MU K KHAI TI SN, THU NHP

(Ban hnh km theo Ngh nh s 78/2013/N-CP ngy 17 thng 7 nm 2013 ca Chnh ph)

I. THNG TIN CHUNG

1. Ngi k khai ti sn, thu nhp
- H v tn: ............................................................................. Nm sinh: ................................
- Chc v/ chc danh cng tc: ...............................................................................................
- C quan/ n v cng tc: .....................................................................................................
- H khu thng tr: ..............................................................................................................
- Ch hin ti: .......................................................................................................................
2. V hoc chng ca ngi k khai ti sn thu nhp
- H v tn: ............................................................................. Nm sinh: ................................
- Chc v/ chc danh cng tc: ...............................................................................................
- C quan/ n v cng tc: .....................................................................................................
- H khu thng tr: ..............................................................................................................
- Ch hin ti: .......................................................................................................................
3. Con cha thnh nin ca ngi k khai ti sn thu nhp
a) Con th nht:
- H v tn: ..............................................................................................................................
- Ngy thng nm sinh: ............................................................................................................
- H khu thng tr: ..............................................................................................................
- Ch hin ti: .......................................................................................................................
b) Con th hai (tr ln): (k khai nh con th nht)
II. THNG TIN M T V TI SN
1. Nh , cng trnh xy dng: (Ngi k khai t m t cc loi nh, cng trnh xy dng khc do bn thn,
v hoc chng, con cha thnh nin s hu hoc s hu mt phn).

a) Nh :
- Nh th 1: (a ch ti: ........................................................................................................)
+ Loi nh: ...................................................................... Cp cng trnh: ...............................
+ Din tch xy dng: ..............................................................................................................
+ Gi tr: ..................................................................................................................................
+ Giy chng nhn quyn s hu: ...........................................................................................
+ Thng tin khc (nu c): ......................................................................................................
- Nh th 2 (tr ln): K khai tng t nh nh th nht.
b) Cng trnh xy dng khc:
- Cng trnh th 1: (a ch ti: ..............................................................................................)
+ Loi cng trnh: ............................................................ Cp cng trnh: ..............................
+ Din tch xy dng: ..............................................................................................................
+ Gi tr: ..................................................................................................................................
+ Giy chng nhn quyn s hu: ...........................................................................................
+ Thng tin khc (nu c): ......................................................................................................
- Cng trnh th 2 (tr ln): K khai tng t nh cng trnh th nht.
2. Quyn s dng t: (Ngi k khai t m t cc loi t do bn thn, v hoc chng. con cha thnh nin c
quyn s dng ton b hoc mt phn).

a) t :
- Mnh th nht: (Ghi theo tng l, khonh, khun vin).
+ a ch: .................................................................................................................................
+ Din tch: ..............................................................................................................................
+ Gi tr: ..................................................................................................................................

+ Giy chng nhn quyn s dng: .........................................................................................

+ Thng tin khc (nu c): ......................................................................................................
- Mnh th 2: (M t nh mnh th nht).
b) Cc loi t khc: (Ghi theo tng l, khonh, khun vin)
- Mnh th nht: (Ghi theo tng l, khonh, khun vin).
+ a ch: .................................................................................................................................
+ Din tch: ..............................................................................................................................
+ Gi tr: ..................................................................................................................................
+ Giy chng nhn quyn s dng: .........................................................................................
+ Thng tin khc (nu c): ......................................................................................................
- Mnh th 2: (M t nh mnh th nht).
3. Tin: Tin mt, tin cho vay, tin gi cc c nhn, t chc trong nc, nc ngoi.
....................................................................................................................................................
....................................................................................................................................................
4. Ti sn khc nc ngoi.
5. t, m t, xe my, tu thuyn v nhng ng sn khc m nh nc qun l (theo quy
nh ca php lut phi ng k s dng v c cp giy ng k) c gi tr t 50 triu ng
tr ln.
6. Kim loi qu, qu, c phiu, cc loi giy t c gi tr chuyn nhng khc c gi tr
t 50 triu ng tr ln.
7. Cc khon n phi tr c gi tr t 50 triu ng tr ln (nu c)
8. Tng thu nhp trong nm.
III. GII TRNH S BIN NG CA TI SN, THU NHP
Loi ti sn
1. Nh , cng trnh xy dng:
a) Nh :
b) Cng trnh xy dng khc:
2. Quyn s dng t:
a) t :
b) Cc loi t khc
3. Tin mt, tin cho vay, tin gi
cc c nhn, t chc trong nc,
nc ngoi.
4. Ti sn khc nc ngoi.
5. t, m t, xe my, tu thuyn v
nhng ng sn khc m nh nc
qun l c gi tr t 50 triu ng tr
ln.
6. Kim loi qu, qu, c phiu,
cc loi giy t c gi tr chuyn
nhng khc c gi tr t 50 triu
ng tr ln.
7. Cc khon n phi tr c gi tr t
50 triu ng tr ln (nu c)
8. Tng thu nhp trong nm.

Tng/gim

Ni dung gii trnh ngun gc ti

sn, thu nhp tng thm

(Ngi k khai t xc nh cc loi ti sn tng, gim trong k k khai v gii trnh s tng, gim ca ti sn
thuc s hu ca bn thn, v hoc chng, con cha thnh nin).

Ngy nhn bn k khai ti sn, thu nhp

Ngy ....... thng ....... nm .......
Ngi nhn bn k khai

Ngy hon thnh bn k khai ti sn, thu nhp

Ngy ....... thng ....... nm .......
Ngi k khai ti sn, thu nhp

(K, ghi r h tn, chc v/chc danh)

(K, ghi r h tn)

Ghi ch: Ngi nhn bn k khai, ngi k khai ti sn, thu nhp phi k trn tng trang ca bn k khai ti
sn, thu nhp.