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INSTITUTO NACIONAL DO SEGURO SOCIAL
ANEXO I
OFÍCIO-CIRCULAR Nº 46 DIRBEN/INSS, DE 13 DE SETEMBRO DE 2019.
AUTODECLARAÇÃO DO SEGURADO ESPECIAL – RURAL

TODAS AS INFORMAÇÕES SERÃO CHECADAS NOS SISTEMAS OFICIAIS
1. Dados do Segurado:
NOME:_____________________________________________________________________________________
DATA DE NASCIMENTO/DN: _____________LOCAL DE NASCIMENTO:_____________________________
ENDEREÇO RESIDENCIAL: ___________________________________________________________________
CPF:___________________ RG:__________________ DATA/LOCAL DE EXPEDIÇÃO:___________________
TITULO ELEITOR:____________________ UF/MUNICIPIO:_________________________________________
CNH:________________________________TIPO:__________________________________________________
CADUNICO SIM ( ) NÃO ( )
2. Forma que exerce/exerceu a atividade de segurado especial:

( ) INDIVIDUALMENTE
( ) REGIME DE ECONOMIA FAMILIAR
2.1. Se exerceu ou exerce atividade em regime de economia familiar, informe sua condição no grupo:
( ) titular
( ) componente
2.2. Grupo Familiar, se exerceu ou exerce a atividade em regime de economia familiar, informe os componentes do grupo
familiar:
NOME______________________________________________DN:_____________________________________
CPF (NÚMERO E LOCAL EXPEDIÇÃO)_________________________________________________________
CNH (NÚMERO, TIPO E LOCAL EXPEDIÇÃO)___________________________________________________
TÍTULO ELEITOR (NÚMERO, ZONA, SEÇÃO)___________________________________________________
ESTADO CIVIL:______________________ PARENTESCO __________________________________________
NOME______________________________________________DN:_____________________________________
NOME______________________________________________DN:_____________________________________
NOME______________________________________________DN:_____________________________________
3. Período(s) de atividade rural (dia/mês/ano):

PERÍODO (xx/xx/xxxx a xx/xx/xxxx) CONDIÇÃO EM RELAÇÃO AO IMÓVEL*
*Proprietário / Possuidor / Comodatário / Arrendatário / Parceiro / Meeiro / Usufrutuário / Condômino / Posseiro / Assentado /
Acampado
3.1. Informe os dados da(s) terra(s):
1
Registro ITR, se possuir_________________________________________________________________________
Nome da propriedade__________________ Município________________________________________________
Área total do imóvel __________________ Área útil _________________________________________________




3.2. Qual o nome e CPF do(s) titular(es) do(s) imóvel(eis) rural:

NOME CPF PERÍODO (xx/xx/xxxx a xx/xx/xxxx)
3.3. Informe a atividade agropecuária principal e destinação (produtor de milho, criador de porcos etc.)
ATIVIDADE SUBSISTÊNCIA/VENDA VALOR ANUAL (em caso de venda)
3.4. Quais os principais locais onde comercializa a produção (feira, Cooperativa, Ceasa etc.):
PRODUTO TIPO DE ESTABELECIMENTO LOCAL
3.5. Informe se há/houve processo de beneficiamento/industrialização artesanal com incidência de Imposto Sobre
Produtos Industrializados – IPI (produção de queijo, doce, farinha etc.): SIM ( ) NÃO ( )
PERÍODO (xx/xx/xxxx a xx/xx/xxxx) LOCAL
3.6. Possui empregado(s) ou prestador(es) de serviço: SIM ( ) NÃO ( ) Especificar.

