Danh Muc Mau Don, TKHC AP Dung Tai Cap Xa

Ph lc I
DANH MC MU N, MU T KHAI HNH CHNH

P DNG TI CP X
(Ban hnh km theo Quyt nh s:1307/Q-UBND ngy27 thng 8 nm 2009
ca U ban nhn dn tnh k Nng)
I. Lnh vc H tch
1. Mu 1-HT
CNG HA X HI CH NGHA VIT NAM
c lp T do Hnh phc
T KHAI NG K LI VIC SINH
Knh gi:......................................................................................................................................
H v tn ngi khai:.............................................................................................................................
Ni thng tr/tm tr:.............................................................................................................................
S Giy CMND/H chiu:.......................................................................................................................
Quan h vi ngi c ng k li khai sinh:........................................................................................
ngh ng k li vic sinh cho ngi c tn di y:
H v tn......................................................Gii tnh:..............................................................................
Ngy, thng, nm sinh:.............................................................................................................................
Ni sinh:...................................................................................................................................................
Dn tc.........................................................Quc tch:.............................................................................
Qu qun (1):...........................................................................................................
Ni thng tr/tm tr:.............................................................................................................................
H v tn cha:.........................................................................................................................................
Dn tc.........................................................Quc tch:.............................................................................
H v tn m:..........................................................................................................................................
Dn tc.........................................................Quc tch:.............................................................................
ng k khai sinh ti:.........................................................................................
.......................................................................ngy ... thng ... nm .......................
Ti cam oan li khai trn y l ng s tht v chu trch nhim trc php lut v cam
oan ca mnh.
ngh................................................ng k.
Lm ti:.......................................ngy ... thng ... nm......
Xc nhn ca UBND cp x
Ngi khai
ni ng k khai t trc y (1)
...................................................
...................................................
...................................................
...................
...................................................
Ngy ... thng ... nm .....
CH TCH Y BAN NHN DN
................................
Ch thch:
(1) Ghi theo qu qun ca cha ; nu khng r cha l ai, th ghi theo qu qun ca m ; trong
trng hp khng xc nh c cha, m , th trng;
(2) Ch cn thit trong trng hp ni ng k li vic sinh khc vi ni ng k khai sinh trc y.
2. Mu 2-HT
Mu STP/HT-2006-KH.1
c lp T do Hnh phc
T KHAI NG K KT HN
Knh gi:.......................................................................................................
NGI KHAI
H v tn
BN NAM
BN N
Ngy, thng, nm sinh

Dn tc
Quc tch
Ni thng tr/tm tr
S CMND/H chiu
Kt hn ln th my
Chng ti cam oan li khai trn y l ng s tht, vic kt hn ca chng ti khng
quy phm php lut Hn nhn v gia nh v chu trch nhim trc php lut v cam oan ca
mnh.
ngh ca UBND ng k.
Lm li.........................................ngy ... thng ... nm.....
Xc nhn v tnh trng hn nhn ca
y ban nhn dn cp x ni c tr (1)/
Bn nam
Bn n
Th trng n v ni cng tc (2)
......................................................
......................................................
......................................................
..............
...............
Xc nhn ny c gi tr trong thi hn
6 thng, k t ngy cp.
Ngy ... thng ... nm ......
CH TCH UBND/TH TRNG N V
...................................
Ch thch:
(1) Ch cn thit trong trng hp ni ng k kt hn khc vi ni thng tr/tm tr ca
ngi ng k kt hn;
(2) ch cn thit trong trng hp ngi ng k kt hn l cn b, chin s ang cng tc
trong lc lng v trang.
3. Mu 3-HT
Y BAN NHN DN
X/phng
Huyn/qun..
Tnh k Nng

c lp - T do - Hnh phc
_______________________
Mu
STP/HT2006-XNHN.3
Ngythngnm
S:./UBND-XN
GIY XC NHN TNH TRNG HN NHN
(Dng cho cng dn Vit Nam c tr trong nc)
Y BAN NHN DN
Cn c Lut t chc Hi ng nhn dn v y ban nhn dn ngy 26 thng 11 nm 2003;
Cn c Ngh nh s 158/2005/N-CP ngy 27 thng 12 nm 2005 ca Chnh ph v ng k
v qun l h tch;
Xt ngh ca ng/b:..
XC NHN:
ng/b:
H v tn:..................................................................................Gii tnh:.................................
Ngy, thng, nm sinh:...............................................................................................................
Ni sinh:.....................................................................................................................................
Dn tc:.........................................................................Quc tch:.............................................
S Giy CMND/H chiu:.........................................................................................................
Ni thng tr/tm tr hin nay:...............................................................................................
....................................................................................................................................................
Tnh trng hn nhn hin ti:.....................................................................................................
....................................................................................................................................................
....................................................................................................................................................
Giy ny c cp :................................................................................................................
....................................................................................................................................................
v c gi tr s dng trong thi hn 6 thng, k t ngy cp.
Vo S cp Giy xc nhn tnh trng hn nhn
S:Quyn s:
Cn b T php h tch
TM. Y BAN NHN DN

CH TCH
4. Mu 4-HT
CNG HO X HI CH NGHA VIT NAM
T KHAI CP GIY XC NHN TNH TRNG HN NHN
(Dng cho cng dn Vit Nam c tr trong nc)
Knh gi: U ban nhn dn...................................................
H v tn ngi khai: ...........................................................................................
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:.....................................................................................
Ni thng tr/tm tr: ..........................................................................................
.................................................................................................................................
Tnh trng hn nhn hin ti
(1):...........................................................................................................................
.................................................................................................................................
Ti cam oan li khai trn y l ng s tht v chu trch nhim trc php lut v
cam oan ca mnh.
ngh U ban nhn dn cp Giy xc nhn tnh trng hn nhn cho
(2).........................................
.................................................................................................................................
(3)............................................................................................................................
..................................................................................................................................
Lm ti:....................,ngy ............thng............nm............
Ngi khai
.......................................
Ch thch:
(1) Ghi r: 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;
(2) Cho bn thn hay cho ngi khc; nu ngh cho ngi khc, th phi ghi r;
(3) Ghi r mc ch s dng Giy xc nhn tnh trng hn nhn.
4
5. Mu 5-HT
c lp T do Hnh phc
T KHAI CP GIY XC NHN TNH TRNG HN NHN
(Dng cho cng dn Vit Nam ang c tr nc ngoi)
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...........................................................................................................................................
Ngy, thng, nm sinh:......................................................................................................................
Ni sinh..............................................................................................................................................
Dn tc.........................................................Quc tch:....................................................................
S Giy CMND/H chiu:................................................................................................................
Ni thng tr/tm tr:......................................................................................................................
................................................................................................................................................
Ni thng tr trc khi xut cnh:..................................................................................................
.......... ................................................................................................................................................
Trong thi gian c tr ti...................................................................................................................
...........................t ngy ... thng ... nm ......, n ngy ... thng ... nm ..........
.......... ................................................................................................................................................
Tnh trng hn nhn (1):....................................................................................................................
.......... ................................................................................................................................................
..........
Ti cam oan li khai trn y ca ti l ng s tht v chu trch nhim trc php
lut v cam oan ca mnh.
ngh y ban nhn dn cp Giy xc nhn tnh trng hn nhn cho (2)..........................
(3) ................................................................................................................................................
..........
Lm ti...........................ngy ... thng ... nm ......
Ngi khai
...................................
Ch thch:
(1) Ghi r: 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;
(2) Cho bn thn hay cho ngi khc; nu ngh cho ngi khc, th phi ghi r;
(3) Ghi r mc ch s dng Giy xc nhn tnh trng hn nhn.
6. Mu 6-HT
T KHAI NG K LI VIC NUI CON NUI

Knh gi: U ban nhn dn..........................................................................................
Chng ti (Ti) l:
NG
H v tn
Ngy, thng, nm sinh
Ni sinh
Dn tc
(Q s: 01/2006/Q-BTP) STP
Quc tch
Ni thng tr/tm tr
S Giy CMND/H
chiu
nhn ngi c tn di y lm con nui:
H v tn: ............................................................................................................Gii
tnh:............................................
Ngy, thng, nm
sinh:..................................................................................................................................................
.
Ni
sinh:..................................................................................................................................................
..........................
Dn tc:....................................................................................Quc
tch:......................................................................
Ni thng tr/tm tr:
.................................................................................................................................................
..........................................................................................................................................................
...................................
Phn khai v bn giao con nui trc y:
NG
H v tn
6
Ngy, thng, nm sinh

Ni sinh
Dn tc
Quc tch
Ni thng tr/tm tr
S Giy CMND/H
chiu
Quan h vi tr c nhn lm con nui

(1):......................................................................................................
Tn c s nui
dng:...........................................................................................................................................
Chc v ca ngi i din c s nui
dng:...............................................................................................
..........................................................................................................................................................
...........................Vic nui con nui c ng k
ti:.......................................................................................................
.................................................................................................................................ngy...........th
ng...........nm...
Chng ti cam oan li khai trn y l ng s tht v chu trch nhim trc php
lut
v
cam oan ca mnh.
ngh............................................................................. ng k.
Lm ti:................................................ngy ............thng............nm............
Xc nhn ca UBND cp x ni
ng k vic nui con nui trc y (2)
..........................................................................
Ngi khai
..........................................................................
..........................................................................
..........................................................................
..........................................................................
Ngy...........thng...........nm...........
CH TCH U BAN NHN DN
..............................
...........................................
7. Mu 7-HT
Mu STP/HT-2006-KH.2
c lp T do Hnh phc
T KHAI NG K LI VIC KT HN
Knh gi:................................................................................................................................
Chng ti l:
H v tn chng:.........................................
Ngy, thng, nm sinh:................................
Dn tc:........................................................
Quc tch:....................................................
Ni thng tr/tm tr:...............................
......................................................................
S Giy CMND/H chiu:..........................
H v tn v:...............................................
Ngy, thng, nm sinh:................................
Dn tc:........................................................
Quc tch:....................................................
Ni thng tr/tm tr:...............................
......................................................................
S Giy CMND/H chiu:..........................
Chng ti ng k kt hn ti........................................................................................
.............
Chng ti cam oan li khai trn y l ng s tht v chu trch nhim trc php
lut v cam oan ca mnh.
ngh .............................................ng k.
Lm ti .................................ngy ... thng ... nm ......
Xc nhn ca UBND cp x
...................................................
...................................................
...................................................
...................................................
Ngy ... thng ... nm .....
CH TCH Y BAN NHN DN
Chng
.................
................
................................
Ch thch:
(1) Ch cn thit trong trng hp ni ng k li vic kt hn khc vi ni ng k kt hn
trc y
8. Mu 8-HT
c lp T do Hnh phc
T KHAI NG K LI VIC T
Knh gi:................................................................................................................................
H v tn ngi khai:......................................................................................................................
Ni thng tr/tm tr:......................................................................................................................
S Giy CMND/H chiu:................................................................................................................
Quan h vi ngi cht:...............................................................................................................
ngh ng k li vic t cho ngi c tn di y:
H v tn......................................................Gii tnh:......................................................................
Ngy, thng, nm sinh:......................................................................................................................
Ni sinh:.............................................................................................................................................
Dn tc.........................................................Quc tch:....................................................................
Ni thng tr/tm tr trc khi cht:..............................................................................................
.................................................................................................................................
S Giy CMND/H chiu:................................................................................................................
cht vo lc...........................gi......pht, ngy ... thng... nm.................................................
Ni cht:............................................................................................................................................
Nguyn nhn cht: ..................................................................................................
ng k khai t ti:............................................................................................
.......................................................................ngy ... thng ... nm .......................
cam oan ca mnh.
ngh................................................ng k.
Lm ti:.......................................ngy ... thng ... nm......
Xc nhn ca UBND cp x
Ngi khai
...................................................
...................................................
...................................................
...................
...................................................
Ngy ... thng ... nm .....
CH TCH Y BAN NHN DN
................................
Ch thch:
(1) Ch cn thit trong trng hp ni ng k li vic t khc vi ni ng k khai t trc
y.
9. Mu 9-HT

c lp T do Hnh phc
T KHAI NG K LI VIC SINH
Knh gi:................................................................................................................................
H v tn ngi khai:......................................................................................................................
Ni thng tr/tm tr:......................................................................................................................
S Giy CMND/H chiu:................................................................................................................
Quan h vi ngi c ng k li khai sinh:................................................................................
ngh ng k li vic sinh cho ngi c tn di y:
H v tn......................................................Gii tnh:......................................................................
Ngy, thng, nm sinh:......................................................................................................................
Ni sinh:.............................................................................................................................................
Dn tc.........................................................Quc tch:....................................................................
Qu qun (1):...........................................................................................................
Ni thng tr/tm tr:......................................................................................................................
H v tn cha:...................................................................................................................................
Dn tc.........................................................Quc tch:....................................................................
H v tn m:....................................................................................................................................
Dn tc.........................................................Quc tch:....................................................................
ng k khai sinh ti:.........................................................................................
.......................................................................ngy ... thng ... nm .......................
cam oan ca mnh.
ngh................................................ng k.
Lm ti:.......................................ngy ... thng ... nm......
Xc nhn ca UBND cp x
Ngi khai
...................................................
...................................................
...................................................
...................
...................................................
Ngy ... thng ... nm .....
CH TCH Y BAN NHN DN
................................
Ch thch:
(1) Ghi theo qu qun ca cha ; nu khng r cha l ai, th ghi theo qu qun ca m ;
trong trng hp khng xc nh c cha, m , th trng;
(2) Ch cn thit trong trng hp ni ng k li vic sinh khc vi ni ng k khai sinh
trc y.
10. Mu 10-HT

GIY THO THUN V VIC CHO V NHN CON NUI
Knh gi: U ban nhn dn..........................................................................................
Chng ti (Ti) l:
NG
H v tn
Ngy, thng, nm sinh
Ni sinh
Dn tc
Quc tch
Ni thng tr/tm tr
S Giy CMND/H
chiu
Quan h vi tr c nhn lm con nui
(1):.............................................................................................
Tn c s nui
dng:...........................................................................................................................................
Chc v ca ngi i din c s nui
dng:...............................................................................................
ng tho thun cho tr em sau y:
H v tn: ............................................................................................................Gii
tnh:..................................
Ngy, thng, nm
sinh:..........................................................................................................................................
Ni
sinh:..................................................................................................................................................
.................
Dn tc:....................................................................................Quc
tch:.............................................................
Qu qun
(2):....................................................................................................................................................
......
Ni thng tr/tm tr:
........................................................................................................................................
L do a vo c s nui dng
(3):....................................................................................................................................................
..........................
..........................................................................................................................................................
...........................
Lm con nui ca ng b:
NG
H v tn
Ngy, thng, nm sinh
Ni sinh
Dn tc
Quc tch
Ni thng tr/tm tr
S Giy CMND/H
chiu
L do ng cho tr em lm con
nui:.................................................................................................................................................
..........................
..........................................................................................................................................................
...........................
L do ng nhn tr em lm con
nui:.................................................................................................................................................
..........................
..........................................................................................................................................................
...........................
Xc nhn
cati
UBND
xvic
ni thng
tr cho v nhn con nui trn y l hon ton t
Chng
cam cp
oan
tha thun
ca
ngi
nhn
con
nui
(6)
kin
ngihn
c
nhn
lm
conVit
nui
nguyn, vic cho v nhn con nui khng vi phm quy
nh ca
ca Lut
nhn
v gia
nh
(nu con nui 9 tui tr ln)
Nam..........................................................................
v chu trch nhim trc php lut v vic cho v nhn con nui ca mnh.
..........................................................................
ngh U ban nhn dn ng k.
..........................................................................
..........................................................................
..........................................................................
..........................................................................
..........................................................................
..........................................................................
..........................................................................
Lm ti:................................................ngy ............thng............nm............
Bn cho con nui (4)

ng/b....................................................................
c iu kin nui con nui theo quy nh
ca Lut hn nhn v gia nh
Ngy...........thng...........nm...........
..............................
Ch Tch
U BAN NHN DN
...........................................
..........................................................................
Bn nhn con nui (5)
..............................
Ch thch:
(1) Ghi r l cha, m ; ngi gim h hay c s nui dng. Nu l c s nui dng th ghi
r tn c s nui dng, chc v ca ngi i din c s nui dng;
(2) Ghi theo qu qun ca cha , nu khng r cha l ai, th theo qu qun ca m ; trong
trng hp khng xc nh c cha, m , th trng;
(3) Ch cn thit trong trng hp tr c nhn lm con nui ang sng ti c s nui
dng;
(4)(5) Nu bn cho/bn nhn con nui l hai v chng, th phi c ch k ca c v v chng;
(6) Ch cn thit trong trng hp ni ng k vic nui con nui khc vi ni thng tr/tm tr
ca ngi nhn con nui.
11. Mu 11-HT
T KHAI NG K VIC NHN CON
Knh gi: ............................................................................................................
H v tn ngi khai: ................................................................................................................
Ngy, thng, nm sinh:.................................................................................................................
Dn tc:....................................................................................Quc tch:....................................
Ni thng tr/tm tr: ................................................................................................................
S Giy CMND/ H chiu:...........................................................................................................
ngh U ban nhn dn cng nhn ngi di y l con ca ti:
H v tn: ............................................................................................Gii tnh:.........................
Ngy, thng, nm sinh:................................................................................................................
Ni sinh:.......................................................................................................................................
Dn tc:......................................................................Quc tch:.................................................
Ni thng tr/tm tr: ...............................................................................................................
S Giy CMND/ H chiu:..........................................................................................................
Hin ang c ngi c tn di y nui dng:
NG
H v tn
Ngy, thng, nm sinh
Dn tc
Quc tch
Ni thng tr/tm tr
Quan h gia ngi nui dng vi ngi c nhn l
con:........................................................................
Ti cam oan vic nhn con ca ti l ng s tht, t nguyn v khng c tranh chp,
chu trch nhim trc php lut v cam oan ca mnh.
Lm ti:.................ngy ............thng............nm............
Ngi khai
kin ca ngi hin ang l m hoc cha (1)
.......................................................................................
.......................................................................................
.....................................................................................
Ngy...........thng...........nm...........
Ch thch:
(1) Ch cn thit trong trng hp cha hoc m nhn con cha thnh nin (tr trng hp
ngi cht, mt tch, mt nng lc hnh vi dn s hoc hn ch nng lc hnh vi dn
s).
12. Mu 12-HT
T KHAI NG K VIC NHN CHA, M

(Dng cho trng hp con thnh nin nhn cha/m)
Knh gi: .......................................................................................................................................
H v tn ngi nhn cha/m: .........................................................................Gii tnh:........
Ngy, thng, nm sinh:.................................................................................................................
Ni
sinh:...............................................................................................................................................
Dn tc:....................................................................................Quc tch:....................................
Ni thng tr/tm tr: ................................................................................................................
S Giy CMND/ H chiu:...........................................................................................................
ngh U ban nhn dn cng nhn ngi di y l........................................... ca ti:
H v tn: .....................................................................................................................................
Ngy, thng, nm sinh:.................................................................................................................
Dn tc:....................................................................................Quc tch:....................................
Ni thng tr/tm tr (1):...........................................................................................................
S Giy CMND/ H chiu:...........................................................................................................
Ti cam oan vic nhn..........................................ca ti l ng s tht, t nguyn, khng c
tranh chp v chu trch nhim trc php lut v cam oan ca mnh.
Lm ti:................................................ngy
............thng............nm............
Ngi khai
..............................
Ch thch:
(1) Trong trng hp ngi c nhn l cha/m cht, th phi ghi r cht.
13. Mu 13-HT

