Mu bin bn s 01a

TN C QUAN CH QUN (1)

TN C QUAN LP BIN
BN
_________

CNG HA X HI CH NGHA VIT NAM

c lp - T do - Hnh phc
_______________________________________

(2), ngy thng nm

S: .......... /BB-VPHC

BIN BN VI PHM HNH CHNH

Trong lnh vc giao thng ng b
_____________

Hm nay, hi . gi . ngy . thng . nm .. ti: .....

Chng ti gm(3):
1. Cp bc/chc v: ....
2. Cp bc/chc v: ........
Vi s chng kin ca (4) (nu c):
1. ............... Ngh nghip/chc v: .....
a ch thng tr (tm tr): .......
S CMND: Ngy cp: /./ Ni cp: .............
2. .............. Ngh nghip/chc v: ......
a ch thng tr (tm tr): .......
S CMND: Ngy cp: /./ Ni cp: .............
Tin hnh lp bin bn VPHC trong lnh vc giao thng ng b
i
vi:
ng (b)/t chc (5): ....................................
a ch: ........................
Ngh nghip (lnh vc hot ng): . Nm sinh (6): .........
S CMND hoc h chiu/Quyt nh thnh lp hoc KKD: ....
Ngy cp: ../.../ Ni cp:...
c cc hnh vi vi phm hnh chnh nh sau (7): ........
.........
......
Cc hnh vi trn vi phm quy nh ca Ngh nh s 34/2010/N-CP ngy 02
thng 4 nm 2010 quy nh x pht vi phm hnh chnh trong lnh vc giao thng
ng b.
1

2
3
4
5
6
7

Nu bin bn do Ch tch y ban nhn dn cc cp lp th ch cn ghi y ban nhn dn tnh, thnh ph trc
thuc Trung ng, huyn, thnh ph thuc tnh, x m khng cn ghi c quan ch qun.
Ghi a danh hnh chnh cp tnh.
Ghi r h tn, chc v, n v cng tc ca ngi lp bin bn.
Ghi r h tn ngi lm chng. Nu c i din chnh quyn phi ghi r h tn, chc v.
Nu l t chc ghi r h tn, chc v ngi i din cho t chc vi phm.
i vi c nhn vi phm.
M t hnh vi vi phm, ghi r ni dung vi phm; nu iu khin phng tin phi ghi r nhn hiu, loi xe v
bin s ng k.

Ngi b thit hi/t chc b thit hi (8) (nu c):

H tn: .....
a ch: ........................
S CMND hoc h chiu/Quyt nh thnh lp hoc KKD: ....
Ngy cp: ../.../ Ni cp:...
kin trnh by ca ngi VPHC/i din t chc VPHC: ...
kin trnh by ca ngi chng kin (nu c): ........
kin trnh by ca ngi/i din t chc b thit hi (nu c): ..
Ngi c thm quyn lp bin bn yu cu ng (b)/t chc vi phm nh
ch ngay hnh vi vi phm.
Cc bin php ngn chn, bo m vic x pht (nu c):
...............................................(9)...........................................................................
Ngoi nhng tang vt, phng tin, giy t nu trn, chng ti khng tm gi
thm th g khc.
Yu cu ng (b)/i din t chc vi phm c mt lc ... gi ... ngy ....
thng . nm .. ti (10).............................. gii quyt v vic vi phm.
Sau khi c li bin bn, nhng ngi c mt ng v ni dung bin bn,
khng c kin g khc v cng k vo bin bn hoc c kin khc nh sau:
kin b sung khc (nu c) (11): ..............
Bin bn ny gm .. trang, c nhng ngi c mt cng k xc nhn vo
tng trang v c lp thnh .. bn, c ni dung v gi tr nh nhau, giao cho
ngi vi phm/i din t chc vi phm 01 bn, lu h s c quan x l vi phm
hnh chnh 01 bn v (12)/.
Ngi vi phm
hoc i din
t chc vi
phm
(K, ghi r
h tn)

Ngi b
thit hi
hoc i
din t
chc b
thit hi
(nu c)
(K, ghi r
h tn)

Ngi chng
kin (nu c)
(K, ghi r
h tn)

i din ca
chnh quyn c
s (nu c)
(k, ghi r
h tn)

Ngi lp
bin bn
(K, ghi r
h tn)

L do ngi vi phm/i din t chc vi phm khng k bin bn (13): ...