NOME CPF, se possuir PERÍODO (xx/xx/xxxx a xx/xx/xxxx)
4. Informe se está/esteve afastado(a) da atividade rural: SIM ( ) NÃO ( ) Especificar

MOTIVO PERÍODO (xx/xx/xxxx a xx/xx/xxxx)
2
4.1. Informe se já morou em local diverso do meio rural.
UF/MUNICÍPIO PERÍODO (xx/xx/xxxx a xx/xx/xxxx)
4.2. Outras atividades exercidas:

ATIVIDADE* LOCAL PERÍODO (xx/xx/xxxx a xx/xx/xxxx)
*Pedreiro, carpinteiro, pintor, entre outros.
4.3. Informe se recebe/recebeu outra renda nas seguintes atividades: atividade turística, artística, artesanal, dirigente
sindical ou de cooperativa, mandato de vereador: SIM ( ) NÃO ( )
ATIVIDADE PERÍODO (xx/xx/xxxx a xx/xx/xxxx) RENDA (R$) OUTRAS INFORMAÇÕES *
* Para atividade artesanal, informar a origem da matéria prima.

Para mandato de vereador, informar o Município.
Para exploração de atividade turística na propriedade, indicar os dias de hospedagem por exercício.
4.4. Informe se participa de plano de previdência complementar: SIM ( ) NÃO ( )

ENTIDADE CNPJ INFORMAR SE É INSTITUÍDA POR
ENTIDADE CLASSISTA RURAL
4.5. Informe se participa de cooperativa: SIM ( ) NÃO ( )

ENTIDADE CNPJ INFORMAR SE É AGROPECUÁRIA OU
DE CRÉDITO RURAL
4.6. Possui outro imóvel, urbano ou rural: SIM ( ) NÃO ( )

ESPECIFICAR REGISTRO LOCAL VALOR
5. Informe quais são os vizinhos da localidade onde exerce atividade rural:

NOME CPF ENDEREÇO
Declaro sob as penas previstas na legislação, que as informações prestadas nesta declaração são verdadeiras, estando
ciente das penalidades do Art. 299 do Código Penal Brasileiro.
Local: ___________________________________ Data: ________________________________
________________________________________________________________
Assinatura do segurado/requerente
3
POLEGAR DIREITO
Art. 299 do Código Penal: Omitir, em documento público ou particular, declaração que dele devia constar ou nele inserir
ou fazer inserir declaração falsa ou diversa da que devia ser escrita, com o fim de prejudicar direito, criar obrigação ou
alterar a verdade sobre fato juridicamente relevante.
Pena - reclusão, de um a cinco anos, e multa, se o documento é público, e reclusão de um a três anos, e multa, se o
documento é particular.
NOTA: esta declaração deverá ser assinada pelo declarante em todas as suas páginas.
4
ANEXO II
AUTODECLARAÇÃO DO SEGURADO ESPECIAL – PESCADOR

NOME:_____________________________________________________________________________________
CNH:________________________________TIPO:__________________________________________________
2. Forma que exerce/exerceu a atividade de segurado especial:

( ) INDIVIDUALMENTE
2.1 Se exerceu ou exerce atividade em regime de economia familiar, informe sua condição no grupo:
( ) titular
( ) componente
familiar:
NOME______________________________________________DN:_____________________________________
NOME______________________________________________DN:_____________________________________
NOME______________________________________________DN:_____________________________________
NOME______________________________________________DN:_____________________________________
3. Período(s) de atividade de pesca (dia/mês/ano):

PERÍODO (xx/xx/xxxx a xx/xx/xxxx) LOCAL ONDE EXERCE A ATIVIDADE*
*Mar / Rio / Estuário / Lagoa / Açude / Represa
3.1. Informe a condição de pescador em relação à embarcação onde exerce/exerceu a atividade:

PERÍODO (xx/xx/xxxx a xx/xx/xxxx) CONDIÇÃO EM RELAÇÃO A EMBARCAÇÃO*
1
* Arrendatário / Comodatário / Meeiro / Parceiro / Proprietário / Pescador Artesanal ou mariscador sem embarcação
3.2 Qual o nome e CPF do(s) titular(es) da embarcação:

