ro|en-a /datum-nadnevak/datum/

/ mjesto / mjesto /

___________________________________ , JMBG __ __ __ __ __ __ __ __ __ __ __ __ __
/ op{tina-op}ina ro|enja / op{tina ro|ewa /

JMBG

sa prebivali{tem u BiH na adresi / sa prebivali{tem u BiH na adresi:

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i boravi{tem u inostranstvu-inozemstvu na adresi / sa boravi{tem u inostransvu na adresi:
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IZJAVLJUJEM/I Z J A V Q U J E M
svojevoljno i bez prinude pod punom moralnom, materijalnom i krivi~nom odgovorno{}u:

svojevoqno i bez prinude pod punom moralnom, materijalnom i krivi~nom odgovorno{}u:

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/ potpis / potpis /