Nu l t chc ghi r h tn, chc v ngi i din cho t chc b thit hi.
Ghi c th bin php p dng. Nu tm gi tang vt, phng tin, giy t phi ghi c th tn, s lng, chng
loi, nhn hiu, xut x, tnh trng.
10
Ghi r a ch tr s ni c nhn, t chc vi phm phi c mt.
11
Nhng ngi c kin khc v ni dung bin bn phi t ghi kin ca mnh, l do c kin khc, k v
ghi r h tn.
12
Ghi c th nhng ngi, t chc c giao bin bn.
13
Ngi lp bin bn phi ghi r l do nhng ngi ny t chi khng k bin bn.
9

L do ngi b thit hi/i din t chc b thit hi khng k bin bn ( 14):

..

14

Ngi lp bin bn phi ghi r l do nhng ngi ny t chi khng k bin bn.

Mu bin bn s 01b

.... (15) ...

.
(16) ...
.

CNG HA X HI CH NGHA VIT NAM

c lp - T do - Hnh phc
_____________________________________

Quyn s: .....

_________

S: ........ /BB-VPHC

BIN BN VI PHM HNH CHNH

Trong lnh vc giao thng ng b
_____________

Hm nay, ngy . thng . nm .. ti: ......

Ti:Cp bc, chc v: .........
n v: .........
Tin hnh lp bin bn VPHC i vi ng (b)/t chc: ............
........... Sinh ngy: .. /. /.........
Ngh nghip (lnh vc hot ng): ..
S CMND hoc HC/Quyt nh thnh lp hoc KKD: ....
Ngy cp:../.../ Ni cp:........
Ni c tr (a ch ca t chc): ..................
Hi .. gi ngy .. /. /. Ti (a im): .
c hnh vi vi phm (nu iu khin xe th phi ghi r loi xe, bin s ng k):
........
..........
. quy nh ti Ngh nh s 34/2010/N-CP ngy 02 thng 4 nm 2010.
Chng c vi phm (trng hp phi c): ....
i din chnh quyn c s hoc 02 ngi chng kin (trng hp phi c):
1. . a ch (chc v):...
2. . a ch:...
kin ca ngi chng kin (nu c): .......
kin ca ngi (hoc i din t chc) vi phm: ...
Ngi (hoc i din t chc) b thit hi: .. a ch: .....
... v kin (nu c): ...
Cc bin php ngn chn, bo m vic x l vi phm (nu c): ......
.........
Ngoi nhng tang vt, phng tin, giy t nu trn, chng ti khng tm gi
g khc.
Yu cu ng (b)/i din t chc vi phm c mt lc . gi ... ngy ../.../...
ti .............................. gii quyt v vic vi phm.
Bin bn ny c li cho nhng ngi c tn nu trn nghe, khng ai c
kin g khc v cng k tn di y. Bin bn c lp thnh 02 bn, c ni dung
v gi tr nh nhau, 01 bn giao cho ngi vi phm hoc i din t chc vi phm;
01 bn lu h s c quan x l vi phm hnh chnh./.
Ngi (hoc i
din t chc)
vi phm
15
16

Ngi (hoc i
din t chc) b
thit hi (nu

Ngi chng kin Ngi lp bin bn

(nu c)
(K, ghi r h tn)
(K, ghi r h tn)

Tn c quan ch qun; nu bin bn do Ch tch UBND cc cp lp th khng cn ghi c quan ch qun.

Tn c quan lp bin bn.

2
(K, ghi r h tn)

c)
(K, ghi r h tn)

Mu bin bn s 02

TN C QUAN CH QUN (17)

TN C QUAN LP BIN
BN
_________

CNG HA X HI CH NGHA VIT NAM

c lp - T do - Hnh phc
_____________________________________

(18), ngy thng nm

S: ........ /BB-KPTVTV

BIN BN KHM PHNG TIN VN TI, VT

THEO TH TC HNH CHNH
_____________

Cn c iu 45, iu 48 ca Php lnh X l vi phm hnh chnh ngy 02

thng 7 nm 2002;
Cn c Ngh nh s 34/2010/N-CP ngy 02 thng 4 nm 2010 ca Chnh
ph quy nh x pht vi phm hnh chnh trong lnh vc giao thng ng b;
Hm nay, hi . gi ., ngy / .. /.. ti .............
Chng ti gm: (19)
1. Cp bc/chc v: .......
2. Cp bc/chc v: .......
Vi s chng kin ca: (20)
1. ng (b): . Ngh nghip: .................
a ch: ........................
S CMND/HC: Ngy cp: /./ Ni cp: ...........
2. ng (b): .. Ngh nghip: ................
a ch: ........................
S CMND/HC: Ngy cp: /./ Ni cp:........
Tin hnh khm phng tin vn ti, vt l: .......( 21)
.......
......................
V c cn c cho rng trong phng tin vn ti, vt ny c ct giu tang
vt vi phm hnh chnh.
Ch phng tin vn ti, vt (hoc ngi iu khin phng tin
vn ti): (22)
1. ......... Ngh nghip: .................
a ch: ............................
17