3.3 Informe a atividade pesqueira (pescador de tambaqui, pescador de ostra etc.):

3.4 Quais os principais locais onde comercializa a produção:

3.5 Informe se há/houve processo de beneficiamento/industrialização artesanal com incidência de Imposto Sobre
Produtos Industrializados – IPI (produção de queijo, doce, farinha, etc): SIM ( ) NÃO ( )

3.7. Utiliza petrechos de pesca: SIM ( ) NÃO ( ) Especificar

TIPO VALOR
4. Informe se está/esteve afastado(a) da atividade pesqueira: SIM ( ) NÃO ( ) Especificar

ATIVIDADE PERÍODO (xx/xx/xxxx a xx/xx/xxxx)
4.1. Informe se já morou em local diverso de onde exerce a atividade: SIM ( ) NÃO ( ) Especificar

2



DE CRÉDITO RURAL


NOME CPF ENDEREÇO
Local: __________________________________ Data: ________________________________
________________________________________________________________
POLEGAR DIREITO
3
4
ANEXO III
AUTODECLARAÇÃO DO SEGURADO ESPECIAL – SERINGUEIRO E EXTRATIVISTA VEGETAL

NOME:_____________________________________________________________________________________
CNH:________________________________TIPO:__________________________________________________
2. O requerente é/foi seringueiro ou extrativista vegetal que explorou os recursos naturais renováveis de modo sustentável
(assegurando a diversidade biológica e dos ecossistemas), sendo esta atividade seu principal meio de vida.
SIM ( ) NÃO ( )
2.1. Forma que exerce/exerceu a atividade de segurado especial:

( ) INDIVIDUALMENTE
2.2. Se exerceu ou exerce atividade em regime de economia familiar, informe sua condição no grupo:
( ) titular
( ) componente
familiar:
NOME______________________________________________DN:_____________________________________
NOME______________________________________________DN:_____________________________________
NOME______________________________________________DN:_____________________________________
NOME______________________________________________DN:_____________________________________
3. Período(s) de atividade extrativista (dia/mês/ano):

PERÍODO (xx/xx/xxxx a xx/xx/xxxx) LOCAL QUE REALIZA A ATIVIDADES
3.1. Informe os dados da(s) terra(s):
1
Registro ITR, se possuir __________________________________________________________________________________
Nome da propriedade____________________________ Município________________________________________________
Registro ITR, se possuir __________________________________________________________________________________

Nome da propriedade____________________________ Município________________________________________________
3.2. Informe a atividade extrativista principal (seringueiro, castanheiro, etc.):

3.3. Quais os principais locais onde comercializa a produção, caso aplicável:

3.4. Informe se há/houve processo de beneficiamento/industrialização artesanal com incidência de Imposto Sobre
Produtos Industrializados – IPI (farinha, processamento de borracha, etc.): SIM ( ) NÃO ( )

NOME CPF, se possuir PERÍODO (xx/xx/xxxx a xx/xx/xxxx)
4. Informe se está/esteve afastado(a) da atividade extrativista: SIM ( ) NÃO ( ) Especificar

MOTIVO PERÍODO (xx/xx/xxxx a xx/xx/xxxx)
4.1. Informe se já morou em local diverso de onde exerce a atividade


2



DE CRÉDITO RURAL


NOME CPF ENDEREÇO
Local: ______________________ Data: ________________________________
________________________________________________________________
POLEGAR DIREITO
3
ANEXO IV
DESPACHO CONCLUSIVO
1. Dados do Segurado (EXTRAÍDOS DO SISTEMA)
2. Análise da Autodeclaração, confrontada com as bases governamentais:
A) Pela análise da autodeclaração, o segurado atende os requisitos para caracterização como segurado especial?
( ) SIM
( ) NÃO. Justifique, indicando o(s) motivo(s), dentre os listados no anexo V.
B) A análise das bases governamentais é suficiente para ratificar a autodeclaração?
( ) SIM (Ir para “D”)