T KHAI NG K VIC NHN CHA, M
(Dng cho trng hp cha/m/ngi gim h nhn m/cha
cho con cha thnh nin)
Knh gi: .......................................................................................................................................
H v tn ngi khai: ...........................................................................................................
Ngy, thng, nm sinh:............................................................................................................
Dn tc:....................................................................................Quc tch:..................................
Ni thng tr/tm tr: .............................................................................................................
S Giy CMND/ H chiu:.....................................................................................................
Quan h vi ngi nhn cha/m:.......................................................................................
ngh U ban nhn dn cng nhn ngi c tn di y:
H v tn: ...................................................................................................................................
Ngy, thng, nm sinh:............................................................................................................
Dn tc:....................................................................................Quc tch:...............................
Ni thng tr/tm tr (1):....................................................................................................
S Giy CMND/ H chiu:.....................................................................................................
L cha/m ca ngi c tn di y:
H v tn: ...............................................................................................................................
Ngy, thng, nm sinh:...........................................................................................................
Ni sinh:.......................................................................................................................................
Dn tc:....................................................................................Quc tch:....................................
Ni thng tr/tm tr: ..........................................................................................................
S Giy CMND/ H chiu:..................................................................................................
Ti cam oan vic nhn..............................................ca ti l ng s tht, t nguyn,
khng c tranh chp v chu trch nhim trc php lut v cam oan ca mnh.
(Q s: 01/2006/Q-BTP) STP
Lm ti:................................................ngy
............thng............nm............
Ngi khai
..............................
Ch thch:
(1) Trong trng hp ngi c nhn l cha/m cht, th phi ghi r cht.
14. Mu 14-HT

T KHAI NG K CHM DT VIC GIM H
Knh gi: .......................................................................................................................................
H v tn ngi khai:...............................................................................................................
Nm sinh:...............................................................................................................................
Ni thng tr/tm tr: .........................................................................................................
S Giy CMND/ H chiu:.....................................................................................................
ngh .......................................................................ng k chm dt vic gim h gia:
Ngi gim h:
NG
H v tn
Ngy, thng, nm sinh
Dn tc
Quc tch
Ni thng tr/tm tr
S Giy CMND/H
chiu
Ngi c gim h:
H v tn: .....................................................................................Gii tnh:.............................
Ngy, thng, nm sinh:...........................................................................................................
Ni sinh:......................................................................................................................................
Dn tc:....................................................................................Quc tch:....................................
Ni thng tr/tm tr: ..........................................................................................................
Theo Quyt nh cng nhn vic gim h
s:..........................................ngy...........thng...........nm............ca.........................................
L do chm dt vic gim h:...................................................................................................
cam oan ca mnh.
ngh............................................................................. ng k.
Lm ti:................................................ngy ............thng............nm............
Ngi ngh chm dt gim h
15. Mu 15-HT

T KHAI NG K VIC THAY I, CI CHNH, B SUNG
H TCH, XC NH LI DN TC, XC NH LI GII TNH
Knh gi: .......................................................................................................
H v tn ngi khai: .........................................................................................................
Ni thng tr/tm tr: ..........................................................................................................
S Giy CMND/ H chiu:......................................................................................................
Quan h vi ngi c thay i, ci chnh, b sung h tch/xc nh li dn tc/xc nh li
gii tnh:........................................................................................................................................
ngh.................................................. ng k vic(1).....................................................
......................................................................................................................................... cho ngi c
tn di y:
H v tn: .......................................................................................Gii tnh:........................
Ngy, thng, nm sinh:...............................................................................................................
Ni sinh:........................................................................................................................................
Dn tc:....................................................................................Quc tch:..................................
Ni thng tr/tm tr: .....................................................................................................
ng k khai sinh ti:..........................................................................................................
.........................................................................................ngy...........thng...........nm..
Theo Giy khai sinh s:.......................................................Quyn s:.....................................
Ni dung xin thay i, ci chnh, b sung h tch/xc nh li dn tc/xc nh li gii
tnh:...............................................................................................................................................
L do:............................................................................................................................................
cam oan ca mnh.
ngh............................................................................. ng k.
Lm ti:................................................, ngy
............thng............nm............
Ngi khai
kin ca ngi c thay i h, tn

(nu ngi t 9 tui tr ln);
xc nh li dn tc (nu ngi
t 15 tui n di 18 tui)
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Ch thch:
(1) Thay i, ci chnh, b sung h tch/xc nh li dn tc/xc nh li gii tnh - yu cu loi vic g
phi ghi r.
II. Lnh vc chng thc

1. Mu 1-PYC

PHIU YU CU CHNG THC

HP NG, VN BN
Knh gi: U ban nhn dn x/phng/th trn ............................
H v tn ngi np phiu:.......................
a ch lin h: .................................
S in thoi: .......................................................
Email: .......................................................................................................
S Fax: .................................................................................
Yu cu chng thc v: ...........................................................................
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Cc giy t np km theo Phiu ny gm c:
1......................................
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3..........................................
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8..........................................................................................................................
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10........................................................................................................................
Thi gian nhn phiu ......... gi, ngy......./......./.........
NGI NHN PHIU
(K v ghi r h tn)
NGI NP PHIU
(K v ghi r h tn)
2. Mu 2-DC
DI CHC
Ti l (1):
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Trong trng thi tinh thn minh mn, sng sut, ti lp di chc ny nh sau (6):
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Ngi lp di chc
(K v ghi r h tn)
LI CHNG CA CH TCH/PH CH TCH

U BAN NHN DN X/PHNG/TH TRN .....................
Ngy.........thng...........nm......... (bng ch ...............................................)
ti .......................................................................................................................(9),
ti ......................................................., Ch tch/Ph Ch tch U ban nhn dn x/phng/th
trn
..................................
huyn/qun/th/x/thnh
ph
thuc
tnh ........................................................ tnh/thnh ph ................................................
CHNG THC:
- ng/b .................................. t nguyn lp di chc ny;
- Theo s nhn bit ca ti, ti thi im chng thc, ng/b c y nng lc hnh vi
dn s ph hp theo quy nh ca php lut;
- Ni dung di chc khng vi phm iu cm ca php lut, khng tri o c x hi;
- .......................................................................................................................
..........................................................................................................................................................
.................................................................................................(10)
- Di chc ny c lm thnh .......... bn chnh (mi bn chnh gm ....... t, ........ trang),
giao cho ngi lp di chc ........... bn chnh; lu ti U ban nhn dn mt bn chnh.
S................................, quyn s ................TP/CC-SCT/HGD.
Ch tch/Ph ch tch
(K, ng du v ghi r h tn)
3. Mu 3-HUQ

HP NG U QUYN
Chng ti gm c:
Bn u quyn (sau y gi l bn A) (1):
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Bn c u quyn (sau y gi l bn B) (1):
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Bng Hp ng ny, bn A u quyn cho bn B theo nhng tho thun sau y:
IU 1
PHM VI U QUYN (7)
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IU 2
THI HN U QUYN
Thi hn u quyn l ................................ k t ngy ....../...../.........
IU 3
NGHA V V QUYN CA BN A
1. Bn A c cc ngha v sau y:
- Cung cp thng tin, ti liu v phng tin cn thit bn B thc hin cng vic;
- Chu trch nhim v cam kt do bn B thc hin trong phm vi u quyn;
- Thanh ton chi ph hp l m bn B b ra thc hin cng vic c u quyn v
tr th lao cho bn B vi s tin l ............................ (nu c);
- Chu trch nhim np l ph chng thc Hp ng u quyn ny.
2. Bn A c cc quyn sau y:
- Yu cu bn B thng bo y v vic thc hin cng vic thuc phm vi u quyn
nu trn;
- Yu cu bn B giao li ti sn, li ch thu c t vic thc hin cng vic c u
quyn, nu khng c tho thun khc;
- c bi thng thit hi, nu bn B vi phm cc ngha v tho thun.
IU 4
NGHA V V QUYN CA BN B
1. Bn B c cc ngha v sau y:
- Thc hin cng vic theo u quyn v bo cho bn A v vic thc hin cng vic ;
- Bo cho ngi th ba trong quan h thc hin u quyn v thi hn, phm vi u quyn
v vic sa i, b sung phm vi u quyn;
- Bo qun, gi gn ti liu, phng tin c giao thc hin vic u quyn;
- Giao cho bn A ti sn nhn v nhng li ch thu c trong khi thc hin u quyn
theo tho thun hoc theo quy nh ca php lut.
2. Bn B c cc quyn sau:
- Yu cu bn A cung cp thng tin, ti liu, phng tin cn thit thc hin cng
vic c u quyn;
- c thanh ton cc chi ph hp l thc hin cc vic c u quyn v c nhn
th lao nh tho thun.
IU 5
CAM OAN CA CC BN
Bn A v bn B chu trch nhim trc php lut v nhng li cam oan sau y:
1. Nhng thng tin ghi trong Hp ng ny l ng s tht;
2. Thc hin ng v y cc tho thun ghi trong Hp ng ny.
IU ....... (10)
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IU .......
IU KHON CUI CNG
Hai bn hiu r quyn, ngha v, li ch hp php ca mnh v hu qu php l ca
vic giao kt Hp ng ny.
Bn A
(K v ghi r h tn)(11)
Bn B

Ngy.........thng...........nm......... (bng ch ..................................................)
ti ......................................................................................................................(12),
trn ................................... huyn/qun/th/x/thnh ph thuc
tnh ..................................................... tnh/thnh ph ......................................................
CHNG THC:
- Hp ng u quyn c giao kt gia bn A l ...........................................
..................................................................................................................................... v bn B l
................................................................................................; cc bn t nguyn
tho thun giao kt hp ng;
- Ti thi im chng thc, cc bn giao kt hp ng c nng lc hnh vi dn s
ph hp theo quy nh ca php lut;
- Ni dung tho thun ca cc bn trong hp ng khng vi phm iu cm ca php
lut, khng tri o c x hi;
- ..........................................................................................................................
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.........................................................................................................(13)
- Hp ng ny c lm thnh .......... bn chnh (mi bn chnh gm ....... t,
........trang), giao cho:
+ Bn A ....... bn chnh;
+ Bn B ....... bn chnh;
Lu ti U ban nhn dn mt bn chnh.
CH TCH/PH CH TCH
4. Mu 4-PYC
HUYN/TH X................................
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X/PHNG/TH TRN..................
.............................................................

..........., ngy.........thng........nm.............
S:
/PYCCC
PHIU YU CU CUNG CP THNG TIN A CHNH

Knh gi: Vn phng ng k quyn s dng t................................
ngh Vn phng ng k quyn s dng t cung cp thng tin v tha t cho
ngi s dng t c tn sau y phc v cho vic chng thc hp ng, vn bn thc hin
quyn ca ngi s dng t:
- Tn ngi s dng t:.......................................................................
- a ch ngi s dng t:.................................................................
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- a ch tha t:.................................................................................
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Cc thng tin yu cu cung cp ( c nh du X l ni dung cn cung cp
thng tin):
Tn ngi s dng t
Hnh thc s dng
Mc ch s dng
T bn s
Thi hn s dng
a ch tha t
Ngun gc s dng
Din tch
Nhng hn ch v quyn s dng
Tha t s
ngh Vn phng ng k quyn s dng t gi Phiu cung cp thng tin a

chnh v thng tin theo c nh du X nu trn cho U ban nhn dn x/phng/th
trn ...............................................................
CH TCH/PH CH TCH
5. Mu 5-SCT
Mu s 61/SCT
S CHNG THC
HP NG, GIAO DCH
U ban nhn dn x (phng, th trn): ........................
Huyn (qun, th x, thnh ph thuc tnh): .................
Tnh (thnh ph): .............................................................
Quyn s: .................... TP/CC-SCT/HGD

M s ngy ............... thng ............. nm ...........
Kho s ngy ............ thng .............. nm ..........
HNG DN S DNG
-------------------------1. S chng thc hp ng, giao dch l ti liu lu tr ca Nh nc, c s dng ghi cc
vic chng thc hp ng, giao dch thc hin ti U ban nhn dn cp x, phc v cho vic
theo di, tra cu, kim tra v thng k s liu chng thc.
2. S phi c ng du gip lai t trang u n trang cui, phi c gi sch, khng
nho hoc rch nt.
3. Ch vit trong S phi r rng, khng ty xo, phi vit cng mt th mc tt, mu en.
4. Trc khi ghi vo S phi kim tra cc s liu s ghi vo S trnh nhm ln. Trng hp
vit nhm, sa li k thut phi gch i vit li, khng c vit ln ch c; khi vit li phi
k, ghi r h tn ngui thc hin vo ct ghi ch v ng du vo ch sa.
5. Phi ghi y cc ct mc c trong S v lu cc im sau y:
- Ct (1): s chng thc trong ct ny l s ghi trong vn bn chng thc;
- Ct (4): ghi ln lt h tn, ni c tr ca tng ngi mt;
- Ct (6): ghi thng tin v i tng hp ng, giao dch.
6. Khi s dng phi ghi ngy m S, khi kt thc phi ghi ngy kho S.
7. S phi c bo qun cht ch, lu tr lu di ti U ban nhn dn cp x.
NGY
NGY
S
THNG THNG
CHNG
NM
NM
THC CHNG
TH
THC
L
(1)
(2)
(3)
H TN, NI C
TR CA
NGI YU
CU
CHNG THC
(4)
LOI VIC
CHNG
THC
TM
TT
NI
DUNG
(5)
(6)
H TN
NGI
K
CHNG
THC
(7)
GHI
CH
(8)
6. Mu 6-PH
HUYN/TH
X................................ ........................
.....................................

X/PHNG/TH TRN..................
..............................................................
PHIU HN
Ngy ...... thng ....... nm .........(.......gi?), U ban nhn dn x/phng/th trn nhn h s
yu cu chng thc do ng/b:......................................................
...................................................................................................................... np.
a ch lin h:.........................
V vic:........................
Xin hn ng/b v cc bn lin quan (nu c) c mt ti U ban nhn dn x/phng/th
trn................................................................................................
vo hi .......... gi, ngy .......... thng ........... nm ............., nhn kt qu chng thc.
NGI GHI PHIU HN
(K v ghi r h tn)
7. Mu 7-VBPC
VN BN PHN CHIA TI SN THA K

Chng ti gm c:
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Chng ti l nhng ngi tha k theo ..................................... (5) ca
ng/b
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cht
ngy ........../.........../............. theo Giy chng t s ....................................... do U ban nhn
dn
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cp
ngy ........../........../.............. Chng ti tho thun v vic phn chia ti sn tha k ca
ng/b ............................................ li nh sau (7):
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Chng ti xin cam oan:
- Nhng thng tin ghi trong Vn bn phn chia ti sn tha k ny l ng s tht;
- Ngoi chng ti ra, ng/b .................................................................. khng cn
ngi tha k no khc;
- Vn bn phn chia ti sn tha k ny do chng ti t nguyn lp v vic phn chia
ti sn tha k nu trn khng nhm trn trnh vic thc hin ngha v ti sn ca mnh i vi
ngi khc.
Nhng ngi tha k
(K v ghi r h tn)

Ngy.........thng...........nm......... (bng ch ...............................................)
ti
.....................................................................................................................(9),
trn
..................................
huyn/qun/th/x/thnh
ph
thuc
tnh ........................................................ tnh/thnh ph ................................................
CHNG THC:
- Vn bn phn chia ti sn tha k ny c lp gia ng/b ......................
.................................................................................................................................
v ng/b ...............................................................................................................; nhng ngi
tha k t nguyn tho thun phn chia ti sn tha k;
- Ti thi im chng thc, nhng ngi tha k u c nng lc hnh vi dn s ph hp
theo quy nh ca php lut;
- Sau khi thc hin nim yt ni dung phn chia ti sn tha k ti ..............
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t ngy .........thng.........nm .......... n ngy ....... thng .........nm........., U ban nhn dn
khng nhn c khiu ni t co no;
- Ni dung Vn bn phn chia ti sn tha k khng vi phm iu cm ca php lut,
khng tri o c x hi;
- .......................................................................................................................
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.................................................................................................(11)
- Vn bn phn chia ti sn tha k ny c lp thnh .......... bn chnh (mi bn chnh
gm ....... t, ........trang), giao cho:
+ ................................ bn chnh;
+ ................................ bn chnh;
CH TCH/PH CH TCH
8. Mu 8-VBN

VN BN NHN TI SN THA K
Ti l (3):
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Ti l ngi tha k duy nht theo php lut ca ng/b ..............................
................................................................................................................................cht
ngy .........../........../........... theo Giy chng t s ......................................... do U ban nhn
dn
...............................................................................................
cp
ngy ........./............/............. Ti xin nhn ti sn tha k ca ng/b
.................................................................................... li nh sau (8):
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Ti xin cam oan:
- Nhng thng tin ghi trong Vn bn nhn ti sn tha k ny l ng s tht;
- Ngoi ti ra, ng/b ..................................................................................... khng cn
ngi tha k no khc.
Ngi nhn ti sn tha k
(K v ghi r h tn)
Ngy.........thng...........nm......... (bng ch ...............................................)
ti
....................................................................................................................(9),
trn
..................................
huyn/qun/th/x/thnh
ph
thuc
tnh ........................................................ tnh/thnh ph ................................................
CHNG THC:
- Vn bn nhn ti sn tha k ny do ng/b ...............................................
.......................................................................................................................... lp;
- Ti thi im chng thc, ngi nhn ti sn tha k c nng lc hnh vi dn s ph
hp theo quy nh ca php lut;
- Sau khi thc hin nim yt ni dung nhn ti sn tha k ti ................. t ngy .........
thng ..... nm ..... n ngy ....... thng ......... nm ......... U ban nhn dn khng nhn c
khiu ni, t co no;
- Ni dung Vn bn nhn ti sn tha k khng vi phm iu cm ca php lut, khng
tri o c x hi;
- .......................................................................................................................
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.................................................................................................(12)
- Vn bn nhn ti sn tha k ny c lm thnh .......... bn chnh (mi bn chnh
gm ....... t, ........trang), giao cho ngi nhn ti sn tha k............... bn chnh; lu ti U
ban nhn dn mt bn chnh.
CH TCH/PH CH TCH
9. Mu 9-HT
HP NG THU QUYN S DNG T