Nu ngi lp bin bn l Ch tch y ban nhn dn x, th trn th ch cn ghi y ban nhn dn x, th

trn m khng cn ghi c quan ch qun.
18
Ghi a danh hnh chnh cp tnh.
19
Ghi h tn, chc v, n v cng tc ca ngi lp bin bn.
20
H v tn ngi chng kin. Nu khng c ch phng tin vn ti, vt hoc ngi iu khin phng tin
vn ti th phi c 02 ngi chng kin.
21
Ghi r loi phng tin vn ti, vt, s bin kim sot (i vi phng tin).
22
Ghi r h tn ch phng tin vn ti, vt hoc ngi iu khin phng tin vn ti.

S CMND/HC: Ngy cp: /./ Ni cp: .......

2. ......... Ngh nghip: .................
a ch: ............................
S CMND/HC: Ngy cp: /./ Ni cp: .......
Phm vi khm: ...........
Nhng tang vt vi phm hnh chnh b pht hin gm:

S TT

Tn tang vt,
phng tin

S lng

Chng loi, nhn hiu,

xut x, tnh trng

Ghi ch

...........

......................................

..................

.............................................

.............

...........

......................................

..................

.............................................

.............

...........

......................................

..................

.............................................

.............

Vic khm phng tin vn ti, vt theo th tc hnh chnh kt thc vo

hi .. gi ...... ngy . thng . nm .............
Sau khi c li bin bn, nhng ngi c mt ng v ni dung bin bn,
khng c kin g khc v cng k vo bin bn hoc c kin khc nh sau:
kin b
.........

sung

khc

(nu

c)

( 23):

...

..........
Bin bn ny gm .. trang, c nhng ngi c mt cng k xc nhn
vo tng trang v c lp thnh bn, c ni dung v gi tr nh nhau, giao
cho ch phng tin vn ti, vt hoc ngi iu khin phng tin vn ti 01
bn, lu h s c quan x l vi phm hnh chnh 01 bn v ( 24)../.
Ngi quyt nh khm
( K, ghi r h tn)

Ch phng tin vn ti,

vt hoc ngi iu
khin phng tin

Ngi lp bin bn
(K, ghi r h tn)

( K, ghi r h tn)

23

Ngi chng kin

Ngi chng kin

Ngi tham gia khm

( K, ghi r h tn)

( K, ghi r h tn)

( K, ghi r h tn)

Nhng ngi c kin khc v ni dung bin bn phi t ghi kin ca mnh, l do c kin khc, k v
ghi r h tn.
24
Ghi c th nhng ngi, t chc c giao bin bn.

Mu bin bn s 03a

TN C QUAN CH QUN (25)

TN C QUAN LP BIN
BN
__________

CNG HA X HI CH NGHA VIT NAM

c lp - T do - Hnh phc
_____________________________________

(26), ngy thng nm

S: ........ /BB-TGTVPT

BIN BN TM GI TANG VT, PHNG TIN VI PHM HNH

CHNH

Trong lnh vc giao thng ng b

____________

Cn c iu 45, iu 46 ca Php lnh X l vi phm hnh chnh ngy 02

thng 7 nm 2002;
Cn c Ngh nh s 34/2010/N-CP ngy 02 thng 4 nm 2010 ca Chnh
ph quy nh x pht vi phm hnh chnh trong lnh vc giao thng ng b;
Cn c Quyt nh tm gi tang vt, phng tin vi phm hnh chnh s .........
ngy . thng . nm . do (27)... chc v .............................. k;
c c s xc minh thm tnh tit lm cn c quyt nh x l hoc ngn
chn ngay vi phm hnh chnh,
Hm nay, hi . gi . ngy . thng . nm ti ............
Chng ti gm: (28)
1. . Cp bc/chc v: ......
2. . Cp bc/chc v: ......
Ngi vi phm hnh chnh l:
ng
(b)/t
....................

chc

(29):

........

a ch: ........................
Ngh nghip (lnh vc hot ng): . Nm sinh ( 30): ...
......
S CMND hoc h chiu/Quyt nh thnh lp hoc KKD: ....
Ngy cp: ../.../ Ni cp: ......
Vi s chng kin ca (31) (nu c):
1. ng/b: Ngh nghip: ............
25

Nu bin bn do Ch tch y ban nhn dn cc cp lp th ch cn ghi y ban nhn dn tnh, thnh ph

trc thuc Trung ng, huyn, thnh ph thuc tnh, x m khng cn ghi c quan ch qun.
26
Ghi a danh hnh chnh cp tnh.
27
Ghi r h tn, chc v ca ngi k Quyt nh tm gi tang vt, phng tin vi phm hnh chnh.
28
H tn, chc v, n v cng tc ca ngi lp bin bn.
29
Nu l t chc th ghi r h tn, chc v ngi i din cho t chc vi phm.
30
i vi c nhn vi phm.
31
H tn ngi chng kin. Nu c i din chnh quyn c s phi ghi r h tn, chc v.

a ch: ........................
S CMND/HC: Ngy cp: /./ Ni cp: .......

