Mu T khai cp giy xc nhn tnh trng hn nhn

(Mu TP/HT-2010 XNHN.1 ban hnh km theo Thng t 08.a/2010/TT-BTP

ngy 25/3/2010 ca B T php)
CNG HO X HI CH NGHA VIT NAM

c lp - T do - Hnh phc
T KHAI CP GIY XC NHN TNH TRNG HN NHN

Knh gi:..............................................................................................
H v tn ngi khai : ..............................................................................................................................
Dn tc:.......................................................................Quc tch:...................................................................
Ni thng tr/tm tr: ...............................................................................................................................
Quan h vi ngi c cp Giy xc nhn tnh trng hn nhn:.....................................
ngh cp Giy xc nhn tnh trng hn nhn cho ngi c tn di y:
H v tn: ...........................................................................................Gii tnh:...........................................
Ngy, thng, nm sinh:.................................................................................................................................
Ni sinh:................................................................................................................................................................
Dn tc:.....................................................................Quc tch:.....................................................................
S Giy CMND/H chiu/Giy t hp l thay th:....................................................................
Ni thng tr/tm tr (1):........................................................................................................................
Trong thi gian c tr ti............................................................................................
..............t ngy..........thng...........nm................., n ngy..........thng..........nm...................(2)
Tnh trng hn nhn (3)...............................................................................................................................
.....................................................................................................................................................................................
.....................................................................................................................................................................................

Mc ch ca vic yu cu cp Giy xc nhn tnh trng hn nhn (4):........................

.....................................................................................................................................................................................

Ti cam oan nhng ni dung khai trn y l ng s tht v chu trch nhim
trc php lut v li khai ca mnh.
Lm ti:..........................., ngy .........thng.........nm...........
Ngi khai
(K, ghi r h tn)
Ch thch:

(1) Trng hp cng dn Vit Nam c tr trong nc th ghi theo ni ng k thng

tr, trong trng hp khng c ni ng k thng tr th ghi theo ni ng k tm tr.
Trng hp cng dn Vit Nam c tr nc ngoi th ghi theo a ch thng tr hoc
tm tr nc ngoi.
(2) Ch khai trong trng hp cng dn Vit Nam ang c tr nc ngoi c yu cu
xc nhn tnh trng hn nhn trong thi gian c tr nc ngoi hoc trong thi gian c tr
ti Vit Nam trc khi xut cnh.
(3) i vi cng dn Vit Nam c tr trong nc th khi r tnh trng hn nhn hin ti:
ang c v hoc c chng; hoc cha ng k kt hn ln no; hoc ng k kt hn,
nhng ly hn hay ngi kia cht.
i vi cng dn Vit Nam c tr nc ngoi c yu cu xc nhn tnh trng hn nhn
trong thi gian c tr ti Vit Nam trc khi xut cnh, th khai v tnh trng hn nhn ca
mnh trong thi gian c tr ti ni (V d: trong thi gian c tr ti...............................,
t ngy...... thng ..... nm......... n ngy........ thng ........nm ........ cha ng k kt hn vi
ai).
i vi cng dn Vit Nam ang c tr nc ngoi, c yu cu xc nhn tnh trng hn
nhn trong thi gian c tr nc ngoi, th khai v tnh trng hn nhn ca mnh trong thi
gian c tr ti nc (V d: trong thi gian c tr ti CHLB c, trong thi gian tm tr
ti... CHLB c t ngy... n ngy... khng ng k kt hn vi ai ti i s qun Vit Nam
ti CHLB c);
(4) Ghi r mc ch s dng Giy xc nhn tnh hn nhn. Trng hp s dng Giy xc
nhn tnh trng hn nhn kt hn, th phi ghi r kt hn vi ai? u? (h tn, quc tch).