Chng ti gm c:
Bn cho thu (sau y gi l bn A) (1):
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Bn thu (sau y gi l bn B) (1):
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Hai bn ng thc hin vic thu quyn s dng t theo cc tho thun sau y:
IU 1
QUYN S DNG T THU
Quyn s dng t ca bn A i vi tha t theo ..........................................
.................................................................................................................................(2),
c th nh sau:
- Tha t s: ..................................................................................................
- T bn s:.................................................................................................
- a ch tha t: ...........................................................................................
- Din tch: ............................... m2 (bng ch: ..............................................)
- Hnh thc s dng:
+ S dng ring: ...................................... m2
+ S dng chung: .................................... m2
- Mc ch s dng:.........................................................................................
- Thi hn s dng:..........................................................................................
- Ngun gc s dng:.......................................................................................
Nhng hn ch v quyn s dng t (nu co): ..................................................
......................................................................................................................................
IU 2
THI HN THU
Thi hn thu quyn s dng t nu ti iu 1 ca Hp
l ........................................., k t ngy ......../......./............
ng ny
IU 3
MC CH THU
Mc ch thu quyn s dng t nu ti iu 1 ca Hp ng ny l: ............
......................................................................................................................................
IU 4
GI THU V PHNG THC THANH TON
1. Gi thu quyn s dng t nu ti iu 1 ca Hp ng ny
l: ............................................................. ng
(bng ch:..........................................................................................ng Vit Nam).
2. Phng thc thanh ton nh sau: ....................................................................
......................................................................................................................................
3. Vic giao v nhn s tin nu ti khon 1 iu ny do hai bn t thc hin v chu
trch nhim trc php lut.
IU 5
1. Bn A c cc ngha v sau y:
- Giao tha t nu ti iu 1 ca Hp ng ny cho bn B vo thi
im .....................................................................................................;
- Kim tra, nhc nh bn B bo v, gi gn t v s dng t ng mc ch;
- Np thu s dng t;
- Bo cho bn B v quyn ca ngi th ba i vi tha t, nu c;
2. Bn A c cc quyn sau y:
- Yu cu bn B tr tin thu;
- Yu cu bn B chm dt ngay vic s dng t khng ng mc ch, hu hoi t

hoc lm gim st gi tr ca t; nu bn B khng chm dt hnh vi vi phm, th bn A c
quyn n phng nh ch hp ng, yu cu bn B hon tr t v bi thng thit hi;
- Yu cu bn B tr li t, khi thi hn cho thu ht.
IU 6
1. Bn B c cc ngha v sau y:
- S dng t ng mc ch, ng thi hn thu;
- Khng c hu hoi, lm gim st gi tr s dng ca t;
- Tr tin thu theo phng thc tho thun;
- Tun theo cc quy nh v bo v mi trng; khng c lm tn hi n quyn, li
ch ca ngi s dng t xung quanh;
- Khng c cho ngi khc thu li quyn s dng t nu khng c bn A ng
bng vn bn.
- Tr li t sau khi ht thi hn thu;
2. Bn B c cc quyn sau y:
- Yu cu bn A giao tha t ng nh tho thun;
- c s dng t n nh theo thi hn thu tho thun;
- c hng hoa li, li tc t vic s dng t.
IU 7
VIC NG K CHO THU QUYN S DNG T
V NP L PH
1. Vic ng k cho thu quyn s dng t ti c quan c thm quyn theo quy nh ca
php lut do bn A chu trch nhim thc hin.
2. L ph lin quan n vic thu quyn s dung t theo Hp ng ny do
bn ................... chu trch nhim np.
IU 8
PHNG THC GII QUYT TRANH CHP
Trong qu trnh thc hin Hp ng ny, nu pht sinh tranh chp, cc bn cng nhau
thng lng gii quyt trn nguyn tc tn trng quyn li ca nhau; trong trng hp khng
thng lng c th mt trong hai bn c quyn khi kin yu cu to n c thm quyn
gii quyt theo quy nh ca php lut.
IU 9
CAM OAN CA CC BN
1. Bn A cam oan
1.1. Nhng thng tin v nhn thn, v tha t ghi trong Hp ng ny l ng s
tht;
1.2. Tha t thuc trng hp c cho thu quyn s dng t theo quy nh ca php
lut;
1.3. Ti thi im giao kt Hp ng ny:

a) Tha t khng c tranh chp;
b) Quyn s dng t khng b k bin bo m thi hnh n;
1.4 Vic giao kt Hp ng ny hon ton t nguyn, khng b la di, khng bi p buc;
1.5 Thc hin ng v y tt c cc tho thun ghi trong Hp ng ny.
2. Bn B cam oan
2.1. Nhng thng tin v nhn thn ghi trong Hp ng ny l ng s tht;
2.2. xem xt k, bit r v tha t nu ti iu 1 ca Hp ng ny v cc giy t v
quyn s dng t;
2.3. Vic giao kt Hp ng ny hon ton t nguyn, khng b la di, khng bi p
buc;
2.4. Thc hin ng v y cc tho thun ghi trong Hp ng ny.
IU ....... (10)
.............................................................................................
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..........................................................................................................................................................
...........................................................................................................................
IU .......
IU KHON CUI CNG
Bn A
(K v ghi r h tn) (11)
Bn B

Ngy.........thng...........nm......... (bng ch ...................................................)
ti ......................................................................................................................(12),
trn ................................... huyn/qun/th x/thnh ph thuc
tnh ....................................................... tnh/thnh ph ......................................................
CHNG THC:
- Hp ng thu quyn s dng t c giao kt gia bn A
l ....................................................................................................................................... v bn B
l ...............................................................................................; cc bn t nguyn
- ............................................................................................................................
..........................................................................................................................................................
.............................................................................................................(13)
+ Bn A ....... bn chnh;
+ Bn B ....... bn chnh;
CH TCH/PH CH TCH
10.- Mu 10-HTC

HP NG TH CHP QUYN S DNG T

Chng ti gm c:
Bn th chp (sau y gi l bn A)(1):
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
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..........................................................................................................................................................
..................................
Bn nhn th chp (sau y gi l bn B)(1):
......................................................................................................................................
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..........................................................................................................................................................
..................................
Hai bn ng thc hin vic th chp quyn s dng t vi nhng tho thun sau
y:
IU 1
NGHA V C BO M
1. Bn A ng th chp quyn s dng t ca mnh bo m thc hin ngha v
dn s i vi bn B.
2. Ngha v c bo m l (8): .....................................................................

..........................................................................................................................................................
..........................................................................................................................................................
..............................................................................................
IU 2
TI SN TH CHP
Quyn s dng t ca bn A i vi tha t
theo ............................................ .....................................................................................................
...........................(2), c th nh sau:
- Tha t s: ......................................................................................................
- T bn s:.....................................................................................................
- a ch tha t: ...............................................................................................
- Din tch: ............................... m2 (bng ch: ..................................................)
- Hnh thc s dng:
+ S dng ring: ............................................................................... m2
+ S dng chung: .............................................................................. m2
- Mc ch s dng:.............................................................................................
- Thi hn s dng:..............................................................................................
- Ngun gc s dng:..........................................................................................
Nhng hn ch v quyn s dng t (nu co): .................................................
.....................................................................................................................................
IU 3
GI TR TI SN TH CHP
Gi tr ti sn th chp nu ti iu 2 ca Hp ng ny l: ......................ng
(bng ch: ............................................................... ng) theo vn bn xc nh gi tr ti sn
th chp ngy ...../......../........
IU 4
1. Ngha v ca bn A:
- Giao cc giy t v ti sn th chp cho bn B;
- Khng c chuyn nhng, chuyn i, tng cho, cho thu, gp vn hoc dng ti sn
th chp bo m cho ngha v khc nu khng c bn B ng bng vn bn;
- Bo qun, gi gn ti sn th chp; p dng cc bin php cn thit bo ton gi tr
ti sn th chp trong trng hp ti sn th chp c nguy c b h hng do khai thc, s dng;
- To iu kin thun li cho bn B kim tra ti sn th chp.
2. Quyn ca bn A:
- c s dng, khai thc, hng hoa li, li tc t ti sn th chp;
- Nhn li cc giy t v ti sn th chp sau khi hon thnh ngha v;
- Yu cu bn B bi thng thit hi nu lm mt, h hng cc giy t v ti sn th

chp.
IU 5
1. Ngha v ca bn B:
- Gi v bo qun cc giy t v ti sn th chp, trong trng hp lm mt, h hng, th
phi bi thng thit hi cho bn A;
- Giao li cc giy t v ti sn th chp cho bn A khi bn A hon thnh ngha v.
2. Quyn ca bn B
- Kim tra hoc yu cu bn A cung cp thng tin v thc trng ti sn th chp;
- Yu cu bn A p dng cc bin php cn thit bo ton gi tr ti sn th chp trong
trng hp ti sn th chp c nguy c b h hng do khai thc, s dng;
- Yu cu x l ti sn th chp theo phng thc tho thun.
IU 6
VIC NG K TH CHP V NP L PH
1. Vic ng k th chp ti c quan c thm quyn theo quy nh ca php lut do
bn .................. chu trch nhim thc hin.
2. L ph lin quan n vic th chp quyn s dung t theo Hp ng ny do
bn ................... chu trch nhim np.
IU 7
X L TI SN TH CHP
1. Trong trng hp ht thi hn thc hin ngha v m bn A khng thc hin hoc thc
hin khng ng ngha v th bn B c quyn yu cu x l ti sn th chp theo phng thc
(9):
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
2. Vic x l ti sn th chp c thc hin thanh ton ngha v cho bn B sau khi
tr chi ph bo qun, bn ti sn v cc chi ph khc c lin quan n vic x l ti sn th
chp.
IU 8
PHNG THC GII QUYT TRANH CHP HP NG
gii quyt c th mt trong hai bn c quyn khi kin yu cu to n c thm quyn gii
quyt theo quy nh ca php lut.
IU 9
CAM OAN CA CC BN
1. Bn A cam oan:
tht;
1.2. Tha t thuc trng hp c th chp quyn s dng t theo quy nh ca
php lut;
1.4. Vic giao kt hp ng ny hon ton t nguyn, khng b la di, khng bi p
buc;
2. Bn B cam oan:
2.2. xem xt k, bit r v tha t nu ti iu 2 ca Hp ng ny v cc giy t
v quyn s dng t;
2.3. Vic giao kt hp ng ny hon ton t nguyn, khng b la di, khng bi p
buc;
IU ....... (10)
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.................................................................................................................
IU .......
IU KHON CUI CNG
Bn A
Bn B

Ngy.........thng...........nm......... (bng ch ....................................................)
ti
........................................................................................................................(12),
trn
...................................
huyn/qun/th
x/thnh
ph
thuc
tnh ....................................................... tnh/thnh ph ......................................................
CHNG THC:
- Hp ng th chp quyn s dng t c giao kt gia bn A
l ...................................................................................................................................... v bn B
l ...............................................................................................; cc bn t nguyn
- .........................................................................................................................
..........................................................................................................................................................
...........................................................................................................(13)
+ Bn A ....... bn chnh;
+ Bn B ....... bn chnh;
CH TCH/PH CH TCH
11. Mu 11-HTA

HP NG TNG CHO QUYN S DNG T

Chng ti gm c:
Bn tng cho (sau y gi l bn A) (1):
......................................................................................................................................
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Bn c tng cho (sau y gi l bn B) (1):
......................................................................................................................................
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......................................................................................................................................
Hai bn ng thc hin vic tng cho quyn s dng t theo cc tho thun sau y:
IU 1
QUYN S DNG T TNG CHO
Quyn s dng t ca bn A i vi tha t theo ...........................................
............................................................................................................................... (2), c th nh
sau:
- Tha t s: ..................................................................................................
- T bn s:.................................................................................................
- a ch tha t: ...........................................................................................
- Din tch: ............................... m2 (bng ch: ..............................................)
- Hnh thc s dng:
+ S dng ring: ...................................... m2
+ S dng chung: .................................... m2
- Mc ch s dng:.........................................................................................
- Thi hn s dng:..........................................................................................
- Ngun gc s dng:.......................................................................................
Nhng hn ch v quyn s dng t (nu co): ..................................................
......................................................................................................................................
Gi tr quyn s dng t l ........................................................................ng (bng ch:
......................................................................................... ng Vit Nam)
..............................................................................................................................
...............................................................................................................................(6)
IU 2
VIC GIAO V NG K QUYN S DNG T
1. Bn A c ngha v giao tha t nu ti iu 1 ca Hp ng ny cng giy t v
quyn s dng t cho bn B vo thi im ..............................................
2. Bn B c ngha v ng k quyn s dng t ti c quan c thm quyn theo quy
nh ca php lut.
IU 3
TRCH NHIM NP THU, L PH
Thu, l ph lin quan n vic tng cho quyn s dng t theo Hp ng ny do
bn ............. chu trch nhim np.
IU 4
IU 5
CAM OAN CA CC BN
1. Bn A cam oan:

tht;
1.2. Tha t thuc trng hp c tng cho quyn s dng t theo quy nh ca
php lut;
buc;
2. Bn B cam oan:
v quyn s dng t;
buc;
IU ....... (10)
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..........................................................................................................................................................
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.......................................
IU .......
IU KHON CUI CNG
Bn A
Bn B

Ngy.........thng...........nm......... (bng ch ....................................................)
ti
........................................................................................................................(12),
trn
...................................
huyn/qun/th
x/thnh
ph
thuc
tnh ....................................................... tnh/thnh ph ......................................................
CHNG THC:
- Hp ng tng cho quyn s dng t c giao kt gia bn A
l ...................................................................................................................................... v bn B
l ...............................................................................................; cc bn t nguyn
- .........................................................................................................................
..........................................................................................................................................................
...........................................................................................................(13)
+ Bn A ....... bn chnh;
+ Bn B ....... bn chnh;
CH TCH/PH CH TCH
12. Mu 12-HCN

HP NG CHUYN NHNG QUYN S DNG T

Chng ti gm c:
Bn chuyn nhng (sau y gi l bn A) (1):
.................................................................................................................................
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Bn nhn chuyn nhng (sau y gi l bn B) (1):
.................................................................................................................................
.................................................................................................................................
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.................................................................................................................................
Hai bn ng thc hin vic chuyn nhng quyn s dng t theo cc tho thun sau
y:
IU 1
QUYN S DNG T CHUYN NHNG
Quyn s dng t ca bn A i vi tha t theo ......................................

.......................................................................................................................... (2),
c th nh sau:
- Tha t s: ...................................................
- T bn s:..................................................
- a ch tha t: ...........................................................................................
- Din tch: ............................... m2 (bng ch: ..............................................)
- Hnh thc s dng:
+ S dng ring: ...................................... m2
+ S dng chung: .................................... m2
- Mc ch s dng:..........................................
- Thi hn s dng:...........................................
- Ngun gc s dng:........................................
Nhng hn ch v quyn s dng t (nu co): .............................................
.................................................................................................................................
IU 2
GI CHUYN NHNG V PHNG THC THANH TON
1. Gi chuyn nhng quyn s dng tha t nu ti iu 1 ca Hp ng ny
l: ...................................................................... ng
(bng ch:.....................................................................................ng Vit Nam).
2. Phng thc thanh ton: ............................................................................
..........................................................................................................................................................
........................................................................................................
3. Vic thanh ton s tin nu ti khon 1 iu ny do hai bn t thc hin v chu trch
nhim trc php lut.
IU 3
1. Bn A c ngha v giao tha t nu ti iu 1 ca Hp ng ny cng giy t v
quyn s dng t cho bn B vo thi im .........................................
2. Bn B c ngha v ng k quyn s dng t ti c quan c thm quyn theo quy
nh ca php lut.
IU 4
TRCH NHIM NP THU, L PH
Thu, l ph lin quan n vic chuyn nhng quyn s dng t theo Hp ng ny do
bn ..................... chu trch nhim np.
IU 5
IU 6
CAM OAN CA CC BN
1. Bn A cam oan:
tht;
1.2. Tha t thuc trng hp c chuyn nhng quyn s dng t theo quy nh
ca php lut;
buc;
2. Bn B cam oan:
v quyn s dng t;
buc;
IU ....... (10)
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...............................................................
IU .......
IU KHON CUI CNG

Bn A
Bn B

Ngy.........thng...........nm......... (bng ch ...............................................)
ti
.....................................................................................................................(12),
trn
..................................
huyn/qun/th
x/thnh
ph
thuc
tnh ....................................................... tnh/thnh ph .................................................
CHNG THC:
- Hp ng chuyn nhng quyn s dng t c giao kt gia bn A
l ................................................................................................................................. v bn B l
.............................................................................................; cc bn t nguyn tho
thun giao kt hp ng;
- .......................................................................................................................
..........................................................................................................................................................
.................................................................................................(13)
+ Bn A ...... bn chnh;
+ Bn B ....... bn chnh;
CH TCH/PH CH TCH
III. Lnh vc Thanh tra

1. Mu 1-KN

c lp T do Hnh phc
......., ngy....thng .....nm...
N KHIU NI
Knh gi:................................................(1)
H v tn:....................................................................(2); M s h s .......................(3)
a ch :.............................................................................................................................
Khiu ni.......................................................................................................................(4)
Ni dung khiu ni........................................................................................................(5)
...........................................................................................................................................
(Ti liu, chng c km theo nu c)
Ngi khiu ni
(k v ghi r h tn)
(1) Tn c quan, t chc, c nhn c thm quyn gii quyt khiu ni.
(2) H tn ca ngi khiu ni,
- Nu l i din khiu ni cho c quan, t chc th ghi r chc danh, tn c quan, t chc m
mnh i din.
- Nu l ngi c u quyn khiu ni th ghi r theo u quyn ca c quan, t chc, c nhn
no.
(3) Ni dung ny do c quan gii quyt khiu ni ghi.
(4) Khiu ni ln u (hoc ln hai) i vi quyt nh, hnh vi hnh chnh ca ai?
(5) Ni dung khiu ni
- Ghi tm tt s vic dn n khiu ni;
- Yu cu ( ngh) ca ngi khiu ni (nu c);
2. Mu 2-TC

c lp T do Hnh phc
..., ngy...thng.....nm ......
N T CO
Knh gi: .......................................................(1)
Tn ti l:...................................................................................................................................
a ch:.......................................................................................................................................
Ti lm n ny t co hnh vi vi phm php lut ca:.............................................................
................................................................................................................................................(2)
Nay ti ngh:......................................................................................................................(3)
....................................................................................................................................................
Ti xin cam oan nhng ni dung t co trn l ng s tht v chu trch nhim trc
php lut nu c tnh t co sai.
Ngi t co
(K, ghi r h tn)
(1) Tn c quan tip nhn t co.
(2) H tn, chc v v hnh vi vi phm php lut ca ngi b t co.
(3) Ngi, c quan c thm quyn gii quyt t co xc minh, kt lun v x l ngi c hnh
vi vi phm theo quy nh ca php lut.
IV. Lnh vc t ai
1. Mu 1-
N XIN CP GIY CHNG NHN

QUYN S DNG T
Knh gi: UBND .............................................................
Mu s 04a/K
PHN GHI CA
NGI NHN H S
Vo s tip nhn h
s:
.....Gi.pht, ngy /
/
Quyn s , S th
t..
Ngi nhn h s
(K v ghi r h, tn)
I. PHN K KHAI CA NGI S DNG T *