2. ng/b: Ngh nghip: ............

a ch: ........................
S CMND/HC: Ngy cp: /./ Ni cp: .......
Tin hnh lp bin bn tm gi tang vt, phng tin vi
phm hnh chnh gm:
S
TT

Tn, nhn hiu, quy

cch, xut x tang
vt, phng tin

n v
tnh

S
lng

Tnh trng tang

vt, phng tin (32)

Ghi ch
(33)

..

Ngoi nhng tang vt, phng tin nu trn, chng ti khng tm gi thm
th g khc.
Sau khi c li bin bn, nhng ngi c mt ng v ni dung bin bn,
khng c kin g khc v cng k vo bin bn hoc c kin khc nh sau:
kin b sung khc (nu c) (34): ..............
..............
Bin bn ny gm .. trang, c nhng ngi c mt cng k xc nhn
vo tng trang v c lp thnh bn, c ni dung v gi tr nh nhau, giao
cho ngi vi phm/i din t chc vi phm 01 bn, lu h s c quan x l vi
phm 01 bn v (35) ../.
Ngi vi
phm
hoc i
din t
chc
vi phm

Ngi ra
quyt nh
tm gi
(K, ghi r
h tn)

Ngi chng
kin
(K, ghi r
h tn)

i din ca
chnh quyn
c s (36)
(k, ghi r
h tn)

Ngi lp
bin bn
(K, ghi r
h tn)

(K, ghi r
h tn)

32

Nu l phng tin ghi thm s ng k, nu l ngoi t th ghi r seri ca tng t.

Ghi r tang vt, phng tin c c nim phong khng, nu c nim phong th trn nim phong phi c
ch k ca ngi vi phm (hoc i din t chc vi phm).
34
Nhng ngi c kin khc v ni dung bin bn phi t ghi kin ca mnh, l do c kin khc, k v
ghi r h tn.
35
Ghi c th nhng ngi, t chc c giao bin bn.
36
Trong trng hp nim phong tang vt m ngi vi phm vng mt th phi c s tham gia v ch k ca
i din chnh quyn c s.
33

Mu bin bn s 03b

. (37)
.
. (38)
.

CNG HA X HI CH NGHA VIT NAM

c lp - T do - Hnh phc
________________________________________

Quyn s: ...

_______

S: ........ /BB-TGTVPT
BIN BN TM GI TANG VT, PHNG TIN VI PHM HNH
CHNH

Trong lnh vc giao thng ng b

__________

Cn c Php lnh X l vi phm hnh chnh ngy 02 thng 7 nm 2002;

Cn c Quyt nh tm gi tang vt, phng tin VPHC s . ngy ././
Hm nay, hi . gi . ngy . thng . nm ti ............
Ti: . Cp bc, chc v: ..............
n v: ....
Lp bin bn tm gi tang vt, phng tin vi phm hnh chnh i vi:
ng (b)/t chc: .............
Sinh ngy: ..... /... /...... Ngh nghip (lnh vc hot ng):
S CMND hoc HC/Quyt nh thnh lp hoc KKD: ....
Ngy cp: ../.../ Ni cp: ......
Ni c tr (hoc a ch ca t chc): .........................
S lng v tnh trng tang vt, phng tin tm gi
..........
.......
...........
...........
.......
Bin bn ny c li cho nhng ngi c tn nu trn nghe, khng ai c
kin g khc v cng k tn di y. Bin bn c lp thnh 03 bn, c ni dung
v gi tr nh nhau, 01 bn giao cho ngi vi phm hoc i din t chc vi phm,
01 bn giao cho ngi bo qun hoc i din t chc bo qun, 01 bn lu h s
c quan x l vi phm hnh chnh./.
Ngi (hoc i din t chc) vi phm

Ngi lp bin bn (39)

(K, ghi r h tn)

(K, ghi r h tn)

37

Tn c quan ch qun; nu bin bn do Ch tch y ban nhn dn cc cp lp th khng cn ghi c quan

ch qun.
38
Tn c quan lp bin bn.
39
Ngi lp bin bn l ngi ra Quyt nh tm gi tang vt, phng tin.

