CNG HA X HI CH NGHA VIT NAM

c lp T do Hnh phc
---oo0oo--N NGH
HNG CH MAI TNG PH THEO QUYT NH 290/2005Q-TTg
CA TH TNG CHNH PH

Knh gi:

- UBND..........................................................................................
- Phng Lao ng TB&XH ........................................................
- S Lao ng TB&XH...............................................................
H v tn ti l:......................................................Nm sinh:................................
Qu qun:................................................................................................................
Ni ng k h khu thng tr:............................................................................
Quan h vi i tng khai di y l:................................................................
H v tn i tng:............................................. B danh:.................................
Ngy, thng, nm sinh:...........................................................................................
Qu qun:................................................................................................................
Ni ng k h khu thng tr:............................................................................
T trn ngythng..nm..
Thuc i tng:.....................................................................................................
Ngy tham gia khng chin chng M cu nc: T ngy/../
n ngy././. Ti n v
Gia nh cha k khai hng ch mai tng ph cho ng (b)............................
................................................................................................ a phng no
Ngoi i tng trn, ng (b)................................................................................
khng thuc i tng hng chnh sch BHXH, chnh sch u i NCC.
Ti lm n ny, ngh c quan c thm quyn, xt cho ti c hng ch
mai tng ph theo Quyt nh s 290/2005/Q-TTg ngy 08/11/2005 ca Th tng
Chnh ph.
Ti cam oan li khai trn l ng, nu sai ti hon ton chu trch nhim trc
php lut./.
UBND x Vn Thng xc nhn:
ngy.thngnm 2013
ng (b):
NGI LM N
(K, ghi r h, tn)
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TM.UBND x