(Xem hng dn cui n ny trc khi k khai; khng ty xo, sa cha trn n)
1. Ngi s dng t:
1.1 Tn ngi s dng t (Vit ch in hoa) :............................................................................
...................................................................................................................................................
...................................................................................................................................................
1.2 a ch (h gia nh, c nhn ghi a ch ng k h khu, t chc ghi a ch tr s):
..................................................................................................................................................
2. Tha t xin cp giy chng nhn quyn s dng t
2.1.Tha t s: ....; 2.2. T bn s: ..;
2.3. a ch ti: .........................................................................................................................
2.4. Din tch: ............. m2; Hnh thc s dng: + S dng chung: ......... m2
+ S dng ring: ........ . m2
2.5. Mc ch s dng t: .............................; 2.6. Thi hn s dng t: ............................
2.7. Ngun gc s dng t: .....................................................................................................
3. Ti sn gn lin vi t:
3.1. Loi ti sn (ghi loi nh hoc loi cng trnh, loi cy):..................................................;
3.2. Din tch chim t (ghi xy dng ca nh, cng trnh hoc din tch c cy): .................m2;
3.3. Thng tin khc (i vi nh) gm : S tng : ... , Kt cu :.............................................. ;
i vi cn h chung c gm : Cn h s : ... , tng s : ... , din tch s dng :......... m2;
4. Nhng giy t np km theo :
*
Hng dn vit n: Tn ngi s dng t: i vi c nhn ghi r h, tn, nm sinh, s giy CMND, ngy
v ni cp giy CMND; i vi ngi Vit Nam nh c nc ngoi v c nhn nc ngoi ghi h, tn, nm
sinh, s h chiu, ngy v ni cp h chiu, quc tch; i vi h gia nh ghi ch H ng/b v ghi h, tn,
nm sinh, s giy CMND, ngy v ni cp giy CMND ca c v v chng ngi i din; trng hp quyn
s dng t l ti sn chung ca hai v chng th ghi h, tn, nm sinh, s giy CMND, ngy v ni cp giy
CMND ca v v ca chng; i vi t chc th ghi tn t chc, ngy thng nm thnh lp, s v ngy, c
quan k quyt nh thnh lp hoc s giy ng k kinh doanh, giy php u t ca c quan nh nc c
thm quyn cp; i vi tha t c nhiu c nhn, h gia nh, t chc cng s dng (tr trng hp tha
t c nh chung c) th ghi cc thng tin v ngi xin cp GCN v lp danh sch nhng ngi cng s dng
t khc theo Mu 04b/K km theo.
...................................................................................................................................................
...................................................................................................................................................
...................................................................................................................................................
5. Nhu cu ghi n i vi loi ngha v ti chnh: ...
Ti xin cam oan ni dung k khai trn n l ng.
, ngy thng nm
Ngi vit n
(K v ghi r h tn, i vi t chc phi
ng du)
II. XC NHN CA U BAN NHN DN X, PHNG, TH TRN I VI H GIA
NH, C NHN
- Ngun gc s dng t:.............................................................................................................;
- Thi im s dng t vo mc ch hin ti:
...;
- Tnh trng tranh chp, khiu ni v t ai: ...............................................................................
- S ph hp vi quy hoch s dng
t : ....................................................................................
Ngy.. thng. nm ..
Cn b a chnh
(K, ghi r h, tn)
Ngy.. thng. nm ..
TM. U ban nhn dn
Ch tch
(K tn, ng du)
III. KT QU THM TRA CA VN PHNG NG K QUYN S DNG T

..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
Ngy.. thng. nm ..
Ngi thm tra h s
(K, ghi r h, tn v chc v)
Ngy.. thng. nm ..
Gim c Vn phng ng k quyn s dng t
(K tn, ng du)
IV. KIN CA C QUAN TI NGUYN MI TRNG

(Thuc U ban nhn dn cp c thm quyn cp giy chng nhn quyn s dng t)
......................................................................................................................................................
..
......................................................................................................................................................
..
......................................................................................................................................................
..
......................................................................................................................................................
..
Ngy ... thng ... nm ...
Th trng c quan
(K tn, ng du)
Hng dn (tip theo): - im 2.5 ghi mc ch s dng t theo quyt nh giao t,

cho thu t, chuyn mc ch s dng t ca c quan c thm quyn cp; trng hp khng
c quyt nh giao t, cho thu t, chuyn mc ch s dng t th ghi theo hin trng ang
s dng;
- im 2.6 ghi thi hn s dng t theo quyt nh giao t, cho thu t ca c quan nh nc c
thm quyn (nu c).Trng hp s dng t c thi hn phi ghi r ngy thng nm ht hn s
dng, nu s dng n nh lu di th ghi Lu di;
- im 2.7 ghi ngun gc s dng t nh sau: nu c Nh nc giao t c thu tin s
dng t th ghi t giao c thu tin, nu khng thu tin th ghi t giao khng thu tin,
nu c Nh nc cho thu t th ghi t thu tr tin hng nm hoc "t thu tr tin
mt ln"; trng hp nhn chuyn i, nhn chuyn nhng, c tha k, c tng cho hoc
ngun gc khc th ghi c th ngun gc v thi im bt u s dng t.
- Trng hp ngi s dng t xin cp mt GCN chung cho nhiu tha t th ti cc im 2.1,
2.2, 2.3, 2.5, 2.6, 2.7 b trng khng ghi; im 2.4 ghi tng din tch cc tha; im 4 ghi ch "Danh sch cc tha t nng nghip cp cng mt GCN"
2. Mu 2-1


N XIN GIAO T LM NH
(Dng cho h gia nh, c nhn)
Knh gi: U ban nhn dn x (phng, th trn).......................................................
U ban nhn dn huyn (qun, th x, thnh ph thuc tnh)......................
1. H v tn ngi xin giao t (vit ch in hoa)*: ..........................................................
......................................................................................................................................
......................................................................................................................................
2. a ch ni ng k h khu thng tr: ...................................................................
........................................................................................................................................
S s h khu: ........................................................cp ngy.......thng.......nm.........
3. a ch lin h: ..................................................................., in thoi: ...............
4. a im khu t xin giao: ........................................................................................
5. Din tch xin giao (m2): ............................................................................................
6. Cam kt s dng t ng mc ch, chp hnh ng cc quy nh ca php lut v t ai.
, ngy ... thng ... nm...
Ngi xin giao t
(K v ghi r h, tn)
XC NHN CA U BAN NHN DN X (PHNG, TH TRN)...

1. V nhu cu ca ngi xin giao t: .........................................................................
.......................................................................................................................................
2. V kh nng qu t giao: ..................................................................................
.......................................................................................................................................
, ngy thng nm
TM. Y BAN NHN DN
CH TCH
(K tn, ng du)
i vi h gia nh th ghi H ng/b v ghi h, tn, nm sinh, s giy CMND v ngy, ni cp

giy CMND ca ch h gia nh; trng hp hai v chng cng xin giao t th ghi h, tn, nm sinh,
s giy CMND v ngy, ni cp giy CMND ca v v ca chng.
Mu 2-2
c lp T do - Hnh phc
N XIN GIAO T NNG NGHIP

1. H v tn ngi xin giao t (vit ch in hoa)*: ..........................................................
........................................................................................................................................
........................................................................................................................................
........................................................................................................................................
S s h khu: ...........................................................cp ngy.......thng.......nm........
3. a ch lin h: ..................................................................., in thoi: ...............
4. a im khu t xin giao: ........................................................................................
5. Din tch xin giao (m2): ............................................................................................
6. s dng vo mc ch: .........................................................................................
7. Cam kt s dng t ng mc ch, chp hnh ng cc quy nh ca php lut v t ai.
..., ngy ... thng ... nm...
Ngi xin giao t
(K v ghi r h, tn)

1. V nhu cu ca ngi xin giao t: .........................................................................
.......................................................................................................................................
2. V kh nng qu t giao: ..................................................................................
.......................................................................................................................................
..., ngy ... thng ... nm...
TM. Y BAN NHN DN
CH TCH
(K tn, ng du)

giy CMND ca ch h gia nh; trng hp hai v chng cng xin giao t th ghi h, tn, nm sinh,
s giy CMND v ngy, ni cp giy CMND ca v v ca chng.
Mu 2-3
N XIN THU T NNG NGHIP

1. H v tn ngi xin thu t (vit ch in hoa)*: ...........................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
S s h khu: .........................................................cp ngy.......thng.......nm........
3. a ch lin h: .........................................................................., in thoi: ............
4. a im khu t xin thu: ........................................................................................
5. Din tch xin thu (m2): .............................................................................................
6. Thi hn thu t (nm): ...........................................................................................
7. s dng vo mc ch: .........................................................................................
8. Cam kt s dng t ng mc ch, chp hnh ng cc quy nh ca php lut t
ai; tr tin thu t y , ng hn.
..., ngy ... thng ... nm...
Ngi xin thu t
(K v ghi r h, tn)

1. V nhu cu ca ngi xin thu t: .........................................................................
.......................................................................................................................................
2. V kh nng qu t cho thu:............................................................................
.......................................................................................................................................
, ngy thng nm
TM. Y BAN NHN DN
CH TCH
(K tn, ng du)

giy CMND ca ch h gia nh; trng hp hai v chng cng xin thu t th ghi h, tn, nm sinh,
s giy CMND v ngy, ni cp giy CMND ca c v v chng.
*
3. Mu 3-1
N XIN CHUYN MC CH S DNG T

Knh gi :
Mu s 11/K
PHN GHI CA
NGI NHN H S
Vo s tip nhn h s:
.....Gi.pht, ngy//
.
Quyn s , S th
t..
Ngi nhn h s
(K, ghi r h tn)
I- K KHAI CA NGI S DNG T

(Xem hng dn cui n ny trc khi vit n; khng ty xo, sa cha ni dung vit )
1. Ngi s dng t:
1.1 Tn ngi s dng t (Vit ch in hoa):.........................................................................
..................................................................................................................................................
..........
........................................................................................................................................
1.2 a ch...............................................................................................................................
..................................................................................................................................................
2. Tha t xin chuyn mc ch s dng:
2.1. Tha t s:....................................; 2.2. T bn s: ...............................................;
2.3. a ch ti:......................................................................................................................
........................................................................ .....................................................................;
2.4. Din tch tha t:................... m2; 2.5. Mc ch s dng t:....................................;
2.6. Thi hn s dng t:............................;
2.7. Ngun gc s dng t: ....................................................... .........................................;
2.8. Ti sn gn lin vi t:...................................................................................................
...................................................................................................................................................
.........
..........................................................................................................................................
2.9. Ngha v ti chnh v t ai:.........................................................................................
2.10. Giy chng nhn quyn s dng t:
- S pht hnh:........................ (S in trang 1 ca giy chng nhn quyn s dng t)
- S vo s cp GCN quyn s dng t:...................., ngy cp ...../...../........
3. Mc ch s dng t xin c chuyn sang:
................................................................................................................................................
4- Giy t np km theo n ny gm c:
- Giy chng nhn quyn s dng t c tha t ni trn
- ..........................................................................................................................................
- ..........................................................................................................................................
- ..........................................................................................................................................
- ..........................................................................................................................................
- ..........................................................................................................................................
.., ngy .... thng ... nm ......
Ngi vit n
(K, ghi r h tn)
Mu 3-2
T KHAI NG K
CHUYN MC CH S DNG T
Knh gi :..........................................................................
Mu s 12/K
PHN GHI CA
NGI NHN H
S
Vo s tip nhn h s:
.....Gi.pht, ngy//
.
Quyn s , S th
t..
Ngi nhn h s
(K, ghi r h tn)

(Xem hng dn cui n ny trc khi vit n; khng ty xo, sa cha trong t khai)
1. Ngi s dng t:
1.1 Tn ngi s dng t (Vit ch in hoa):..........................................................................
...................................................................................................................................................
.........
..........................................................................................................................................
1.2 a ch : ............................................................................................................................
...................................................................................................................................................
2. Tha t ng k chuyn mc ch s dng:
2.1. Tha t s:....................................; 2.2. T bn s: ................................................;
2.3. a ch ti:.......................................................................................................................
........................................................................ ......................................................................;
2.4. Din tch tha t:................... m2; 2.5. Mc ch s dng t:.....................................;
2.6. Thi hn s dng t:............................;
2.7. Ngun gc s dng t: .................................................................................................;
2.8. Ti sn gn lin vi
t:...................................................................................................
......................................................
.............................................................................................
2.9. Ngha v ti chnh v t ai:.........................................................................................
- S pht hnh:........................ (S in trang 1 ca giy chng nhn quyn s dng t)
- S vo s cp GCN quyn s dng t:....................., ngy cp ...../...../.......
3. Mc ch s dng t ng k chuyn sang : ..................................................................
..................................................................................................................................................
5- Giy t np km theo n ny gm c:
- Giy chng nhn quyn s dng t c tha t ni trn
- ...........................................................................................................................................
- ...........................................................................................................................................
- ...........................................................................................................................................
- ...........................................................................................................................................
- ...........................................................................................................................................
, ngy .... thng ... nm ......
Ngi vit n
(K, ghi r h tn)
II- KT QU THM TRA CA VN PHNG NG K QUYN S DNG T
................................................................................................................................................. ..................
............................................................................................................................... ....................................
.............................................................................................................
................................................................................................................................................. ...................
..............................................................................................................................
Ngy.. thng. nm ..
Ngi thm tra
(K, ghi r h tn, chc v)
Ngy.. thng. nm ..
Gim c Vn phng ng k quyn s dng t
(K tn, ng du)
Hng dn
- T khai ny dng trong cc trng hp ng k chuyn mc ch s dng t m khng
phi xin php;
- gi n: H gia nh, c nhn, cng ng dn c th gi Phng Ti nguyn v
Mi trng; T chc, c s tn gio, t chc v c nhn nc ngoi, ngi Vit Nam
nh c nc ngoi th gi S Ti nguyn v Mi trng;
- im 1 ghi tn v a ch ca ngi s dng t nh trn giy chng nhn quyn s
dng t;
- im 2 ghi cc thng tin v tha t hin ang s dng nh trn giy chng nhn
quyn s dng t. Trng hp ti sn gn lin vi t ng k quyn s hu ti sn
theo quy nh ca php lut th ghi thng tin v ti sn nh trn giy chng nhn quyn
s hu i vi ti sn .
- im 3 ghi r mc ch s dng t mun xin c chuyn sang; trng hp
chuyn mc ch mt phn din tch tha t th ghi thm din tch xin chuyn mc ich
s dng;
- Ngi vit n k v ghi r h tn cui phn khai ca ngi s dng t; trng
hp y quyn vit n th ngi c y quyn k, ghi r h tn v ghi (c u quyn);
i vi t chc s dng t phi ghi h tn, chc v ngi vit n v ng du ca t
chc.
4. Mu 4-HC
HP NG CHUYN I
QUYN S DNG T NNG NGHIP
CA H GIA NH, C NHN
Chng ti gm c:
Bn A (1)
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
Bn B (1)
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
Hai bn ng thc hin vic chuyn i quyn s dng t theo cc tho thun sau y:
IU 1
CC QUYN S DNG T CHUYN I
1. Quyn s dng t ca bn A i vi tha t theo ...................................

...........................................................................................................................(2),
c th nh sau:
- Tha t s: ...................................................
- T bn s:..................................................
- a ch tha t: ...........................................................................................
- Din tch: ............................... m2 (bng ch: ..............................................)
- Hnh thc s dng:
+ S dng ring: ...................................... m2
+ S dng chung: .................................... m2
- Mc ch s dng:..........................................
- Thi hn s dng:...........................................
- Ngun gc s dng:........................................
.................................................................................................................................
Gi tr quyn s dng t do hai bn tho thun l:...............................ng
(bng ch: ....................................................................................ng Vit Nam).
2. Quyn s dng t ca bn B i vi tha t theo ..................................
...........................................................................................................................(2),
c th nh sau:
- Tha t s: ...................................................
- T bn s:..................................................
- a ch tha t: ...........................................................................................
- Din tch: ............................... m2 (bng ch: ..............................................)
- Hnh thc s dng:
+ S dng ring: ..................................... m2
+ S dng chung: .................................... m2
- Mc ch s dng:..........................................
- Thi hn s dng:...........................................
- Ngun gc s dng:.......................................
.................................................................................................................................
Gi tr quyn s dng t do hai bn tho thun l: ...............................ng
(bng ch: ....................................................................................ng Vit Nam).
3. Chnh lch v gi tr quyn s dng t l: ........................................ng
(bng ch: ....................................................................................ng Vit Nam).
IU 2
1. Cc bn chuyn i c ngha v giao cc tha t nu ti iu 1 ca Hp ng ny
cng vi giy t v quyn s dng t cho nhau vo thi im ............
..........................................................................
2. Cc bn chuyn i c ngha v ng k quyn s dng t i vi cc tha t

chuyn i ti c quan c thm quyn theo quy nh ca php lut.
IU 3
THANH TON CHNH LCH
V GI TR QUYN S DNG T
1. Bn ........ tr cho bn ....... khon chnh lch v gi tr quyn s dng t nu ti khon
3 iu 1 ca Hp ng ny.
2. Phng thc thanh ton: ............................................................................
..........................................................................................................................................................
........................................................................................................
3. Vic thanh ton khon chnh lch v gi tr nu ti khon 3 iu 1 ca Hp ng ny
do hai bn t thc hin v chu trch nhim trc php lut.
IU 4
TRCH NHIM NP L PH
L ph lin quan n vic chuyn i quyn s dng t theo Hp ng ny do:
- Bn A chiu trach nhim np ...................................
- Bn B chiu trach nhim np ...................................
IU 5
IU 6
CAM OAN CA CC BN
Bn A va bn B chu trch nhim trc php lut v nhng li cam oan sau y:
1. Nhng thng tin v nhn thn, v tha t ghi trong Hp ng ny l ng s tht;
2. Tha t thuc trng hp c chuyn i quyn s dng t theo quy nh ca
php lut;
3. xem xt k, bit r v tha t nhn chuyn i nu ti iu 1 ca Hp ng ny
v cc giy t v quyn s dng t;
4. Ti thi im giao kt Hp ng ny:

4.1. Tha t khng c tranh chp;
4.2. Quyn s dng t khng b k bin bo m thi hnh n;
5. Vic giao kt Hp ng ny hon ton t nguyn, khng b la di, khng bi p
buc;
6. Thc hin ng v y cc tho thun ghi trong Hp ng ny.
IU ....... (10)
.............................................................................................
.............................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..................................
IU .......
IU KHON CUI CNG
Bn A
Bn B

Y BAN NHN DN X/PHNG/TH TRN .....................
Ngy.........thng...........nm......... (bng ch ...............................................)
ti .....................................................................................................................(12),
ti .........................................................., Ch tch/Ph Ch tch U ban nhn dn
x/phng/th trn .................................. huyn/qun/th x/thnh ph thuc tnh
....................................................... tnh/thnh ph .................................................
CHNG THC:
- Hp ng chuyn i quyn s dng t nng nghip ca h gia nh, c nhn c
giao kt gia bn A l ........................................................................... v bn B l
.............................................................................................; cc bn t nguyn tho

thun giao kt hp ng;
- .......................................................................................................................
..........................................................................................................................................................
.................................................................................................(13)
+ Bn A ....... bn chnh;
+ Bn B ....... bn chnh;
CH TCH/PH CH TCH
5. Mu 5-HGV
HP NG GP VN BNG QUYN S DNG T

Chng ti gm c:
Bn gp vn (sau y gi l bn A) (1):
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
Bn nhn gp vn (sau y gi l bn B) (1):
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
......................................................................................................................................
Cc bn ng thc hin vic gp vn bng quyn s dng t theo cc tho thun sau
y :
IU 1
QUYN S DNG T GP VN
Quyn s dng t ca bn A i vi tha t theo ..........................................
................................................................................................................................(2),
c th nh sau:
- Tha t s: ...................................................
- T bn s:..................................................
- a ch tha t: ...........................................................................................
- Din tch: ............................... m2 (bng ch: ..............................................)
- Hnh thc s dng:
+ S dng ring: ...................................... m2
+ S dng chung: .................................... m2
- Mc ch s dng:..........................................
- Thi hn s dng:...........................................
- Ngun gc s dng:.......................................
Nhng hn ch v quyn s dng t (nu co): .................................................
....................................................................................................................................
IU 2
GI TR GP VN
Gi tr quyn s dng t nu ti iu 1 ca Hp ng ny
l: ................................................................. ng
(bng ch:...................................................................................ng Vit Nam)
IU 3
THI HN GP VN
Thi hn gp vn bng quyn s dng t nu ti iu 1 ca Hp ng ny
l: ............................... k t ngy ......./......../..........
IU 4
MC CH GP VN
Mc ch gp vn bng quyn s dng t nu ti iu 1 ca Hp ng ny
l: .................................................................................................................................
IU 5
VIC NG K GP VN V NP L PH
1. Vic ng k gp vn ti c quan c thm quyn theo quy nh ca php lut do
bn ..... chu trch nhim thc hin.
2. L ph lin quan n vic gop vn bng quyn s dung t theo Hp ng ny do
bn ......................... chu trch nhim np.
IU 6
gii quyt c, th mt trong hai bn c quyn khi kin yu cu to n c thm quyn gii
IU 7
CAM OAN CA CC BN
1. Bn A cam oan:
1.1. Nhng thng tin v nhn thn, tha t ghi trong Hp ng ny l ng s tht;
1.2. Tha t thuc trng hp c gp vn bng quyn s dng t theo quy nh ca
php lut;
buc;
2. Bn B cam oan:
2.2. xem xt k, bit r v tha t nu ti iu 1 ca Hp ng ny v cc giy t v
quyn s dng t;
buc;
IU ....... (10)
.............................................................................................
.............................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
.................................................................................................................
IU .......
IU KHON CUI CNG
Bn A
Bn B