Mu bin bn s 04

TN C QUAN CH QUN (40)

TN C QUAN LP BIN
BN

CNG HA X HI CH NGHA VIT NAM

c lp - T do - Hnh phc
_____________________________________

________

(41), ngy thng nm

S: ........ /BB-KNCGTVPT
BIN BN KHM NI CT GIU TANG VT,
PHNG TIN VI PHM HNH CHNH
__________

Cn c iu 45, iu 49 ca Php lnh X l vi phm hnh chnh ngy 02

thng 7 nm 2002;
Cn c Ngh nh s 34/2010/N-CP ngy 02 thng 4 nm 2010 ca Chnh
ph quy nh x pht vi phm hnh chnh trong lnh vc giao thng ng b;
Cn c Quyt nh khm ni ct giu tang vt, phng tin vi phm hnh
chnh s .. ngy . thng .. nm .. do (42) chc v ..
k;
Hm nay, hi . gi ., ngy / .. /.. ti .............
Chng ti gm: (43)
1. Cp bc/chc v: .......
2. Cp bc/chc v: .......
Vi s chng kin ca: (44)
1. ng (b): .. Ngh nghip: ................
a ch: ........................
S CMND/HC: Ngy cp: /./ Ni cp: .......
2. ng (b): .. Ngh nghip: ................
a ch: ........................
S CMND/HC: Ngy cp: /./ Ni cp: .......
Tin
hnh
...............

khm

(45):

..

L ni ct giu tang vt, phng tin vi phm hnh chnh v lp bin bn v vic khm.
Ngi ch ni b khm l: (46)

40

Nu ngi lp bin bn l Ch tch y ban nhn dn x, th trn th ch cn ghi y ban nhn dn x, th

trn m khng cn ghi c quan ch qun.
41
Ghi a danh hnh chnh cp tnh.
42
Ghi r h tn, chc v ca ngi k Quyt nh khm ni ct giu tang vt, phng tin vi phm hnh chnh.
43
Ghi h tn, chc v, n v cng tc ca ngi lp bin bn.
44
H v tn nhng ngi chng kin. Nu c i din chnh quyn phi ghi r h tn, chc v.
45
Ghi r a ch ni khm.
46
Nu ch ni b khm vng mt th ghi r h tn ngi thnh nin trong gia nh.

(47):

ng
(b)/t
chc
..................

......

a ch: ../.....................
Ngh nghip (lnh vc hot ng): ..........
S CMND hoc h chiu/Quyt nh thnh lp hoc KKD: .
Ngy cp: ../.../ Ni cp: ...
Sau khi khm, chng ti thu gi nhng tang vt, phng tin vi phm hnh chnh gm:

S lng

Chng loi, nhn hiu,

xut x, tnh trng (48)

Ghi ch

...........

Tn tang vt,
phng tin b
tm gi
......................................

..................

.............................................

.............

...........

......................................

..................

.............................................

.............

S TT

(49)

Ngoi nhng tang vt, phng tin nu trn, chng ti khng tm gi thm th g khc.
Vic khm kt thc vo hi .. gi ...... ngy . thng . nm .............
Sau khi c li bin bn, nhng ngi c mt ng v ni dung bin bn,
khng c kin g khc v cng k vo bin bn hoc c kin khc nh sau:
kin b sung khc (nu c) (50): ............
............
Bin bn ny gm .. trang, c nhng ngi c mt cng k xc nhn vo
tng trang v c lp thnh bn, c ni dung v gi tr nh nhau, giao cho
ch ni b khm 01 bn, lu h s c quan x l vi phm hnh chnh 01 bn v ( 51)
../.
Ch ni b khm hoc
ngi thnh nin trong
gia nh

Ngi quyt nh
tm gi

Ngi lp bin bn
(K, ghi r h tn)

( K, ghi r h tn)

( K, ghi r h tn)

47

Ngi chng kin

i din chnh quyn

( K, ghi r h tn)

( K, ghi r h tn)

Nu ni b khm l ca t chc th ghi h tn, chc v ngi i din cho t chc.

Nu c phng tin phi ghi r bin kim sot.
49
Ghi r tang vt, phng tin c c nim phong khng, nu c nim phong th trn nim phong phi c ch
k ca ngi vi phm (hoc i din ca t chc vi phm), c s chng kin ca i din gia nh, i din
t chc hay i din chnh quyn khng, nu khng c phi ghi r c s chng kin ca ng (b).
50
Nhng ngi c kin khc v ni dung bin bn phi t ghi kin ca mnh, l do c kin khc, k v
ghi r h tn.
51
Ghi c th nhng ngi, t chc c giao bin bn.
48

Mu bin bn s 05

TN C QUAN CH QUN (52)

