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: _____________________________________________,
nositelj pasoa/line karte broj: __________________ izdate: __________________ od strane: ________
(broj)

(datum izdavanja)

____________________________________, JMB
(naziv organa koji je izdao ispravu)

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

_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

Potpis podnosioca izjave:

U_____________________, _____________
(mjesto)

_______________________________

(datum)

Ovjera potpisa kod Notary Public:

VI.2.b. - Obrazac izjave - Declaration Form - 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: __________________ izdate: _________________ 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)

Ovjera potpisa kod javnog biljenika:

VI.2.b. - Obrazac izjave - Declaration Form - 04062010

, ________________________________, - _______________, ___________________________

( )
( )
( )
: _______________________________________________________
: ___________________________________________,
/ : ________________ : ________________ : ____________
()
( )
____________________________________________,
( )
, :
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

:
_____________________, _____________
()
()

_______________________________

Notary Public:

VI.2.b. - Obrazac izjave - Declaration Form - 04062010

DECLARATION

I, ___________________________________, born____________________________, ______________

(Name and surname)

(place of birth)

(date of birth)

residential address: _____________________________________________________________________

Identification document : __________________________ issued: _______________________________
(No)

(date of issue)

Issued by: _____________________________________,

(Authority)

PIN (JMB)
Declare under penalty
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

Signature:
In____________________, _____________
(place)
(date)
__________________________

Stamped by Notary Public

VI.2.b. - Obrazac izjave - Declaration Form - 04062010