Ngy.........thng...........nm......... (bng ch ....................................................)
ti
........................................................................................................................(12),
trn
...................................
huyn/qun/th/x/thnh
ph
thuc
tnh ....................................................... tnh/thnh ph ......................................................
CHNG THC:
- Hp ng gp vn bng quyn s dng t c giao kt gia bn A
l ...................................................................................................................................... v bn B
l ...............................................................................................; cc bn t nguyn
- Ti thi im chng thc, cc bn giao kt hp ng c nng lc hnh vi dn s ph
hp theo quy nh ca php lut;
- Ni dung tho thun ca cc bn trong hp ng khng vi phm iu cm ca php lut,
khng tri o c x hi;
- ............................................................................................................................
..........................................................................................................................................................
...........................................................................................................(13)
+ Bn A ....... bn chnh;
+ Bn B ....... bn chnh;
CH TCH/PH CH TCH
6. Mu 6-KTK
N XIN NG K THA K QUYN S DNG T

(Trng hp tha k theo php lut m ngi tha k l duy nht)
Knh gi: ................................................................
Mu s 16/K
PHN GHI CA
NGI NHN
H S
Vo s tip nhn
h s:
.....Gi.pht,
ngy//.
Quyn s , S
th t..
Ngi
nhn h s
(K, ghi
r h tn)
I- K KHAI NHN THA K QUYN S DNG T

(Xem hng dn cui n ny trc khi vit n; khng ty xo, sa cha trn n)
1. Ngi xin ng k tha k quyn s dng t:
1.1. Tn ngi s dng t (Vit ch in hoa):......................................................................
................................................................................................................................................
................................................................................................................................................
1.2. a ch :.........................................................................................................................
2. Ngi tha k quyn s dng t:
2.1. Tn ngi s dng t (Vit ch in hoa):......................................................................
................................................................................................................................................
2.2. a ch :.........................................................................................................................
3. Tha t xin ng k tha k quyn s dng:
3.1. Tha t s: .................................; 3.2. T bn s:.............................................;
3.3. a ch tha t: ........................................................................................................
3.4. Din tch tha t:.......................m2; 3.5. Mc ch s dng t:...............................;
3.6. Thi hn s dng t:...................................;
3.7. Ngun gc s dng t :...............................................................................................
3.8. Ti sn gn lin vi
t:................................................................................................
............................................
....................................................................................................
3.9. Ngha v ti chnh v t ai:.......................................................................................
- S pht hnh:........................ (S in trang 1 ca giy chng nhn quyn s dng
t)
- S vo s cp GCN quyn s dng t:.....................; ngy cp ...../...../.......
3.11. Giy t khc:.............................................................................................................
4. Giy t np km theo n ny gm c:
- Giy chng nhn quyn s dng t c tha t trn
- .......................................................................................................................................
- .......................................................................................................................................
Ti xin cam oan ni dung k khai trn n l ng v thc hin y ngha v ca

ngi tha k trong vic s dng tha t m ti c nhn tha k.
, ngy .... thng ... nm ......
Ngi vit n
(K, ghi r h tn)
II- CHNG THC CA U BAN NHN DN X, PHNG, TH TRN
................................................................................................................................................ ...................
............................................................................................................................. ......................................
..........................................................................................................
................................................................................................................................................ ....................
............................................................................................................................
Ngy.. thng. nm ..
Cn b a chnh
(K, ghi r h tn)
Ngy.. thng. nm ..
TM. U ban nhn dn
Ch tch
(K tn, ng du)
Hng dn vit n
- n ny dng trong trng hp ngi tha k quyn s dng t khng c di chc v
ngi nhn tha k quyn s dng t l duy nht theo php lut.
- gi n: H gia nh, c nhn, cng ng dn c nhn tha k th gi Phng Ti
nguyn v Mi trng; t chc, ngi Vit Nam nh c nc ngoi nhn tha k th gi
S Ti nguyn v Mi trng.
- im 1 ghi tn v a ch ca ngi xin ng k tha k theo quy nh sau y:
* i vi c nhn th ghi h, tn, nm sinh, s giy CMND,ngy v ni cp giy
CMND,a ch ni ng k h khu thng tr;
* i vi ngi Vit Nam nh c nc ngoi, c nhn nc ngoi s dng t th ghi
h, tn, nm sinh, s h chiu, ngy v ni cp h chiu, quc tch, a ch tm tr ti Vit
Nam.
* i vi h gia nh th ghi ch H ng (hoc b) v h, tn, nm sinh, s giy
CMND, ngy v ni cp giy CMND ca ch h gia nh, s v ngy cp s h khu ca h,
a ch ni ng k h khu thng tr ca h gia nh;
* i vi t chc th ghi tn t chc; s hiu, ngy v ni k quyt nh thnh lp, giy
ng k kinh doanh, giy php u t ca c quan nh nc c thm quyn; a ch tr s ca
t chc s dng t; i vi c s tn gio th ghi tn ca c s tn gio v a ch theo n
v hnh chnh; i vi cng ng dn c th ghi cng ng dn c, tn ca cng ng dn
c v a ch theo n v hnh chnh;
- im 2 v im 3 ghi tn, a ch ca ngi s dng t tha k v thng tin v tha
t tha k nh trn giy chng nhn quyn s dng t.
Trng hp ti sn gn lin vi t ng k quyn s hu ti sn theo quy nh ca
php lut th ghi thng tin v ti sn nh trn giy chng nhn quyn s hu i vi ti sn .
- Ngi lm n phi k, ghi r h tn cui "Phn k khai nhn tha k quyn s dng
t"; i vi t chc s dng t phi ghi h tn, chc v ngi vit n v ng du
ca t chc; trng hp y quyn vit n th ngi c y quyn k, ghi r h tn v
ghi (c u quyn).
6. Mu 6-TTHT
Mu s 16/K

PHN GHI CA NGI NHN H S
Vo s tip nhn h s:
.....Gi.pht, ngy//.
N XIN TCH THA T, HP THA T
Quyn s , S th t..
Knh gi: ..
Ngi nhn h s
(K, ghi r h tn)

(Xem k hng dn cui n ny trc khi vit n; khng ty xo, sa cha ni dung vit )
1. Ngi s dng t:
1.1 Tn ngi s dng t (Vit ch in hoa):...........................................................................
1.2 a ch........................................................................................................................... .....
.....................................................................................................................................................
2. Xin tch, hp tha t nh sau:

2.1. Xin tch thnh . tha t i vi tha t di y:
a) Tha t s:.....;
b) T bn s:................;
c) a ch tha t:.........
d) S pht hnh Giy chng nhn: .......................................................................
S vo s cp Giy chng nhn :..................................; ngy cp ...../...../.......
2.2. Xin hp cc tha t di y thnh mt tha t:

Tha t T bn
a ch tha t
S pht hnh
s
s
Giy chng nhn
S vo s cp giy
chng nhn
3. L do tch, hp tha
t...................................................................................................... .....................................................................
................................................................................
- Giy chng nhn quyn s dng t ca tha t trn;
- S d kin phn chia cc tha t trong trng hp tch tha (nu c);
.....................................................................................................................................
, ngy .... thng ... nm ......
Ngi vit n
(k, ghi r h tn)
7. Mu 7-CLC
N XIN CP LI, CP I
GIY CHNG NHN QUYN S DNG T
Mu s 15/K
PHN GHI CA NGI NHN H S
Vo s tip nhn h s:
.....Gi.pht, ngy//.
Quyn s , S th t..
Knh gi:
Ngi nhn h s
(K, ghi r h tn)

(Xem hng dn cui n ny trc khi vit n; khng ty xo, sa cha ni dung vit )
1. Ngi s dng t:
1.1. Tn ngi s dng t (Vit ch in hoa):..............................................................................
...................................................................................................................................................
...................................................................................................................................................
1.2. a ch :.............................................................................................................................
...................................................................................................................................................
2. Giy chng nhn quyn s dng t xin cp li, cp i:

2.1. S pht hnh:........................... ; 2.2. S vo s cp GCNQSD:.................................
2.3. Ngy cp:................................. ; 2.4. C quan cp:......................................................
3. Tha t:
3.1. Thng tin tha t theo GCN cp
3.2. Thng tin tha t theo bn a chnh mi (nu c)
Tha t s:
Tha t s:
T bn s:
T bn s:
Din tch:
Din tch:
3.3. a ch ti:......................................................................................................................
4. Ni dung k khai b sung (k khai theo hng dn ca c quan tip nhn h s)
4.1. ....................................................................................................................................
...................................................................................................................................................
...................................................................................................................................................
...................................................................................................................................................
5. L do xin cp li, cp i giy CNQSD:........................................................................

...................................................................................................................................................
.............................................................................................................................
......................
- Giy chng nhn quyn s dng t ................................................................................
- ...........................................................................................................................................
- ...........................................................................................................................................

., ngy .... thng ... nm ......
Ngi vit n
(K, ghi r h tn)
V. Lnh vc Bo tr x hi
1. Mu s 1
Mu s 1

....................... , ngy
thng
nm 200
N NGH HNG TR CP X HI
(dng cho c nhn, h gia nh)
Knh gi: - Ch tch U ban nhn dn x (phng, th trn).......................................
- Ch tch U ban nhn dn huyn (qun, th x, thnh ph)...................
Tnh, thnh ph...........................................................................................
Tn ti l: ......................................................................... Nam, n..........................................
Sinh ngy....................thng.......................nm .......................................................................
Qu qun: ....................................................................................................................................
Hin c h khu thng tr ti .............................................................................................
X (phng, th trn) ............................. huyn (qun, th x, TP)...........................
Tnh.......................................................................................................................................
Nu hon cnh c nhn, gia nh, dng i tng...........................................................
.........................................................................................................................................................
........................................................................................................................................................
.......................................................................................................................................................
........................................................................................................................................................
Vy ti lm n ny ngh ......................................................................................
.......................................................................................................................................................
Ngi vit n
( K, ghi r h tn)
Xc nhn ca Trng thn,
xc nhn trng hp ng (b)..................
nu trn l ng ngh UBND x, huyn
xem xt cho ..............................................
(K, ghi r h tn)
Xc nhn v ngh ca UBND cp x
UBND x........................................
Cn c h s v kt qu nim yt cng khai ti Tr s
UBND x v thng bo trn cc phng tin thng tin ca x
t ngy.... thng....nm 200.. n ngy... thng.... nm 200...
ngh Ch tch UBND huyn xem xt, quyt nh.
Ch tch UBND x
2. Mu s 1a
Mu s 1a

.........................ngy
thng
nm 200
N NGH
H TR KINH PH MAI TNG I TNG BO TR X HI
Knh gi: - U ban nhn dn x (phng, th trn)..........................................................
- U ban nhn dn huyn (qun, th x, thnh ph)........................................
Tnh, thnh ph........................................................................................
Tn ti l: ................................................................... Nam, n.........................................
X (phng, th trn) ............................. huyn (qun, th x, TP).............................
Tnh..............................................................................................................................
c quan h vi ngi cht: .................................................................................................
ng ra t chc l tang cho .................................................................................
l ngi ang hng tr cp x hi hng thng qua i ngy
thng nm 200...
ti .......................................................................... (giy chng t s............
ngy
thng
nm 200.. do UBND x ......................................cp).
Vy ti lm n ny ngh cho ti c hng ch h tr kinh ph mai tng
cho ........................................................... nu trn.
Ti xin cam oan li khai trn l ng s tht, nu sai ti xin chu hon ton trch
nhim.
Ngi vit n
( K, ghi r h tn)
Xc nhn ca Trng thn,
xc nhn trng hp ng (b)...........
nu trn l ng, ngh UBND x, huyn
xem xt h tr kinh ph mai tng.
(K, ghi r h tn)
Xc nhn v ngh ca UBND cp x
UBND x....................................................
xc nhn trng hp trn l ng ngh UBND huyn
h tr kinh ph mai tng cho .........................................
theo quy nh.
Ch tch UBND x
(k tn, ng du)
3. Mu s 1b
Mu s 1b
.........................ngy
thng
nm 200
N NHN NUI TR EM M CI, B B RI

Knh gi: - U ban nhn dn x (phng, th trn)...............................................
- U ban nhn dn huyn (qun, th x, thnh ph)..............................
Tnh, thnh ph...............................................................................
Tn ti l: ................................................................... Nam, n..............................
Hin c h khu thng tr ti ................................................................................
X (phng, th trn) ............................. huyn (qun, th x, TP)....................
Tnh....................................................................................................................
Giy chng minh nhn dn s..................................do CA..............................cp
ngy .............thng ....... nm..........
xin ngh UBND x ............................................. UBND huyn..........................
cho php ti c nhn nui chu: .............................................................................
hin : .........................................................................................................................
sinh ngy.........thng ......nm 200.... l tr em m ci c cha ln m (hoc b b ri).
Ti xin cam oan s nui dng, chm sc chu v m bo cho chu c thc hin
quyn ca tr em.
kin ca ngi gim h v tr em c nhn nui
(trng hp tr t 9 tui tr ln)
.....................................................................................
.....................................................................................
....................................................................................
(K, ghi r h tn)
kin chp thun ca U ban nhn dn cp x

UBND x: .......................................................
hp .........................
ng ng b :.............................nhn nui
thn.............................
chu.................................theo n ngh trn
Ch tch UBND x
Ngi vit n
( K, ghi r h tn)
Xc nhn ca Trng thn,

xc nhn trng
hin c tr ti
(K, ghi r h tn)
4. Mu s 1c
Mu s 1c
........................., ngy
thng
nm 200
N NGH C NUI DNG TI C S BO TR X HI
Knh gi: - U ban nhn dn x (phng, th trn).....................................................

- U ban nhn dn huyn (qun, th x, thnh ph)...................................
- Gim c S Lao ng-Thng binh v X hi
Tnh, thnh ph...................................................................................
Tn ti l: ................................................................... Nam, n...................................
Sinh ngy ...................thng ..................nm ..............................................................
Tr qun ti thn..........................................................................................................
X (phng, th trn) ............................. huyn (qun, th x, TP)........................
Tnh........................................................................................................................
hin nay, ti..................................................................................................................
......................................................................................................................................
.......................................................................................................................................
.......................................................................................................................................
.......................................................................................................................................
.......................................................................................................................................
Ti ngh Qu c quan xem xt cho ti c vo sng ti ..............................
.........................................................................................................................................
Ti xin cam oan thc hin ng ni quy, quy nh ca c s bo tr x hi v Lut
php ca Nh nc.
Ngi vit n
( K, ghi r h tn)
Xc nhn ca Trng thn,
xc nhn trng hp ng (b)....................
hin c tr ti thn......................................
(K, ghi r h tn)
ngh ca UBND cp x
UBND
x....................................................................
ngh U ban nhn dn huyn xem xt, gii quyt
Ch tch UBND x
5. Mu s 2
Mu s 2
BIN BN
HP HI NG XT DUYT TR CP X HI
Hm nay, vo hi .........gi..........ngy ............thng...........nm 200..
ti ...................................................................................................................
Chng ti, gm:
1. ng (b).............................................Ch tch UBND x .........................
Ch tch Hi ng xt duyt tr cp x hi
2. ng (b) ................................... Cn b LTBXH, thng trc Hi ng;
3. ng (b).....................................Ch tch Mt trn T quc x, Thnh vin;
4. ng (b) .................................... i din................................. Thnh vin;
5. ng (b) ................................... i din................................. Thnh vin;
6. ng (b) ............................... .... i din................................. Thnh vin;
................
hp Hi ng xt duyt tr cp x hi (thng xuyn, t xut hoc a vo Nh
x hi, C s bo tr x hi) xem xt nhng ni dung sau:
1. .........................................................................................................................
2. .........................................................................................................................
3. ........................................................................................................................
Hi ngh thng nht mt s kt lun sau:
a) Cc trng hp tiu chun hng tr cp (thng xuyn, t xut hoc a vo
Nh x hi, c s bo tr x hi):
1. .........................................................................................................................
2. .........................................................................................................................
b) Cc trng hp cha tiu chun hng tr cp (thng xuyn, t xut hoc a
vo Nh x hi, c s bo tr x hi):
1. .........................................................................................................................
L do:..................................................................................................................
2. .........................................................................................................................
L do:..................................................................................................................
Hi ngh nht tr ngh Ch tch U ban nhn dn x xem xt, ngh cp c thm
quyn quyt nh.
Hi ngh kt thc hi .........gi......ngy........thng......nm 200.....
Bin bn ny c lm thnh 04 bn, gi UBND huyn 02 bn (qua Phng Ni v-Lao
ng-Thng binh v X hi) v lu ti x 02 bn.
Th k Hi ng
(K, ghi r h tn)
Ch tch Hi ng
(K, ghi r h tn v ng du)
6. Mu s 3
Mu s 3
Y BAN NHN DN
HUYN...............................

S: ....../Q-UB
......................ngy
thng
nm 200...
QUYT NH
v vic tr cp x hi
( Dng cho c nhn, h gia nh)
ch tch u ban nhn dn huyn..............................
Cn c Lut T chc Hi ng nhn dn, U ban nhn dn ngy 26/11/2003;
Cn c Ngh nh s 67/2007/N-CP ngy 13/4/2007 ca Chnh ph v chnh sch tr
gip cc i tng bo tr x hi;
Cn c Thng t s......../2007/TT-BLTBXH, ngy / /2007ca B Lao ngThng binh v X hi hng dn mt s iu ca Ngh nh s 67 /N-CP ngy 13/4/2007
ca Chnh ph v chnh sch tr gip cc i tng bo tr x hi;
Xt ngh ca Trng phng Ni v- Lao ng-Thng binh v X hi,
QUYT NH:
iu 1. Tr cp cho .........................................................................................................
c tr ti thn..............................................x..........................................huyn...........................
tnh..................................................l i tng...........................................................................
.......................................................................................................................................................
.......................................................................................................................................................
Mc tr cp l ........................ ng/thng, (Bng ch:...................................................
.....................................................................................................................................................)
k t ngy
thng
nm 200......
iu 2. Quyt nh ny c hiu lc thi hnh k t ngy k.
iu 3. Cc ng (b) Chnh Vn phng U ban nhn dn huyn, Trng phng Ni v
- Lao ng - Thng binh v X hi, Trng phng Ti chnh, Ch tch UBND x....................
v i tng c tn nu ti iu 1 chu trch nhim thi hnh Quyt nh ny.
CH TCH
Ni nhn:
- Nh iu 3;
- Lu: VPUB, NV-L-TBXH.
7. Mu s 3a
Mu s
3a
Y BAN NHN DN
HUYN...............................
S: ....../Q-UB
........................, ngy
thng
nm 200...
QUYT NH
V vic iu chnh mc tr cp x hi
( Dng cho c nhn, h gia nh)
ch tch u ban nhn dn
QUYT NH:
iu 1. iu chnh mc tr cp ca .............., h gia nh ng (b) ...............................
..........................................................................................................................................
c tr ti thn.......................................x.............................................huyn...............................
tnh..................................................l i tng...........................................................................
.......................................................................................................................................................
.......................................................................................................................................................
ang hng mc tr cp l ........................ ng/thng,
Nay hng mc tr cp l ...........................ng/thng (Bng ch:................................
..........................................................................................................................................k
t ngy
thng
nm 200..
- Lao ng - Thng binh v X hi, Trng phng Ti chnh, UBND x.................... v i
tng c tn nu ti iu 1 chu trch nhim thi hnh Quyt nh ny.
CH TCH
Ni nhn:
- Nh iu 3;
8. Mu s 4
Mu s 4
Y BAN NHN DN
HUYN...............................