TN C QUAN LP BIN
BN

CNG HA X HI CH NGHA VIT NAM

c lp - T do - Hnh phc

________

_______________________________________

(53), ngy thng nm

S: ........ /BB-KN

BIN BN KHM NGI THEO TH TC HNH CHNH

_____________

Cn c iu 45, iu 47 Php lnh X l vi phm hnh chnh ngy 02 thng 7

nm 2002;
Cn c Ngh nh s 34/2010/N-CP ngy 02 thng 4 nm 2010 ca Chnh
ph quy nh x pht vi phm hnh chnh trong lnh vc giao thng ng b;
Cn c Quyt nh khm ngi theo th tc hnh chnh s ngy .
thng .. nm .. do (54) .. chc v ... k hoc
cn c (55);
Hm nay, hi . gi ., ngy / .. /.. ti .........
Chng ti gm: (56)
1.Cp bc/chc v: ......
2. Cp bc/chc v: ........
Vi s chng kin ca: (57)
1. ng (b): ..Ngh nghip: ............
a ch: ...............
S CMND/HC: Ngy cp: /./ Ni cp: ......
2. ng (b): .. Ngh nghip:
a ch: ........................
S CMND/HC: Ngy cp: /./Ni cp: .............
Tin hnh khm ngi v lp bin bn khm ngi i vi:
ng (b): ........... Tui: ...........
a ch: ....................
52

Nu ngi lp bin bn l Ch tch y ban nhn dn x, th trn th ch cn ghi y ban nhn dn x, th

trn m khng cn ghi c quan ch qun.
53
Ghi a danh hnh chnh cp tnh.
54
Ghi r h tn, chc v ca ngi k Quyt nh khm ngi theo th tc hnh chnh.
55
Nu ngi k Quyt nh khm khng phi l ngi c thm quyn quy nh ti iu 45 Php lnh X l vi
phm hnh chnh, th phi ghi r thm cn c cho rng nu khng tin hnh khm ngay th vt, ti liu,
phng tin vi phm hnh chnh c th b tu tn, tiu hy; ghi h tn, chc v ngi quyt nh khm
trong trng hp ny.
56
Ghi h tn, chc v, n v cng tc ca ngi lp bin bn.
57
H v tn ngi chng kin.

Ngh nghip: ...

S CMND/HC: Ngy cp: /./ Ni cp: ....
Sau khi khm ngi, chng ti thu c nhng vt, ti liu, phng tin vi
phm hnh chnh nh sau:
S TT
..........
..........

Tn vt, ti liu,
phng tin
.............................
.............................

S lng
..................
..................

Chng loi, nhn hiu,

xut x
...................................
...................................

Ghi ch
.............
.............

Vic khm ngi kt thc vo hi .. gi ...... ngy . thng . nm ............

Sau khi c li bin bn, nhng ngi c mt ng v ni dung bin bn,
khng c kin g khc v cng k vo bin bn hoc c kin khc nh sau:
kin b sung khc (nu c) (58): ......
.........
Bin bn ny gm .. trang, c nhng ngi c mt cng k xc nhn vo
tng trang v c lp thnh 03 bn, c ni dung v gi tr nh nhau, giao cho
ngi b khm 01 bn, lu h s c quan x l vi phm hnh chnh 01 bn v gi
cho (59)../.

58

Ngi b khm

Ngi tham gia khm

( K, ghi r h tn)

( K, ghi r h tn)

Ngi chng kin

Ngi chng kin

( K, ghi r h tn)

( K, ghi r h tn)

Ngi lp bin bn
(K, ghi r h tn)

Nhng ngi c kin khc v ni dung bin bn phi t ghi kin ca mnh, l do c kin khc, k v
ghi r h tn.
59
Nu ngi quyt nh khm khng phi l ngi c thm quyn quy nh ti iu 45 Php lnh X l vi
phm hnh chnh, th phi ghi r thm bin bn ny c gi bo co cho Th trng.

Mu quyt nh s 01a

TN C QUAN CH QUN (60)

TN C QUAN RA QUYT
NH
__________

CNG HA X HI CH NGHA VIT NAM

c lp - T do - Hnh phc
_______________________________________

(61), ngy thng nm

S: ........ /Q-XPHC

QUYT NH X PHT VI PHM HNH CHNH

Trong lnh vc giao thng ng b
___________

Cn c Php lnh X l vi phm hnh chnh ngy 02 thng 7 nm 2002;

Cn c Ngh nh s 34/2010/N-CP ngy 02 thng 4 nm 2010 ca Chnh ph
quy nh x pht vi phm hnh chnh trong lnh vc giao thng ng b;
Cn c Bin bn vi phm hnh chnh s: . /BB-VPHC do ( 62) .....lp
hi . gi . ngy thng . nm .. ti .......
Xt hnh vi vi phm hnh chnh do ng (b)/t chc: . thc
hin v cc tnh tit gim nh, tnh tit tng nng (nu c): ......
....
Ti
(63):
..