( ) NÃO. Justifique, especificando o(s) motivo(s), dentre os listados no anexo V, e a(s) base(s) consultada(s)
C) Caso a resposta anterior (B) seja negativa, o(s) documento(s) apresentado(s), dentro dos critérios previstos, ratificam
a autodeclaração?
( ) SIM
( ) NÃO. Justifique, indicando o(s) motivo(s), dentre os listados no anexo V.
D) Há elementos que descaracterizam a condição de segurado especial?
( ) SIM. Justifique, especificando o(s) motivo(s), dentre os listados no anexo V, e a(s) base(s) consultada(s)
( ) NÃO.
__________________________________________________________
Assinatura do servidor (Não necessário assinar para inclusão no GET)
Anexo relatório automatizado das bases governamentais

ANEXO V
CRITÉRIOS PARA CARACTERIZAÇÃO DO SEGURADO ESPECIAL
1. Dados do Segurado (EXTRAÍDOS DO SISTEMA)
2. Análise da Autodeclaração, confrontada com as bases governamentais:
O que observar*:
1) A ocupação desenvolvida permite o enquadramento como segurado especial?
2) A localização da propriedade rural é no mesmo município ou em município contíguo ao do endereço residencial

declarado?
3) O imóvel rural possui até 4 Módulos Fiscais?
4) Se pescador que utilize embarcação, a arqueação bruta é igual ou menor que 20 (vinte)?
5) Se houve outorga, foi respeitado o limite de outorga de até 50% da área da propriedade e esta em sua área total não
excede 4 Módulos Fiscais?
6) Foi constatado que o titular não é outorgante de arrendamento?
7) Foi respeitado o limite da razão de 120 dias dentro do ano civil para contratação empregado ou prestador de serviço
eventual?
8) Se participa ou participou de sociedade empresarial ou de sociedade simples, a empresa é considerada microempresa

nos termos da Lei Complementar 123/2006, é de objeto agrícola, agroindustrial ou agroturístico, composta apenas de
segurados de igual natureza e sediada no mesmo município ou em município limítrofe àquele em que eles desenvolvam
suas atividades?
9) Se utilizou a propriedade para turismo, foi respeitado o limite de 120 dias de hospedagem por ano?
10) Se exerceu atividade remunerada por período superior a 120 dias dentro do exercício, houve comprovação do retorno?
11) Se houve recebimento de benefício em categoria diferente de segurado especial, este é inferior ao salário mínimo?
12) Se houve beneficiamento/industrialização artesanal, foi sem incidência de IPI?
13) Se possui plano de previdência complementar, o plano é em razão da condição de produtor rural?
14) Se participa de cooperativa, a cooperativa é de natureza rural?
15) Se exerceu mandato de dirigente sindical, a entidade é de categoria de trabalhador rural?
16) Se exerceu mandato de vereador, o exercício foi no município em que desenvolvia a atividade rural?
17) Se auferiu rendimento mensal decorrente de atividade turística, o rendimento foi de até um salário-mínimo?
18) Se houve atividade artesanal com renda mensal superior ao salário-mínimo, a matéria-prima foi produzida pelo
respectivo grupo familiar?
* Descaracteriza a condição de segurado especial se houver resposta negativa para qualquer uma das questões.
0123034351780517952 4 5258079

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1234145462891628 63 5636918 

OFÍCIO-CIRCULAR Nº 46 DIRBEN/INSS, DE 13 DE SETEMBRO DE 2019.

AUTODECLARAÇÃO DO SEGURADO ESPECIAL – RURAL

2. Forma que exerce/exerceu a atividade de segurado especial:

3. Período(s) de atividade rural (dia/mês/ano):

3.1. Informe os dados da(s) terra(s):

Registro ITR, se possuir_________________________________________________________________________

Registro ITR, se possuir_________________________________________________________________________

Registro ITR, se possuir_________________________________________________________________________

Registro ITR, se possuir_________________________________________________________________________

3.2. Qual o nome e CPF do(s) titular(es) do(s) imóvel(eis) rural:

3.6. Possui empregado(s) ou prestador(es) de serviço: SIM ( ) NÃO ( ) Especificar.

4. Informe se está/esteve afastado(a) da atividade rural: SIM ( ) NÃO ( ) Especificar

4.2. Outras atividades exercidas:

*Pedreiro, carpinteiro, pintor, entre outros.

