Mu s 04/2013/TT-LLTP

CNG HO X HI CH NGHA VIT NAM

c lp - T do - Hnh phc
T KHAI YU CU CP PHIU L LCH T PHP
(Dng cho c nhn trong trng hp y quyn yu cu cp Phiu l lch t php s 1 v c
nhn l cha, m ca ngi cha thnh nin yu cu cp Phiu l lch t php s 2)
Knh gi: .....................................
1. Tn ti l1:..........................................................................................................................
2. Tn gi khc (nu c).................................................................3. Gii tnh:.......................
4. Ngy, thng, nm sinh: ././.....5.Ni sinh2:..................................................................
6. a ch3: ........................................................................................................................ .....
.....................................................................................S in thoi :......................................
7. Giy CMND/H chiu: .4 S:......................................................
Cp ngy.........thng...........nm.............Ti:.......................................................................
8. c s y quyn :............................................................................................................
8.1. Mi quan h vi ngi u quyn5 :.................................................................................
8.2. Theo vn bn y quyn k ngy 6.................thng..........nm...........................................
Ti lm T khai ny ngh cp Phiu l lch t php cho ngi c tn di y :
PHN KHAI V NGI Y QUYN HOC NGI CHA THNH NIN
1. H v tn7:...........................................................................................................................
2.Tn gi khc (nu c):................................................................3. Gii tnh......................
4. Ngy, thng, nm sinh: ./ ./ ....5.Ni sinh2 :.................................................................
6. Quc tch :................................................7.Dn tc:...........................................................
8. Ni thng tr8: ........................................................................................................... ......
...............................................................................................................................................
9. Ni tm tr9:.......................................................................................................................
...............................................................................................................................................
10. Giy CMND/H chiu :.......................................... 10S:..................................................
Cp ngy.......thng.........nm..............Ti:.............................................................................
11. S in thoi/e-mail:........................................................................................................
PHN KHAI V CHA, M, V/ CHNG CA NGI Y QUYN HOC CHA, M
CA NGI CHA THNH NIN
CHA

V/ CHNG

H v tn
Ngy, thng,
nm sinh

QU TRNH C TR CA NGI Y QUYN HOC NGI CHA THNH NIN11

T thng, nm
n thng, nm

Ni thng tr/ Tm tr

Ngh nghip, ni lm vic12

Phn khai v n tch, v ni dung cm m nhim chc v, thnh lp, qun l doanh
nghip, hp tc x (nu c):...............................................................................................
...............................................................................................................................................
Yu cu xc nhn v ni dung cm m nhim chc v, thnh lp, qun l doanh nghip,
hp tc x theo quyt nh tuyn b ph sn: C
Khng
Mc ch yu cu cp Phiu l lch t php:
.
S lng Phiu l lch t php yu cu cp:Phiu
Ti xin cam oan nhng li khai trn l ng s tht v chu trch nhim v li khai ca mnh.
, ngy thng nm .
Ngi khai
(K, ghi r h tn)

Ghi ch:
H v tn ngi c y quyn hoc ca cha/m ngi cha thnh nin; ghi bng ch in hoa, du.
2
Ghi r x/phng, huyn/qun, tnh/ thnh ph trc thuc Trung ng.
3
Ghi r a ch lin lc khi cn thit.
4
Ghi r l chng minh nhn dn hay h chiu.
5
Ghi r mi quan h trong trng hp ngi c y quyn l cha, m, v, chng, con ca ngi y quyn;
trong trng hp ny khng cn c vn bn y quyn.
6
Ghi r trong trng hp c vn bn y quyn.
7
Ghi bng ch in hoa, du.
8,9
Trng hp c ni thng tr v ni tm tr th ghi c hai ni.
10
Trng hp l ngi cha thnh nin di 14 tui th khng phi ghi ni dung ny.
11
K khai qu trnh c tr, ngh nghip, ni lm vic t khi t 14 tui tr ln.
12
i vi ngi tng l qun nhn ti ng, cng chc, cng nhn quc phng, qun nhn d b, dn qun t
v th ghi r chc v trong thi gian phc v trong qun i.