Cp

bc/chc

v:

n v: ...
QUYT NH:
iu 1. X pht vi phm hnh chnh i vi:
ng
(b)/t
chc
(64):
..............................................
a ch: ..............................
Ngh nghip (lnh vc hot ng): Nm sinh ( 65):

S CMND hoc h chiu/Quyt nh thnh lp hoc KKD: ... ..

Ngy cp: ../.../ Ni cp: ....
Vi cc hnh thc sau:
1. Pht tin i vi hnh vi vi phm quy nh ca Ngh nh
s 34/2010/N-CP ti:
- im ....... khon ... iu ........ Mc pht: ...............ng.
60

Nu Quyt nh x pht ca Ch tch y ban nhn dn cc cp th ch cn ghi y ban nhn dn tnh, thnh ph
trc thuc Trung ng, huyn, thnh ph thuc tnh, x m khng cn ghi c quan ch qun.
61
Ghi a danh hnh chnh cp tnh.
62
Ghi h, tn chc v ngi lp bin bn.
63
Ghi h, tn ngi ra Quyt nh x pht.
64
Nu l t chc ghi r h tn, chc v ngi i din cho t chc vi phm.
65
i vi c nhn vi phm.

- im ....... khon ... iu ........ Mc pht: ...............ng.

- ..................................................................................................................................
Tng cng tin pht l: ....................................... ng (Bng ch: ...
.
..)
2. Hnh thc x pht b sung (nu c): .
........
3. Cc bin php khc phc hu qu (nu c): ..........
........................................
iu 2. ng (b)/t chc c tn ti iu 1 phi nghim chnh chp hnh Quyt
nh x pht trong thi hn 10 (mi) ngy, k t ngy c giao Quyt nh x pht l
ngy .. thng .. nm , tr trng hp c hon chp hnh theo quy nh
ca php lut v (66): .....Qu thi hn nu trn, nu
khng t nguyn chp hnh th b cng ch thi hnh theo quy nh ca php lut.
S tin pht quy nh ti iu 1 phi c np vo ti khon s .......
ca Kho bc Nh nc (67) . trong vng 10 (mi) ngy, k t ngy
c giao Quyt nh x pht.
ng (b)/t chc c tn ti iu 1 c quyn khiu ni hoc khi kin i vi
Quyt nh x pht vi phm hnh chnh ny theo quy nh ca php lut.
iu 3. Quyt nh ny c hiu lc thi hnh k t ngy ( 68) / /...........
v c lp thnh 03 bn c ni dung v gi tr nh nhau, 01 bn giao cho ngi vi
phm hoc i din t chc vi phm, 01 bn giao cho Kho bc Nh nc ni thu tin
pht, 01 bn lu h s c quan x l vi phm hnh chnh.
Quyt nh ny gm . trang, c ng du gip lai gia cc trang./.
Quyt nh ny giao cho ngi
vi phm hoc i din t chc vi phm
lc . gi .. ngy ././

Ngi ra quyt nh
(K, ghi r h tn v ng du)

(Ngi nhn k, ghi r h tn)

66

Ghi r l do.
Ghi r tn, a ch ca Kho bc.
68
Ngy k Quyt nh hoc ngy do ngi c thm quyn x pht quyt nh.
67

.. (69)
.. (70)
__________

S: ........ /Q-XPHC

Mu quyt nh s 01b

CNG HA X HI CH NGHA VIT NAM

c lp - T do - Hnh phc
_______________________________________

Quyn s:

71

( ), ngy thng nm

QUYT NH X PHT VI PHM HNH CHNH

Trong lnh vc giao thng ng b
_____________

Cn c Php lnh X l vi phm hnh chnh ngy 02 thng 7 nm 2002;

Cn c Ngh nh s 34/2010/N-CP ngy 02 thng 4 nm 2010 ca Chnh
ph quy nh x pht vi phm hnh chnh trong lnh vc giao thng ng b;
Cn c Bin bn vi phm hnh chnh s: .. /BB-VPHC lp
ngy .././..... v cc tnh tit gim nh, tnh tit tng nng (nu c):
..........
Ti: .. Cp bc, chc v: .....
n v: .....
QUYT NH:
iu 1. X pht vi phm hnh chnh i vi: ng (b)/t chc: ...
.. Sinh ngy: ..... /. /..................
Ngh nghip (lnh vc hot ng): ..
S CMND hoc HC/Quyt nh thnh lp hoc KKD: ....
Ngy cp: ../.../ Ni cp: ......
Ni c tr (hoc a ch ca t chc): .........................
c hnh vi vi phm: ..
.quy nh ti im ..... khon ..... iu ...... Mc tin pht: ........
.quy nh ti im ..... khon ..... iu ...... Mc tin pht: ........
.quy nh ti im ..... khon ..... iu ...... Mc tin pht: ........
Hnh thc x pht hnh chnh: ....
Tng mc tin pht chung: (bng ch): .....
Hnh thc x pht b sung (nu c): ...
Bin php ngn chn, khc phc hu qu (nu c): ............
69

