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V.

05 Edition January 2023


IFISHI 12.a
IFISHI ISABA IHEREREKANYA RY’UBURENGANZIRA K’UBUTAKA
RISHINGIYE KU MPANO HAGATI Y’ABAKIRIHO CYANGWA KU NDAGANO

Umwirondoro
Njyewe/Twebwe: .....…………………………………………………………………………………………………………………...........
Indangamuntu/Pasiporo: …………………..………………………………………………………………………………………..........
Aderesi: Akarere ka…………………….…. Umurenge wa ……………………………Akagari ka ……………………............
Umudugudu wa ………………................Telefoni : …………………………………….E-mail:…………………………...............
Numero ya telefoni y’uhawe/ababahawe:..............................................................................

Ndasaba gukora ihererekanya ry’uburenganzira k’ubutaka rishingiye ku mpamo cyangwa indagano

Amakuru ku kibanza/Isambu
Nimero y'ikibanza/isambu (UPI): …………………………..................................
Umujyi wa Kigali/Intara: ………………………………………................
Akarere: …………………………………………………...
Umurenge: …………………………………….……………..
Akagari: …………………………………….……………..
Umugabane utwangwa: .......................%

Ibisobanuro k'ubusabe………………………………………………………………………………………….....................................
……………………………………………………………………………………………………………………………….....................................

Ibisabwa
Kopi y’ibiranga uwahawe
Icyemezo cy’irangamimerere cy’uwahawe impano/ uwatanze impano
Amasezerano y’impano hagati y’abazima yashyizweho umukono n’uwatanze n’uwahawe
impano yakorewe imbere ya noteri mu by’ubutaka /Indangano yakorewe imbere ya noteri mu
by’ubutaka
Icyemezo cy’uko uwatanze yitabye Imana (Mu gihe impano yatanzwe mu buryo bw’indagano)
Ibyangombwa by’ubutaka1 butanzweho impano hagati y’abazima cyangwa indagano

Ahagenewe gusaba guhuza imikoreshereze y’ubutaka n’igishushanyo mbonera

Ndasaba ko icyo ubutaka bwagenewe gukoreshwa gihuzwa n’igishushanyo mbonera


cy’imikoreshereze y’ubutaka( uzuza ahabugenewe)

…………………………….. ………………………………………………………………………………
Itariki y'ubusabe Umukono w'usaba (w'abasaba)

Byakiriwe kandi bisuzumwa na: ………………………………...................................................................................................


Icyo ashinzwe:……………………………………………………………………………………………………………………………..................................

Itariki: ………………………………………………………
Kashe
Umukono: …………………………………………………

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Ibi bireba ibyangombwa byatanzwe mbere y’itariki ya 09 Mutarama 2023.

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