* Para atividade artesanal, informar a origem da matéria prima.

4.4. Informe se participa de plano de previdência complementar: SIM ( ) NÃO ( )

4.5. Informe se participa de cooperativa: SIM ( ) NÃO ( )

4.6. Possui outro imóvel, urbano ou rural: SIM ( ) NÃO ( )

5. Informe quais são os vizinhos da localidade onde exerce atividade rural:

Local: ___________________________________ Data: ________________________________

OFÍCIO-CIRCULAR Nº 46 DIRBEN/INSS, DE 13 DE SETEMBRO DE 2019.

AUTODECLARAÇÃO DO SEGURADO ESPECIAL – PESCADOR

2. Forma que exerce/exerceu a atividade de segurado especial:

3. Período(s) de atividade de pesca (dia/mês/ano):

*Mar / Rio / Estuário / Lagoa / Açude / Represa

3.1. Informe a condição de pescador em relação à embarcação onde exerce/exerceu a atividade:

3.2 Qual o nome e CPF do(s) titular(es) da embarcação:

3.3 Informe a atividade pesqueira (pescador de tambaqui, pescador de ostra etc.):

3.4 Quais os principais locais onde comercializa a produção:

3.6. Possui empregado(s) ou prestador(es) de serviço: SIM ( ) NÃO ( ) Especificar.

3.7. Utiliza petrechos de pesca: SIM ( ) NÃO ( ) Especificar

4. Informe se está/esteve afastado(a) da atividade pesqueira: SIM ( ) NÃO ( ) Especificar

4.2. Outras atividades exercidas:

*Pedreiro, carpinteiro, pintor, entre outros.

* Para atividade artesanal, informar a origem da matéria prima.

4.4. Informe se participa de plano de previdência complementar: SIM ( ) NÃO ( )

4.5. Informe se participa de cooperativa: SIM ( ) NÃO ( )

4.6. Possui outro imóvel, urbano ou rural: SIM ( ) NÃO ( )

5. Informe quais são os vizinhos da localidade onde exerce atividade rural:

Local: __________________________________ Data: ________________________________

OFÍCIO-CIRCULAR Nº 46 DIRBEN/INSS, DE 13 DE SETEMBRO DE 2019.

AUTODECLARAÇÃO DO SEGURADO ESPECIAL – SERINGUEIRO E EXTRATIVISTA VEGETAL

2.1. Forma que exerce/exerceu a atividade de segurado especial:

3. Período(s) de atividade extrativista (dia/mês/ano):

3.1. Informe os dados da(s) terra(s):

Registro ITR, se possuir __________________________________________________________________________________

3.2. Informe a atividade extrativista principal (seringueiro, castanheiro, etc.):

3.3. Quais os principais locais onde comercializa a produção, caso aplicável:

3.5. Possui empregado(s) ou prestador(es) de serviço: SIM ( ) NÃO ( ) Especificar.

4. Informe se está/esteve afastado(a) da atividade extrativista: SIM ( ) NÃO ( ) Especificar

4.1. Informe se já morou em local diverso de onde exerce a atividade

4.2. Outras atividades exercidas:

*Pedreiro, carpinteiro, pintor, entre outros.

* Para atividade artesanal, informar a origem da matéria prima.

4.4. Informe se participa de plano de previdência complementar: SIM ( ) NÃO ( )

4.5. Informe se participa de cooperativa: SIM ( ) NÃO ( )

4.6. Possui outro imóvel, urbano ou rural: SIM ( ) NÃO ( )

5. Informe quais são os vizinhos da localidade onde exerce atividade rural:

1234145462891628 63 5636918

Local: ___ Data:

Local: __ Data:

Local: Data: __________

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