S: ....../Q-UB
..................ngy
thng
nm 200...
QUYT NH
V vic tip nhn vo Nh x hi
(Dng cho i tng vo nh x hi )
ch tch u ban nhn dn
- Cn c Lut T chc Hi ng nhn dn, U ban nhn dn ngy 26/11/2003;
- Cn c Ngh nh s 67/2007/N-CP ngy 13/4/2007 ca Chnh ph v chnh sch tr
- Cn c Thng t s......../2007/TT-BLTBXH, ngy
/2007ca B Lao ngThng binh v X hi hng dn mt s iu ca Ngh nh s 67 /N-CP ngy 13/4/2007
QUYT NH:
iu 1. ng tip nhn ................................................................................................
Qu qun: thn .................................................x..................................huyn...........................
tnh...............................................................l i tng.............................................................
t:..................................................................................................................................................
vo sng ti nh x hi.....................................................................................................
k t ngy
thng
nm 200.. ,
iu 2. .................... c hng mc tr cp l ................................ ng/thng
(Bng ch: .....................................................................................................................)
v cc khon tr gip khc theo quy nh hin hnh.
- Lao ng - Thng binh v X hi, Trng phng Ti chnh, UBND x.................... v i
tng c tn nu ti iu 1 chu trch nhim thi hnh Quyt nh ny.
CH TCH
Ni nhn:
- Nh iu 4;
9. Mu s 5
Mu s 5
S LAO NG-THNG BINH
V X HI
Trung tm bo tr x hi
S: ....../Q- TTBTXH
................ngy
thng
nm 200...
QUYT NH
V vic chuyn i tng v gia nh hoc nh x hi
Gim c c s bo tr x hi
Cn c Ngh nh s
/200../N-CP ngy thng nm 200... ca Chnh ph v
ban hnh Quy ch thnh lp v hot ng ca c s bo tr x hi;
Cn c Bin bn hp Hi ng t vn ca Trung tm.....................................................
Xt ngh ca.................................................................................................................
QUYT NH:
iu 1. Chuyn ng (b)..................................................................................................
Qu qun thn...............................................x...........................................................................
huyn........................................................tnh...............................................................................
l ...................................................................................................................................................
n.................................................................................................................................................
k t ngy
thng
nm 200.. ,
L do............................................................................................................................................
n.............................................................................................x................................................
huyn.................................................. tnh...................................................................................
iu 3. Cc ng (b) Trng phng T chc - Hnh chnh, Trng phng Qun l i
tng, Trng phng y v, Trng phng bo v v ng (b) c tn nu ti iu 1 chu trch
nhim thi hnh Quyt nh ny.
GIM C
Ni nhn:
- Nh iu 3;
- S LTBXH ( b/c);
- Lu: TCCB, QLT.
10. Mu s 6
Mu s 6
Y BAN NHN DN
HUYN...............................

S: ....../Q-UB
..................ngy
thng
nm 200...
QUYT NH
V vic cp kinh ph h tr mai tng
CH TCH U BAN NHN DN
Cn c Thng t s......../2007/TT-BLTBXH, ngy /
/2007ca B Lao ngThng binh v X hi hng dn mt s iu ca Ngh nh s 67 /N-CP ngy 13/4/2007
QUYT NH:
iu 1. Cp kinh ph h tr mai tng cho ng (b)..........................................c tr ti
thn
(p,
bn,
t
dn
ph).......................x............................huyn...................
tnh..................................................l ....................................................................................
t chc mai tng cho .........................................................................................................
l i tng ang hng tr cp x hi, t trn ngy
thng
nm 200..
(Giy chng t s............................. do ..........................................................cp).
S tin h tr l : 2.000.000 ng (Bng ch: Hai triu ng chn)
- Lao ng - Thng binh v X hi, Trng phng Ti chnh, UBND x.................... v ng
(b) c tn nu ti iu 1 chu trch nhim thi hnh Quyt nh ny.
CH TCH
Ni nhn:
- Nh iu 3;
VI. Lnh vc ngi c cng

1. MU 1A

BN KHAI C NHN
ngh hng ch tr cp hng thng theo Quyt nh s 142/2008/Q-TTg ngy
27/10/2008 ca Th tng Chnh ph
H v tn:........................................ B danh:.................................................. Nam/n.
Ngy, thng, nm sinh:......./....../....... S CMND: .........................................................
Qu qun: .......................................................................................................................
Ni ng k h khu thng tr: ...................................................................................
Vo ng:............................................... Chnh thc: ...................................................
Nhp ng: Ngy thng nm......, n v (c, d, e.f ) ............................................
Ni nhp ng: X................................ huyn.......................... tnh................................
Ti ng: Ngy thng nm ......, n v (c, d, e.f ) ...............................................
Phc vin, xut ng: Ngy thng nm ...........................................................
Ni phc vin, xut ng: X....................... huyn......................... tnh ........................
Cp bc, chc v, n v khi phc vin, xut ng (c,d,e.f):.......................................
.........................................................................................................................................
Ngh nghip sau khi phc vin, xut ng: ......................................................................
.........................................................................................................................................
v ang c hng ch ngh hu, bnh binh, mt sc lao ng hng thng (hoc cha
c hng chnh sch g): ............................................................................................
Cc giy t cn lu gi: .................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
QU TRNH CNG TC TRONG QUN I
T thng,
nm
n thng,
nm
Cp bc,
Chc v
n v
(c,d,e,f)
a bn cng tc
(huyn, tnh)
Tng thi gian cng tc thc t trong qun i l:.. nm.. thng.
Ti xin cam oan li khai trn y l ng, nu sai ti hon ton chu trch nhim trc php
lut.
.., ngy thng nm 200
Ngi khai
(K, ghi r h tn)
2. MU 1B
BN KHAI C NHN
ngh hng ch tr cp mt ln theo Quyt nh s 142/2008/Q-TTg ngy 27/10/2008
ca Th tng Chnh ph
H v tn:...................................... B danh: .................................................... Nam/n.
Ngy, thng, nm sinh: .........../....../............ S CMND: ...............................................
Qu qun: .......................................................................................................................
Ni ng k h khu thng tr: ...................................................................................
Vo ng: ...................................................... Chnh thc: ............................................
Nhp ng: Ngy thng nm ......, n v (c, d, e.f ) ..........................................
Ni nhp ng: X .................................... huyn ............................ tnh ........................
Ti ng: Ngy thng nm ......, n v (c, d, e.f ) ..............................................
Phc vin, xut ng: Ngy thng nm ...........................................................
Ni phc vin, xut ng: X......................... huyn .......................... tnh ......................
Cp bc, chc v, n v khi phc vin, xut ng (c,d,e.f):.........................................
...........................................................................................................................................
Ngh nghip sau khi phc vin, xut ng: .......................................................................
...........................................................................................................................................
c hng chnh sch g): ...............................................................................................
Cc giy t cn lu gi: ...................................................................................................
............................................................................................................................................
............................................................................................................................................
............................................................................................................................................
QU TRNH CNG TC TRONG QUN I
T thng,
nm
n thng,
nm
Cp bc,
Chc v
n v
(c,d,e,f)
a bn cng tc
(huyn, tnh)
Tng thi gian cng tc thc t trong qun i l:.. nm.. thng.
lut.
.., ngy thng nm 200
Ngi khai
(K, ghi r h tn)
3. MU 1C
BN KHAI THN NHN

ngh hng ch tr cp theo Quyt nh s 142/2008/Q-TTg
ngy 27/10/2008 ca Th tng Chnh ph (i vi i tng t trn)
1. Phn khai v thn nhn ca i tng
H v tn:.............................................. B danh:............................................... Nam/n.
Ngy, thng, nm sinh: ............................ S CMND: ....................................................
Qu qun: .........................................................................................................................
Ni ng k h khu thng tr: .....................................................................................
n v, c quan cng tc hin nay: .................................................................................
Quan h vi i tng khai di y l: .........................................................................
2. Phn khai v i tng
H v tn:.......................................... B danh:.................................................. Nam/n.
Ngy, thng, nm sinh:.....................................................................................................
Qu qun: ........................................................................................................................
T trn: Ngy .. thng .. nm ti: ...............................................................
.........................................................................................................................................
Vo ng:... Chnh thc: ........................................................
Nhp ng: Ngy thng nm ......, n v (c, d, e.f ) ..........................................
Ni nhp ng: X............................. huyn ............................ tnh ...............................
Ti ng: Ngy thng nm ......, n v (c, d, e.f ) .............................................
Phc vin, xut ng: Ngy thng nm ..........................................................
Ni phc vin, xut ng: X.......................... huyn .......................... tnh ....................
Cp bc, chc v, n v khi phc vin, xut ng (c,d,e.f):........................................
..........................................................................................................................................
Tng thi gian cng tc trong qun i: ......................... nm thng.
Ngh nghip sau khi phc vin, xut ng: .......................................................................
............................................................................................................................................
c hng ch ngh hu, bnh binh, mt sc lao ng hng thng (hoc cha c
hng chnh sch g):
Cc giy t cn lu gi: .................................................................................................
............................................................................................................................................
............................................................................................................................................
............................................................................................................................................
............................................................................................................................................
............................................................................................................................................
lut.
.., ngy thng nm 200
Ngi khai
(K, ghi r h tn)
KIN Y QUYN V CH K CA CC THN NHN CN LI
XC NHN
ca y ban nhn dn x (phng)
4. MU 02
BIN BN HI NGH LIN TCH
ngh hng ch tr cp mt ln theo Quyt nh s 142/2008/Q-TTg
ngy 27/10/2008 ca Th tng Chnh ph
Hm nay, ngy thng nm 200
Ti thn (bn, p, t dn ph):.. x (phng).............................................
huyn (qun). tnh (thnh ph) ...........................................
Chng ti gm:
1. Trng thn (bn, p, t dn ph): .............................................................................
2. i din chi y (chi b):.. Chc v..........................................
3. i din Chi hi Cu chin binh:... Chc v...................................
4. i din Hi ng chnh sch x:.. Chc v....................................
hp xem xt, ngh i tng hng ch tr cp mt ln theo Quyt nh s
142/2008/Q-TTg ngy 27 thng 10 nm 2008 ca Th tng Chnh ph.
Nht tr xc nhn:
ng (b): . B danh.. sng (cht).
Sinh nm. T trn ngy thng .. nm..
Qu qun: .........................................................................................................................
L qun nhn tham gia khng chin chng M cu nc thuc i tng hng ch .
Nhp ng: Ngy thng nm Ti ng: Ngy thng nm..
Phc vin, xut ng: Ngy thng. nm.
Tng thi gian cng tc thc t trong qun i c hng ch l.. nm .. thng.
c hng chnh sch g): ...........................................................................................
Cc giy t ca i tng cn lu gi: .........................................................................
............................................................................................................................................
ngh cp trn xem xt v gii quyt cho i tng l ng (b) ..................................... hoc
thn nhn ca i tng l ng (b) c hng ch tr cp mt ln
theo quy nh hin hnh.
Bin bn lp thnh bn, cc i din c mt nht tr cng k tn di y:
Trng thn
i din
i din
(bn, p, t dn ph) Chi y (Chi b)
Chi hi CCB
(K, ghi r h tn) (K, ghi r h tn) (K, ghi r h tn)
i din
Hi ng chnh sch
x (phng)
(K, ghi r h tn)
5. MU 03
BIN BN HI NGH CA BCH HI CU CHIN BINH
Xt ngh i tng hng ch theo Quyt nh s 142/2008/Q-TTg
ngy 27/10/2008 ca Th tng Chnh ph
Hm nay, ngy thng nm 200
Ti ... x (phng).............................................................
huyn (qun).... tnh (thnh ph) ......................................................
Chng ti gm:
1. BCH Hi Cu chin binh x (phng) .....................................................................
Tng s c mt. vng mt..
2. i biu Cu chin binh tham gia khng chin chng M........................................
........................................................................................................................................
hp xem xt, ngh i tng hng ch (hng thng; mt ln):...........................
theo Quyt nh s 142/2008/Q-TTg ngy 27 thng 10 nm 2008 ca Th tng Chnh ph.
Nht tr xc nhn:
ng (b):.. B danh.. Sng, cht.
Sinh nm., T trn ngy thng.. nm..
Qu qun: ........................................................................................................................
L qun nhn tham gia khng chin chng M cu nc c hng ch .
Nhp ng: Ngy thng nm Ti ng: Ngy thng nm ..
Phc vin, xut ng: Ngy thng . nm .
Tng thi gian cng tc thc t trong qun i c tnh hng ch l .. nm.. thng.
S tin tr cp: .. ng/. (Bng ch: ..................................
........................................................................................................................................)
c hng chnh sch g): ............................................................................................
Cc giy t ca i tng cn lu gi: ..........................................................................
............................................................................................................................................
ngh cp trn xem xt v gii quyt cho i tng l ng (b) .................................. hoc
thn nhn ca i tng l ng (b) c hng ch theo quy
nh hin hnh.
TM. BAN CHP HNH
(K tn, ng du)
6. MU 04
Y BAN NHN DN
S:./.

, ngy. thng.. nm 200
V/v xc nhn v ngh i tng c

hng ch tr cp theo Quyt nh s
142/2008/Q-TTg
Knh gi: .
Cn c Quyt nh s 142/2008/Q-TTg ngy 27 thng 10 nm 2008 ca Th tng Chnh
ph; Thng t lin tch s 144/2008/TTLT-BQP-BLTBXH-BTC ngy 27 thng 11 nm 2008
ca B Quc phng, B Lao ng - Thng binh v X hi, B Ti chnh;
Cn c ngh ca thn (bn, p, t dn ph) ................................................................... ;
ngh ca BCH Hi Cu chin binh v Hi ng Chnh sch x (phng).
y ban nhn dn x (phng) . t chc xc minh, xt duyt v
nim yt, thng bo danh sch i tng trn cc phng tin thng tin i chng xin kin
nhn dn a phng, sau 15 ngy, chng ti thy khng c kin g v i tng xt duyt,
nht tr xc nhn v ngh:
ng (b):.. B danh.. Sng, cht.
Sinh nm.. T trn ngy thng .. nm ..
Qu qun: ...........................................................................................................................
Ni ng k h khu thng tr: .......................................................................................
L qun nhn tham gia khng chin chng M cu nc c hng ch tr cp (hng
thng, hoc mt ln)
Tng thi gian c hng ch l .. nm .. thng.
S tin tr cp: .. l:................................. ng/.
(Bng ch: ...................................................................................................................... )
(c h s km theo)
y ban nhn dn x (phng) .. xc nhn ch , mc hng nu trn
ca i tng l ng v chu trch nhim v s xc nhn ny. ngh cp trn xem xt v gii
quyt.
Ni nhn:
- Nh trn;
- Lu.
CH TCH
(K tn, ng du)
7. MU 05
.. (1)
S:./.
V/v ngh i tng c hng ch tr
cp theo Quyt nh s 142/2008/Q-TTg

Knh gi: .
. (2)
ca B Quc phng, B Lao ng - Thng binh v X hi, B Ti chnh v thc hin ch
i vi qun nhn tham gia khng chin chng M cu nc c di 20 nm cng tc trong
qun i phc vin, xut ng v a phng;
Cn c vo h s ca i tng v ngh ca ......................................................... (1)
ngh. (2) gii quyt ch tr cp (3) cho
i tng (c danh sch v h s km theo).
ngh (2) xem xt gii quyt.
Ni nhn:
- Lu.
Ghi ch:
- Mu ny dng cho cp x (phng) tr ln;
- (1) Cp ngh;
- (2) Cp trn trc tip;
- (3) Ch tr cp hng thng hoc tr cp mt ln;
- (4) Chc v ngi k.
.(4)
(K tn, ng du)
8. MU 05A
.. (1)
S:./.
V/v xt duyt v ngh i tng c
hng ch tr cp hng thng theo
Quyt nh s 142/2008/Q-TTg

Knh gi: Cc Chnh sch/Tng cc Chnh tr

ca B Quc phng, B Lao ng - Thng binh v X hi, B Ti chnh;
Cn c h s ca i tng v vn bn ngh ca cc cp,
. (1) t chc xt duyt v ngh:
ng (b):.. B danh.. sng, cht.
Sinh ngy thng.. nm ..
Qu qun: .........................................................................................................................
Ni ng k h khu thng tr: ......................................................................................
L qun nhn tham gia khng chin chng M cu nc c hng ch tr cp hng
thng.
Tng thi gian c hng ch l .. nm .. thng.
S tin tr cp: .. ng/thng.
(Bng ch: .....................................................................................................................)
(c h s km theo)
. (1) xt duyt ch , mc hng nu trn ca i
tng l ng v chu trch nhim v s xc nhn ny. ngh cp trn xem xt v gii quyt.
Ni nhn:
- Nh trn;
- Lu.
.(2)
(K tn, ng du)
Ghi ch:
- Mu ny dng cho B Ch huy qun s tnh (TP) v B T lnh Th H Ni;
- (1) n v ngh;
- (2) Chc v ngi k.
9. MU 6A
..
(1)
DANH SCH QUN NHN THAM GIA KHNG

CHIN CHNG M PHC VIN, XUT
NG V A PHNG
c hng ch tr cp hng thng theo
Quyt nh s 142/2008/Q-TTg ngy 27/10/2008
ca Th tng Chnh ph
Km theo Cng vn ngh s... ngy thng nm 200 ca )
STT
H v
tn
Nm
sinh
Qu
qun
Ni ng k h
khu thng tr
- Tng s i tng:
- Tng s tin: ng/thng.
Ngi lp danh sch
(K tn, ghi r cp bc hoc chc v)
Ghi ch:
- Mu ny dng cho t cp x (phng) tr ln;
- (1) Cp ngh;
- (2) Chc v ngi k.
Sng hay S nm c Mc tr cp
cht
hng
(ng/thng)
., ngy. thng. nm 200

. (2)
(K tn, ng du)
Ghi
ch
10. MU 6B
..
(1)
DANH SCH QUN NHN THAM GIA KHNG CHIN

CHNG M PHC VIN, XUT NG V A
PHNG
c hng ch tr cp mt ln theo Quyt nh s 142/2008/QTTg ngy 27/10/2008 ca Th tng Chnh ph
(Km theo Cng vn ngh s... ngy thng nm 200 ca...)
STT
H v
tn
Nm
sinh
Qu
qun
Ni ng k h
khu thng tr
- Tng s i tng:
- Tng s tin:
Ngi lp danh sch
(K tn, ghi r cp bc hoc chc v)
Ghi ch:
- Mu ny dng cho cp x (phng) tr ln;
- (1) Cp ngh;
- (2) Chc v ngi k.
- S t 2 nm tr xung ghi bng 2 nm.
Sng hay S nm c Mc tr cp Ghi

cht
hng
(ng)
ch
., ngy. thng. nm 200

. (2)
(K tn, ng du)
11. Mu s 7-HH1
..................................
UBND..........................

c lp T do Hnh phc
S: ......./Q.........
............, ngy...... thng...... nm......
GIY XC NHN
NGI HOT NG KHNG CHIN B NHIM CHT C HO HC
ng (B):.................................................................Nm sinh:....................................................
Nguyn qun:................................................................................................................................
Tr qun:.......................................................................................................................................
Nhp ng hoc tham gia khng chin ngy......... thng......... nm.............................................
C quan, n v:............................................................................................................................
B nhim cht c ho hc do c thi gian hot ng chin trng t ngy..... thng.....
nm..... n ngy..... thng..... nm...................
Tnh trng bn thn:(v sinh, khng c v hoc chng, c con trc khi tham gia khng
chin sau khi v a phng khng sinh con c):...................................................................
.......................................................................................................................................................
Bnh tt hin nay:.........................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
C con b d dng, d tt:
H v tn
Nm
sinh
Tnh trng
d dng, d tt
Cn kh nng t
lc c trong
sinh hot
TM. UBND
CH TCH
(Ghi r h tn, k v ng du)
Khng cn kh
nng t lc c
trong sinh hot
12. Mu s 7-HH2
c lp T do Hnh phc
BN KHAI C NHN
I.Ngi tham gia khng chin:
- H v tn: ................................................................Nm sinh:.................................................
- Nguyn qun:..............................................................................................................................
- Tr qun:.....................................................................................................................................
- Nhp ng hoc tham gia khng chin ngy............ thng.............. nm...................................
- C quan, n v, chc v khi chin trng:...........................................................................
- Thi gian chin trng: t ngy..... thng..... nm..... n ngy..... thng..... nm...................
- a bn hot ng:......................................................................................................................
Bnh tt do nhim
cht c ho hc
Khng cn
kh nng lao ng
Suy gim
kh nng lao ng
Tnh trng bn thn hin nay (v sinh, khng c v hoc chng, c con trc khi tham gia
khng chin sau khi v a phng khng sinh con c)..........................................................
.......................................................................................................................................................
.......................................................................................................................................................
II. Con ca ngi tham gia khng chin:
H v tn
Nm
sinh
Tnh trng
d dng, d tt
Cn kh nng
t lc c trong
sinh hot
Khng cn kh
nng t lc c
trong sinh hot
Xc nhn ca UBND x, phng.....................

