I Z J A VA

Ja, ________________________________, roen-a _______________, u________________________

(ime i prezime)

(datum roenja)

(mjesto roenja)

s prebivalitem u BiH na adresi: ________________________________________________________ i

privremenim boravkom u inostranstvu na adresi: _____________________________________________,
nosilac pasoa/line karte: __________________ izdane: ____________________ od strane: _________
(broj)

(datum izdavanja)

____________________________________, JMB
(naziv organa koji je izdao ispravu)

svojevoljno i pod punom moralnom, materijalnom i krivinom odgovornou izjavljujem:

_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

Potpis davaoca izjave:

U_____________________, _____________
(mjesto)

_______________________________

(datum)

Svjedok potpisa - Justice of the Peace:

(Witness of signature Justice of the Peace)
________________________________

Peat
(Stamp)

VI.1.b. - Obrazac izjave - BiH - 04062010

I Z J A VA

Ja, ________________________________, roen-a _______________, u________________________

(ime i prezime)

(datum roenja)

(mjesto roenja)

s prebivalitem u BiH na adresi: ________________________________________________________ i

privremenim boravkom u inozemstvu na adresi: _____________________________________________,
nositelj putovnice/osobne iskaznice broj: __________________ izdane: _________________ od strane:
(broj)

(datum izdavanja)

____________________________________, JMB
(naziv organa koji je izdao ispravu)

svojevoljno i pod punom moralnom, materijalnom i krivinom odgovornou izjavljujem:

_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

Potpis davatelja izjave:

U_____________________, _____________
(mjesto)

_______________________________

(datum)

Svjedok potpisa - Justice of the Peace:

(Witness of signature Justice of the Peace)
________________________________

Peat
(Stamp)

VI.1.b. - Obrazac izjave - BiH - 04062010


, ________________________________, - _______________, ___________________________
( )
( )
( )
: _______________________________________________________
: ___________________________________________,
/ : ________________ : ________________ : ____________
()
( )
____________________________________________,
( )
, :
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
:
_____________________, _____________
()
()

_______________________________

- Justice of the Peace:

(Witness of signature Justice of the Peace)
________________________________

(Stamp)

VI.1.b. - Obrazac izjave - BiH - 04062010