Ni dung bn khai v ch k ca ng (b)............
l ng.
Ngy.... thng.... nm 200...
TM. UBND
Ch tch
Ngy.... thng.... nm 200...

Ngi khai k tn
(Ghi r h v tn)
13. Mu s 7-HH3
c lp T do Hnh phc
BIN BN XC NHN
NGI HOT NG KHNG CHIN B NHIM
CHT C HO HC
Hm nay, ngy..... thng..... nm......., i din ng U, U ban nhn dn, cc t chc on th
v nhn dn x (phng):.............................................................................................................
bao gm (ghi r h tn v chc danh):.........................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
hp xem xt ngh hng ch ngi hot ng khng chin v con b nhim cht
c ho hc do M s dng trong chin tranh Vit Nam ca:
- ng (b).............................................................. Nm sinh.......................................................
- Nguyn qun:..............................................................................................................................
- Tr qun:.....................................................................................................................................
- Nhp ng hoc tham gia khng chin ngy............ thng............ nm.....................................
- Thi gian chin trng t ngy..... thng..... nm...... n ngy..... thng..... nm.........
- a bn hot ng:......................................................................................................................
- Tnh trng sc kho hin ti do nhim cht c ho hc:
1. i vi ngi hot ng khng chin:
Bnh tt do nhim
cht c ho hc
Khng cn
kh nng lao ng
Suy gim
kh nng lao ng
Tnh trng bn thn hin nay (v sinh, khng c v hoc chng, c con trc khi tham gia
khng chin sau khi v a phng khng sinh con c)..........................................................
.......................................................................................................................................................
2. Con ca ngi hot ng khng chin:
H v tn
Nm
sinh
I DIN
MT TRN T QUC
Tnh trng
d dng, d tt
Cn kh nng t
lc c trong
sinh hot
I DIN
NG U
Khng cn kh nng
t lc c trong sinh
hot
I DIN
UBND CP X
14. Mu s 7-HH4a
UBND TNH K NNG
S LAO NG - THNG
BINH V X HI

c lp T do Hnh phc
..........., ngy...... thng..... nm......
S............/
S h s:................
QUYT NH
V vic tr cp
i vi ngi hot ng khng chin b nhim cht c ho hc
GIM C S LAO NG - THNG BINH V X HI
- Cn c Ngh nh s 54/2006/N-CP ngy 26 thng 5 nm 2006 ca Chnh ph hng dn
thi hnh Php lnh u i ngi c cng vi cch mng;
- Cn c Ngh nh s 147/2005/N-CP ngy 30 thng 11 nm 2005 ca Chnh ph quy nh
v mc tr cp, ph cp u i i vi ngi c cng vi cch mng; (1)
- Cn c h s ca ng (b)..........................................................................................................
- Xt ngh ca Trng phng Chnh sch Thng binh Lit s,
QUYT NH
iu 1.
Tr cp i vi ng (b):............................................... Nm sinh..............................................
Nguyn qun:................................................................................................................................
Tr qun:.......................................................................................................................................
tham gia khng chin ti a bn............................................................................................
t ngy...... thng...... nm.................. n ngy...... thng...... nm............................................
iu 2.
ng (b):...................................................................................c hng tr cp hng thng
mc:...........................................................ng
(bng ch:............................................................................................................................ng)
k t ngy......... thng......... nm..............................
iu 3.
Cc ng (b) Trng phng Chnh sch Thng binh Lit s; Trng phng K ton -Ti
chnh; Trng phng Lao ng - Thng binh v X hi..........................................................
v ng (b)................................. chu trch nhim thi hnh Quyt nh ny./.
Ni nhn:
- Nh iu 3
- Cc TBLSNCC - B LTBXH
- Lu VP.
(1): S c thay i khi c quyt nh ca Chnh ph
GIM C
(K tn, ng du)
15. Mu s 7-HH4b
UBND TNH K NNG
S LAO NG - THNG
BINH V X HI

c lp T do Hnh phc
..........., ngy...... thng..... nm......
S............/
S h s:................
QUYT NH
V vic tr cp i vi con
ca ngi hot ng khng chin b nhim cht c ho hc
GIM C S LAO NG THNG BINH V X HI
- Cn c Ngh nh s 54/2006/N-CP ngy 26 thng 5 nm 2006 ca Chnh ph hng dn thi hnh
Php lnh u i ngi c cng vi cch mng;
- Cn c Ngh nh s 147/2005/N-CP ngy 30 thng 11 nm 2006 ca Chnh ph quy nh v mc
tr cp, ph cp u i i vi ngi c cng vi cch mng; (1)
- Cn c h s ca ng (b).................................................................................................................
QUYT NH
iu 1.
Tr cp hng thng i vi cc con ca:
ng (b):.................................................................. Nm sinh.............................................................
Nguyn qun:......................................................................................................................................
Tr qun:.............................................................................................................................................
tham gia khng chin ti a bn....................................................................................................
t ngy..... thng..... nm..... n ngy..... thng..... nm...................
iu 2.
Cc con ca ng (b)...................... c hng tr cp hng thng k t ngy..... thng......
nm........, c th theo danh sch di y:
H v tn cc con
b d dng, d tt
Nm
sinh
Kh nng t lc
trong sinh hot
C
Mc tr cp hng thng
Khng
iu 3.
Cc ng (b) Trng phng Chnh sch Thng binh Lit s; Trng phng K ton Ti chnh; Trng phng Lao ng Thng binh v X hi.................................................................................
v cc con ca ng (b)........................... c tn trong danh sch trn chu trch nhim thi hnh
Quyt nh ny./.
Ni nhn:
- Nh iu 3
- Cc TBLSNCC B LTBXH
- Lu VP.
GIM C
(K tn,ng du)
16. Mu s 7-HH5a
UBND TNH K NNG
S LAO NG - THNG
BINH V X HI

c lp T do Hnh phc
..........., ngy...... thng..... nm......
S............/
S h s:................
PHIU TR CP
i vi ngi hot ng khng chin b nhim cht c ho hc
H v tn:............................................................. Nm sinh........................................................
Nguyn qun:................................................................................................................................
Tr qun:.......................................................................................................................................
Nhp ng hoc tham gia khng chin ngy......... thng........... nm...........................................
C quan, n v khi chin trng:............................................................................................
Thi gian hot ng chin trng t ngy.............. thng............. nm..................................
n ngy.............. thng............. nm....................
Tnh trng bn thn hin nay (bnh tt; v sinh, khng c v hoc chng, c con trc khi
tham gia khng chin sau khi v a phng khng sinh con c, c con b d dng, d tt):
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
Giy xc nhn s:................... ngy........... thng............ nm....................................................
ca y ban nhn dn.....................................................................................................................
c hng tr cp k t ngy.......... thng......... nm.......................
Theo Quyt nh s:..................... ngy........ thng........ nm............ ca Gim c S Lao ng
- Thng binh v X hi...............................................................................................................
PHN TR CP, PH CP
- Tr cp hng thng:...............................................................................................
- Tr cp khc:.........................................................................................................
- Tr cp c truy lnh (nu c):...........................................................................
NGI LP PHIU
GIM C
(K tn, ng du)
17. Mu s 7-HH5b
UBND TNH K NNG
S LAO NG - THNG
BINH V X HI

c lp T do Hnh phc
..........., ngy...... thng..... nm......
S............/
S h s:................
PHIU TR CP
i vi con ca ngi hot ng khng chin

b nhim cht c ho hc
H v tn:......................................................... Nm sinh............................................................
Nguyn qun:................................................................................................................................
Tr qun:.......................................................................................................................................
L con ca ng (b)..................................................................................................................
Nguyn qun:................................................................................................................................
Tr qun:.......................................................................................................................................
Giy xc nhn s:.................................. ngy....... thng....... nm..............................................
ca y ban nhn dn.....................................................................................................................
Kh nng t lc trong sinh hot:..................................................................................................
c hng tr cp k t ngy...... thng...... nm.................
Theo Quyt nh s:.................... ngy...... thng....... nm............ ca Gim c S Lao
ng - Thng binh v X hi...................................................................................................
PHN TR CP, PH CP
- Tr cp hng thng:...............................................................................................
- Tr cp khc:.........................................................................................................
- Tr cp c truy lnh (nu c):...........................................................................
NGI LP PHIU
GIM C
(K tn, ng du)
18. Mu s 7-HH6
...................................
...................................
HI NG GIM NH
Y KHOA..................

c lp T do Hnh phc
S: ............/
.........., ngy...... thng...... nm........

BIN BN GIM NH BNH TT
Hi ng gim nh Y khoa.........................................................................................................
Hp ngy................................ ti........................................... gim nh bnh tt i vi
ng (b):.................................................Nm sinh.....................................................................
Nguyn qun:...............................................................................................................................
Tr qun:.....................................................................................................................................
C quan gii thiu n:.................................................................................................................
Theo Giy xc nhn ngi hot ng khng chin b nhim cht c ho hc s: .......................
ngy...... thng...... nm............... ca...........................................................................................
Tnh trng bnh tt:.......................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
KT QU KHM
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
KT LUN
Theo tiu chun bnh tt quy nh ti Thng t Lin B s 12/TT-LB ngy 26 thng 7 nm
1995 ca Lin B Y t Lao ng Thng binh v X hi, ng ch: ..................................
.......................................................................................................................................................
- C t l suy gim kh nng lao ng do bnh tt l:..................%
(bng ch:................................................................................................................................%)
U VIN
U VIN THNG TRC
CH TCH HI NG
19. Mu 8-TT
Mu s 12-TT1

BN KHAI CA THN NHN
NGI C CNG VI CCH MNG T TRN
H v tn ngi t trn:...................................................... Nm sinh:.......................................
Nguyn qun:................................................................................................................................
Tr qun:.......................................................................................................................................
Thuc i tng hng tr cp u i: (thng binh, bnh binh, thn nhn lit s...)..............
.......................................................................................................................................................
S s tr cp (nu c):..................................................................................................................
T l suy gim kh nng lao ng:...............................................................................................
T trn ngy...... thng...... nm....................................................................................................
Theo giy khai t s............. ngy...... thng....... nm....... ca U ban nhn dn x (phng).
Tr cp nhn n ht thng........ nm......... Mc tr cp:......................................................
H tn ngi nhn mai tng ph v 3 thng tr cp, ph cp......................................................
Nguyn qun:................................................................................................................................
Tr qun:.......................................................................................................................................
Quan h vi ngi c cng vi cch mng t trn:.....................................................................
DANH SCH THN NHN IU KIN HNG TUT T TRN (nu c)
TT
H v tn
Nm sinh
Quan h vi
ngi cht
Ngh nghip hin ti
1
2
3
4
5
.............., ngy..... thng..... nm......

Chng nhn UBND x (phng)
Ch tch
(K tn, ng du)
20. Mu 9
............, ngy..... thng..... nm.....

Ngi khai nhn tr cp
(K tn, ghi r h tn)

................, ngy...... thng....... nm.........
BN KHAI C NHN
H v tn:........................................................... ngy sinh..........................................................
Nguyn qun:................................................................................................................................
Tr qun:.......................................................................................................................................
Ngh nghip, chc v hin nay (nhn dn, hu tr, mt sc lao ng, cn b x,...).................
.......................................................................................................................................................
c hng tr cp:
- Thng binh, ngi hng chnh sch nh thng binh:
- Thn nhn lit s
- Ngi hot ng khng chin
.......
Ti cha c cp th bo him y t. ngh c quan c thm quyn xem xt cp th bo him
y t./.
Xc nhn ca UBND x,phng
Ngi khai k tn
(K v ghi r h tn)
Ni dung k khai trn v ch k ca

ng (b):.....................................
l ng s tht./.
.........., Ngy........ thng......... nm.........
TM. UBND
Ch tch
21. Mu s 10

c lp T do Hnh phc
BN KHAI CA THN NHN
NGI C CNG VI CCH MNG
1/ Phn khai v thn nhn (ngi ng khai);
H v tn:................................................................ Nm sinh:...................................................
Nguyn qun:................................................................................................................................
Tr qun:.......................................................................................................................................
Quan h vi ngi c cng vi cch mng: (v, chng, cha, m, con...)...................................
.......................................................................................................................................................
2/ Phn khai v ngi c cng:
H v tn:................................................................ Nm sinh:...................................................
Nguyn qun:................................................................................................................................
Ni ng k h khu trc khi cht (tr lit s):.........................................................................
cht ngy:...... thng....... nm.......... ti .................................................................................
L i tng: (LTCM, TKN, HKC, ch bt t, y):..............................................................
Thuc din hng mt tr cp i vi:........................................................................................
Giy chng nhn km theo (Quyt nh; giy chng nhn; l lch; giy bo t; giy khai t;
bin bn ca gia nh, h tc...)
-...
-...
Ti xin cam oan li khai trn l ng, nu sai ti xin hon ton chu trch nhim trc php
lut./.
.......ngy.... thng.... nm 200...
Xc nhn ca x (phng)
ng (b)....................................................................
Hin c tr ti:..........................................................
l.................. ca ng (b)........................................
(tn ngi c cng) cht ngy .thng..........
nm........
ngh c gii quyt tr cp mt ln.
TM. UBND
Ch tch
22. Mu 11-T1
........ngy.... thng.... nm 200...

Ngi khai
(K, ghi r h v tn)

..............ngy....... thng....... nm 200....
BN KHAI C NHN
H v tn :...................................................................... Nm sinh.............................................
Nguyn qun:................................................................................................................................
Tr qun:.......................................................................................................................................
Tham gia hot ng cch mng, hot ng khng chin t ngy......... thng......... nm............
n ngy......... thng......... nm............
Cp bc................................. chc v:.........................................................................................
n v hot ng trc khi b ch bt t, y:...........................................................................
B ch bt t, y ngy...... thng...... nm........ n ngy...... thng...... nm............................
Ni b t:.......................................................................................................................................
Ngy vo ng hoc cc t chc qun chng khc.....................................................................
hng cc ch :
- Thng binh, ngi hng chnh sch nh thng binh
- Tut lit s
- Ngi hot ng khng chin
- Ngi c cng gip cch mng
- .....................................................................................................................................................
c khen thng tng kt thnh tch khng chin (nu c):
+ Hun chng chin thng, Hun chng khng chin hng....................... Quyt nh
s:.......................... ngy................ thng.................. nm..........................................................
+ Huy chng chin thng, Huy chng khng chin hng.................... Quyt nh
s:......................... ngy.......... thng............. nm.......................................................................
Chng nhn ca UBND x, phng (hoc c quan qun l)
Ngy
thng
nm
(K tn, ng du)
23. Mu 11-T2
Ngi khai
(K ghi r h, tn)
UBND TNH K NNG

S LAO NG - THNG
BINH V X HI

c lp T do Hnh phc
..........., ngy...... thng..... nm......
S............/
S h s:................
QUYT NH
V vic tr cp mt ln i vi ngi b ch bt t, y
QUYT NH
iu 1. Tr cp mt ln i vi:
ng (b)........................................................................ Nm sinh:..............................................
l ngi hot ng cch mng hoc ngi hot ng khng chin b ch bt t, y.
Nguyn qun:................................................................................................................................
Tr qun:.......................................................................................................................................
Cp bc, chc v khi b bt:.........................................................................................................
n v khi b ch bt:..................................................................................................................
Thi gian b t, y ......................... nm ............. thng.
c hng tr cp mt ln......................................................ng.
( Bng ch:...................................................................................................................................)
iu 2. Cc ng (b) Trng phng Chnh sch Thng binh Lit s, Phng K hoch Ti
chnh, Phng Lao ng - Thng binh v X hi........................ v ng (b)............................
chu trch nhim thi hnh Quyt nh ny./.
Ni nhn:
- Nh iu 2
- Lu
GIM C
(K tn, ng du)
24. Mu 12-CC1
............., ngy...... thng...... nm.........
BN KHAI C NHN
H v tn................................................................ Nm sinh:....................................................
Nguyn qun:................................................................................................................................
Tr qun:.......................................................................................................................................
c Nh nc tng:
- Bng C cng vi nc theo Quyt nh s:..................... ngy.......... thng....... nm..........
ca Ch tch nc.
- Hun chng khng chin hng:.................. theo Quyt nh s:............................................
ngy............ thng............ nm...........
- Huy chng khng chin hng:.................... theo Quyt nh s:............................................
ngy............ thng............ nm...........
Cc ch chnh sch hng:
- Thng binh, ngi hng chnh sch nh thng binh
- Khng chin
.....
Chng nhn ca UBND x,phng
Chng nhn ni dung k khai trn v ch k
ca ng (b):.....................................l ng s tht./.
Ngy........ thng......... nm.........

(K tn, ng du)
Ngi khai k tn
(k v ghi r h tn)
25. Mu s 12-CC2
UBND TNH K NNG
S LAO NG - THNG
BINH V X HI

c lp T do Hnh phc
..........., ngy...... thng..... nm......
S h s:................
QUYT NH
V vic tr cp hng thng
i vi ngi c cng gip cch mng
GIM C S LAO NG - THNG BINH V X HI

QUYT NH
iu 1. Tr cp i vi:
ng(b):............................................................... Nm sinh:.......................................................
l ngi c cng gip cch mng.
Nguyn qun:................................................................................................................................
Tr qun:.......................................................................................................................................
c Nh nc tng:
- Bng C cng vi nc theo Quyt nh s:.................. ngy.......... thng..........................
nm............. ca Ch tch nc.
- Hun chng khng chin hng:............... theo Quyt nh s:................................................
ngy........ thng.......... nm................
Mc tr cp hng thng l: ...................................ng,
(Bng ch:....................................................................................................................................)
k t ngy.......... thng.......... nm.............
chnh, Phng Lao ng - Thng binh v X hi........................................................................
v ng (b)............................... chu trch nhim thi hnh Quyt nh ny./.
Ni nhn:
- Nh iu 2
- Lu
GIM C
(K tn, ng du)
26. Mu s 12-CC3
UBND TNH K NNG
S LAO NG - THNG
BINH V X HI

c lp T do Hnh phc
..........., ngy...... thng..... nm......
S h s:................
QUYT NH
V vic tr cp mt ln
i vi ngi c cng gip cch mng

QUYT NH
iu 1. Tr cp 1 ln i vi:
ng(b):................................................................. Nm sinh:.....................................................
l ngi c cng gip cch mng.
Nguyn qun:................................................................................................................................
Tr qun:.......................................................................................................................................
c Nh nc tng Huy chng khng chin theo Quyt nh s.......................................
ngy......... thng......... nm.............. ca...........................
c hng tr cp mt ln mc:...............................................................................................
(bng ch.....................................................................................................................................)
chnh, Phng Lao ng - Thng binh v X hi........................................................................
v ng(b)...................... chu trch nhim thi hnh Quyt nh ny./.
Ni nhn:
- Nh iu 2
- Lu
GIM C
(K tn, ng du)
27. Mu s 13 - KC1
ngy
thng
nm
BN KHAI C NHN
H v tn.............................................................. Nm sinh:.......................................................
Nguyn qun:................................................................................................................................
Tr qun:.......................................................................................................................................
Tham gia hot ng khng chin t ngy........ thng........ nm............ n ngy........
thng........ nm............
S nm thc t tham gia khng chin:............. thng ............ nm.
Khen thng tng kt thnh tch khng chin:
Hun chng Chin thng hng
Huy chng Chin thng hng
Hun chng KC chng Php hng
Huy chng KC chng Php hng
Hun chng KC chng M hng
Huy chng KC chng M
Chng nhn ca UBND x,phng
Chng nhn ni dung k khai trn v ch k
ca ng (b):.....................................l ng s tht./.
Ngy
thng
nm
(K tn, ng du)
Ngi khai k tn
(k v ghi r h tn)
28. Mu s 13 - KC2
UBND TNH K NNG
S LAO NG - THNG
BINH V X HI

c lp T do Hnh phc
..........., ngy...... thng..... nm......
S h s:................
QUYT NH
V vic tr cp mt ln i vi ngi hot ng khng chin
QUYT NH
iu 1. Tr cp mt ln i vi ng (b).................................... Nm sinh...............................
l ngi hot ng khng chin gii phng dn tc
Nguyn qun:................................................................................................................................
Tr qun:.......................................................................................................................................
c khen thng.................................................................................................theo Quyt
nh s..................... ngy...... thng...... nm.............. ca..........................................................
c hng tr cp mt ln l: .........................................ng
(Bng ch.....................................................................................................................................)
chnh, Phng Lao ng - Thng binh v X hi................................................................... v
ng (b) chu trch nhim thi hnh Quyt nh ny./.
Ni nhn:
- Nh iu 2
- Lu
GIM C
(K tn, ng du)
VII. Lnh vc vic lm

1. Mu s 1
---------------------- N T HAM GIA D N VAY V N GI I QUY T VI C L M
Knh gi: ng/B..............................................................................
Ch d n nhm h...........................................................
Tn ti l:...................................................... Nm sinh:....................................
S CMND:............................Cp ngy:.................. ti:....................................
Tr ti:..............................................................................................................
H khu thng tr:.........................................................................................
Ngh nghip chnh:............................................................................................
C t liu sn xut:
- t rung: .................m2; vn:................. m2; chung tri:................. m2
- Vt nui (s lng gia sc, gia cm):.................... con, gi tr:.......... (ng);
- Cy trng (s lng cy): ..................................... cy, gi tr:.......... (ng);
- Cng c sn xut (ghi c th, s lng): .... ...........ci, gi tr:.......... (ng);
- Lao ng trong h (ngi):.............................................................................
- Tin mt (ng): .............................................................................................
Tng s vn hin c: ............................................... (ng)
Nay ti c nhu cu tham gia d n vay vn gii quyt vic lm vay vn u t sn
xut (ghi c th mc ch s dng vn vay):...................................................
S vn cn vay (ng): ........................ Li sut vay: ....................... %/thng
Thi hn vay: ...............thng, to vic lm mi cho: .................... lao ng
Trong :
+ Lao ng n:.............. ngi; Lao ng l ngi tn tt:.....................ngi
+ Lao ng l ngi dn tc:...... ngi; Lao ng b thu hi t do chuyn i mc ch
s dng t: ................. ngi.
Ti lm n ny knh ngh ng/B......................... cho ti c tham gia d n vay
vn cho Qu cho vay gii quyt vic lm, nu c vay vn ti bo m s dng vn vay ng
mc ch c duyt v cam kt hon tr vn v li ng thi hn. Nu sai ti xin chu hon
ton trch nhim trc php lut.
Xc nhn ca UBND x,
phng, th trn
...... Ngy ....... thng ........ nm 200.....

Ngi lm n
(K v ghi r h tn)
2. Mu s 2a
D N VAY V N QU CHO VAY GI I QUY T VI C LM
(p dng cho c s sn xut kinh doanh)
Tn d n:..............................................................................................................
H v tn ch d n: .............................................................................................
a ch lin h: ....................................................................................................
a im thc hin d n: .....................................................................................
I. BI CNH
- c im tnh hnh c s sn xut kinh doanh: ..................................................
- Bi cnh kinh t - x hi :..................................................................................
- Kh nng pht trin c s sn xut kinh doanh trong d n:............................
...............................................................................................................................
II. MC TIU D N
1. u t pht trin, m rng sn xut kinh doanh, tng sn phm, doanh thu, li nhun.
2. Gii quyt vic lm cho lao ng:
- To thm ch lm vic mi, thu ht thm lao ng vo lm vic.
- m bo vic lm, n nh ch lm vic cho ngi lao ng.
- m bo thu nhp gp phn n nh cuc sng cho ngi lao ng.
III. NI DUNG D N
1. Ch th d n: ...............................................................................................
- Tn gi c s sn xut, kinh doanh: ...............................................................
- Chc nng: .......................................................................................................
- Tn ngi ng u: .....................................................................................
- a ch tr s sn xut: .................................................................................
- Vn hot ng: ..................................................................................... ng
- S hiu ti khon tin gi: ...........................................................................
2. Mt bng sn xut, kinh doanh (hin trng, din tch):
- Vn phng (a ch, m2): ...............................................................................
- Nh xng, kho bi (a ch, m2): ..............................................................
3. Ngun vn hot ng (quy ra tin): ...........................................................
- Tng s:
Trong : - Vn t c.................... ng - Vn vay:.....................ng
Chia ra: - Vn c nh: .............. ng - Vn lu ng ............ng
4. Nng lc sn xut:
- Xng sn xut (s lng, din tch, tnh trng hot ng):
- Trang thit b, my mc (s lng, gi tr, tnh trng hot ng):
- T chc, b my (s lng phng ban, s lng lao ng):
5. Kt qu sn xut kinh doanh (2 nm gn nht):
- Sn phm (s lng, khi lng tng loi sn phm): .....................................
- Doanh thu: ............................................................................................ (ng)
- Thu: .................................. (ng). Li nhun :................ ..................(ng)
- Tin lng cng nhn:.................................................................(ng/thng)
6. Nhu cu m rng sn xut kinh doanh, pht trin doanh nghip:
a. u t trang thit b:
- My mc, thit b (chng loi, s lng, gi tr): ...........................................
- Phng tin (chng loi, s lng, gi tr): ..................................................
b. u t vn lu ng:
- Vt t, nguyn, nhin liu (chng loi, s lng, gi tr): ...........................
c. Nhu cu s dng lao ng:
- Lao ng hin c: ......................................................... ........................ngi
- Lao ng tng thm: ..............................................................................ngi
Trong :
+ Lao ng n: .................................................................ngi
+ Lao ng l ngi tn tt: ............................................. ngi
+ Lao ng l ngi dn tc: ........................................... ngi
+ Lao ng b thu hi t do chuyn i mc ch s dng t nng nghip :.............
ngi
7. S vn xin vay t Qu Quc gia v vic lm:
- Tng s vn xin vay: .................................... ng (% so vi tng s vn thc hin d
n).
- Mc ch s dng vn vay: ...........................................................................
- Thi hn vay: ..................... thng. Li sut:....................................% thng
8. Ti sn th chp: (ghi c th ti sn v gi tr)
IV. HIU QU KINH T CA D N
1. i vi doanh nghip:
- Tng nng lc sn xut (my mc, thit b): ............................

- Tng sn phm, doanh thu (s lng, gi tr): ........................
- Tng li nhun: ...................... ng. Tng s thu phi np ngn sch nh nc ...........
ng.
2. i vi ngi lao ng:
- Thu ht v m bo n nh vic lm cho: .................................... lao ng
- Tin cng:....................................................................................ng/thng
V. PHN CAM KT CA CH D N
Ti xin cam kt:
- Thu ht lao ng: .................................................. (ngi)
- S dng vn ng mc ch nu trong d n.
- m bo thi hn hon tr vn.
- Thc hin y , ng ch : thi gian lm vic v ngh ngi, bo h lao ng, bo
him i vi ngi lao ng v ngha v i vi Nh nc.
Xc nhn ca UBND x,
phng, th trn
...... Ngy ....... thng ........ nm .......

Ch d n
(K tn, ng du)
3. Mu s 2b
D N VAY V N QU CHO VAY GI I QUY T VI C LM
(p dng cho d n h v nhm h gia nh)
Tn d n:...............................................................................................................
H v tn ch d n: .............................................................................................
Chc v: .............................................................................................................
a ch thng tr: ...............................................................................................
a im thc hin d n: ..................................................................................
I. MC TIU D N
1. Pht trin kinh t h gia nh, tng sn phm, doanh thu, li nhun.
2. Gii quyt vic lm cho lao ng:
- To thm ch lm vic mi, thu ht thm lao ng vo lm vic.
- m bo vic lm, n nh thu nhp cho ngi lao ng.
II. NI DUNG D N
1. Ngnh ngh chnh tham gia d n:
- Trng trt (s lng h tham gia): ..................................................................
- Chn nui (s lng h tham gia): ................................................................
- Tiu, th cng nghip, ch bin (s lng h tham gia): ...............................
2. Tng s h tham gia d n (Biu tng hp km theo):
- Tng s lao ng cc h tham gia d n: ......................................... (ngi)
- S lao ng c to vic lm mi: ..................................................(ngi)
Trong :
+ Lao ng n:........... ngi; Lao ng l ngi tn tt:......................ngi
+ Lao ng l ngi dn tc:...... ngi; Lao ng b thu hi t do chuyn i mc ch
s dng t: ................. ngi.
3. Tng s vn thc hin d n:
- Ngun vn hin c:................ (ng), trong : Vn bng tin:......... (ng)
4. Tng s vn xin vay t Qu cho vay gii quyt vic lm:.................ng
5. Thi hn vay vn: ................ thng. Li sut vay: ........................%/thng
6. Mc ch s dng tin vay: .......................................................................
7. Thi gian thc hin d n:
III. CAM KT CA CH D N:
Ti cam kt qun l v c trch nhim n c cc thnh vin vay vn s dng ng mc
ch v hon tr vn v li ng thi hn cho nh nc.
Xc nhn ca UBND x,
phng, th trn
...... Ngy ....... thng ........ nm .......

Ch d n
(K v ghi r h tn)
VIII. Lnh vc Y t
1. Mu 1
c lp T do Hnh phc
....., ngy........... thng.......... nm 200...
N NGH
Cp Giy chng nhn iu kin v sinh an ton thc phm
Knh gi: (tn n v c thm quyn cp, c th: Cc An ton v sinh thc phm, Trung
tm Y t d phng tnh, thnh ph trc thuc Trung ng, Trung tm Y t, UBND huyn, qun,
th x, thnh ph trc thuc tnh)
C s ............................................c thnh lp ngy:..........................................
Tr s ti:.................................................................................................................
in thoi:....................................Fax:....................................................................
Giy php kinh doanh s....................ngy cp:..................n v cp:..................
Loi hnh sn xut, kinh doanh:.............................................................
Cng sut sn xut/nng lc phc v:....................................................................
S lng cng nhn vin:................... (c nh:.......................thi v:.................)
Nay np h s xin cp Giy chng nhn iu kin v sinh an ton thc
phm ................(ghi c th mt hng, loi hnh kinh doanh).
Xin trn trng cm n.
H s gi km gm:
-Bn sao cng chng Giy ng k kinh doanh;
-Bn thuyt minh v c s vt cht;
-Bn sao cng chng Giy chng nhn GMP,
SSOP, HACCP (nu c);
-Bn cam kt bo m v sinh, an ton thc phm
i vi nguyn liu TP v sn phm TP do c s
SX, KD;
-Giy chng nhn iu kin sc kho ca ch c
s v ngi trc tip tham gia SX, KD;
-Bn sao Giy chng nhn c tp hun kin
thc v VSATTP.
CH C S
(k tn & ng du)
2. Mu 2
BN CAM KT BO M V SINH AN TON THC PHM
I VI NGUYN LIU V SN PHM THC PHM
S..........................................
C s:.......................................................................................................................
a ch:....................................................................................................................
in thoi:........................ Fax:..............................E-mail:.....................................
CAM KT
p dng cho sn phm:...........................................................................................
Chng ti cam kt bo m v sinh an ton thc phm i vi nguyn liu thc phm
v sn phm thc phm do c s sn xut, kinh doanh v chu hon ton trch nhim trc
ngi tiu dng v c quan qun l nh nc v nhng vi phm v sinh an ton thc phm theo
quy nh ca php lut.
......, ngy ........thng........nm 200...
CH C S
(k tn & ng du)
IX. Lnh vc xy dng

1. Mu 1
_________________________________________
N XIN CP GIY PHP XY DNG

(S dng cho nh nng thn)
Knh gi: UBND x ..........................................................
1. Tn ch u t: ........................................................ .........................................
- S chng minh th: .....................................Ngy cp: ....................................
- a ch thng tr: ........................................................ ........................................
- S in thoi: ........................................................ ..................................................
2. a im xy dng: ........................................................ .....................................
- Ngun gc t: ........................................................ ..............................................
3. Ni dung xin php xy dng: ...........................................................................
- Din tch xy dng tng mt .......................m2 ..................................................
- Tng din tch sn ....................... m2 ...................................................................
- Chiu cao cng trnh .......................m; s tng .............................................
4. Cam kt:
Ti xin cam oan lm theo ng Giy php xy dng c cp, nu sai ti xin hon ton
chu trch nhim v b x l theo quy nh ca php lut.
........, ngy ........ thng ........nm........
Ngi lm n
(K ghi r h tn)

Danh Muc Mau Don, TKHC AP Dung Tai Cap Xa

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Danh Muc Mau Don, TKHC AP Dung Tai Cap Xa

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Ph lc I

DANH MC MU N, MU T KHAI HNH CHNH

Ngy, thng, nm sinh

CNG HA X HI CH NGHA VIT NAM

TM. Y BAN NHN DN

T KHAI NG K LI VIC NUI CON NUI

Ngy, thng, nm sinh

Quan h vi tr c nhn lm con nui

CNG HA X HI CH NGHA VIT NAM

CNG HO X HI CH NGHA VIT NAM

Bn cho con nui (4)

T KHAI NG K VIC NHN CHA, M

CNG HO X HI CH NGHA VIT NAM

CNG HO X HI CH NGHA VIT NAM

CNG HO X HI CH NGHA VIT NAM

kin ca ngi c thay i h, tn

II. Lnh vc chng thc

CNG HA X HI CH NGHA VIT NAM

PHIU YU CU CHNG THC

LI CHNG CA CH TCH/PH CH TCH

CNG HA X HI CH NGHA VIT NAM

LI CHNG CA CH TCH/PH CH TCH

CNG HA X HI CH NGHA VIT NAM

PHIU YU CU CUNG CP THNG TIN A CHNH

ngh Vn phng ng k quyn s dng t gi Phiu cung cp thng tin a

Quyn s: .................... TP/CC-SCT/HGD

CNG HA X HI CH NGHA VIT NAM

VN BN PHN CHIA TI SN THA K

LI CHNG CA CH TCH/PH CH TCH

CNG HO X HI CH NGHA VIT NAM

HP NG THU QUYN S DNG T

- Yu cu bn B chm dt ngay vic s dng t khng ng mc ch, hu hoi t

1.3. Ti thi im giao kt Hp ng ny:

LI CHNG CA CH TCH/PH CH TCH

CNG HA X HI CH NGHA VIT NAM

HP NG TH CHP QUYN S DNG T

2. Ngha v c bo m l (8): .....................................................................

- Yu cu bn B bi thng thit hi nu lm mt, h hng cc giy t v ti sn th

LI CHNG CA CH TCH/PH CH TCH

CNG HO X HI CH NGHA VIT NAM

HP NG TNG CHO QUYN S DNG T

1.1. Nhng thng tin v nhn thn, v tha t ghi trong Hp ng ny l ng s

LI CHNG CA CH TCH/PH CH TCH

CNG HO X HI CH NGHA VIT NAM

HP NG CHUYN NHNG QUYN S DNG T

Quyn s dng t ca bn A i vi tha t theo ......................................

Hai bn hiu r quyn, ngha v, li ch hp php ca mnh v hu qu php l ca

LI CHNG CA CH TCH/PH CH TCH

III. Lnh vc Thanh tra

CNG HA X HI CH NGHA VIT NAM

CNG HA X HI CH NGHA VIT NAM

N XIN CP GIY CHNG NHN

I. PHN K KHAI CA NGI S DNG T *

III. KT QU THM TRA CA VN PHNG NG K QUYN S DNG T

IV. KIN CA C QUAN TI NGUYN MI TRNG

Hng dn (tip theo): - im 2.5 ghi mc ch s dng t theo quyt nh giao t,

CNG HO X HI CH NGHA VIT NAM

XC NHN CA U BAN NHN DN X (PHNG, TH TRN)...

i vi h gia nh th ghi H ng/b v ghi h, tn, nm sinh, s giy CMND v ngy, ni cp

N XIN GIAO T NNG NGHIP

XC NHN CA U BAN NHN DN X (PHNG, TH TRN)...

i vi h gia nh th ghi H ng/b v ghi h, tn, nm sinh, s giy CMND v ngy, ni cp

N XIN THU T NNG NGHIP

XC NHN CA U BAN NHN DN X (PHNG, TH TRN)...