Tn c quan ch qun; nu Quyt nh x pht ca Ch tch y ban nhn dn cc cp th khng cn ghi c quan ch qun.
Tn c quan ra quyt nh.
71
Ghi a danh hnh chnh cp tnh.
70

iu 2. Trong thi hn 10 (mi) ngy, k t ngy c giao Quyt nh x

pht, ng (b) hoc t chc c tn ti iu 1 c trch nhin chp hnh Quyt nh
x pht ti: ..........., trng hp c quyt nh hon
chp hnh quyt nh pht tin th thc hin theo quyt nh . Qu thi hn nu
trn, nu khng t nguyn chp hnh th b cng ch thi hnh theo quy nh ca
php lut.
ng (b) hoc t chc c tn ti iu 1 c quyn khiu ni hoc khi kin i
vi Quyt nh x pht vi phm hnh chnh ny theo quy nh ca php lut.
iu 3. Quyt nh ny c hiu lc thi hnh k t ngy / /...........
v c lp thnh 03 bn c ni dung v gi tr nh nhau, 01 bn giao cho ngi vi
phm hoc i din t chc vi phm, 01 bn giao cho Kho bc Nh nc ni thu
tin pht, 01 bn lu h s c quan x l vi phm hnh chnh./.
Quyt nh ny giao cho ngi vi phm hoc i
din t chc vi phm lc . .. ngy ././
(Ngi nhn k, ghi r h tn)

Ngi ra quyt nh
(K, ghi r h tn v ng du)

Mu quyt nh s 02a

TN C QUAN CH QUN (72)

TN C QUAN RA QUYT
NH

CNG HA X HI CH NGHA VIT NAM

c lp - T do - Hnh phc

_________

(73), ngy thng nm

_____________________________________

S: ........ /Q-XPHC

QUYT NH X PHT VI PHM HNH CHNH

Trong lnh vc giao thng ng b
(Theo th tc n gin)
_________

Cn c Php lnh X l vi phm hnh chnh ngy 02 thng 7 nm 2002;

Cn c Ngh nh s 34/2010/N-CP ngy 02 thng 4 nm 2010 ca Chnh
ph quy nh x pht vi phm hnh chnh trong lnh vc giao thng ng b;
Xt hnh vi vi phm hnh chnh do (74) ...................
thc hin v cc tnh tit gim nh, tnh tit tng nng (nu c):
..;
Ti (75): .. Cp bc/chc v: .......
..
n v: .....................
QUYT NH:
iu 1. X pht vi phm hnh chnh bng hnh thc (76) ....... i vi:
ng (b)/t
.

chc

(77):

...

a ch: ........................
Ngh nghip (lnh vc hot ng): . Nm sinh
(78): .....
S CMND hoc h chiu/Quyt nh thnh lp hoc KKD: ....
Ngy cp: ../.../ Ni cp: ......
Tng cng mc tin pht (nu l hnh thc pht tin): ... ng.
(Ghi bng ch....)
L do: c hnh vi vi phm quy nh ca Ngh nh s 34/2010/N-CP ti:
72

Nu Quyt nh x pht ca Ch tch y ban nhn dn cc cp th ch cn ghi y ban nhn dn tnh,

thnh
ph trc thuc Trung ng, huyn, thnh ph thuc tnh, x m khng cn ghi c quan ch qun.
73
Ghi a danh hnh chnh cp tnh.
74
Ghi h tn ngi/i din t chc vi phm.
75
H v tn ngi ra Quyt nh x pht.
76
Nu x pht bng hnh thc cnh co th ghi cnh co, x pht bng hnh thc pht tin th ghi pht tin.
77
Ghi h tn ngi/i din t chc vi phm.
78
i vi c nhn vi phm.

- im ....... khon ... iu ........

ng.
- im ....... khon ... iu ........
a
im
xy
..

ra

vi

Mc pht: ( 79)...

Mc pht: ... ng.

phm:

(80)..

Cc bin php khc phc hu qu (nu c): ...................................................

..............................................................................................................................
iu 2. ng (b)/t chc c tn ti iu 1 phi nghim chnh chp hnh
Quyt nh x pht trong thi hn 10 (mi) ngy, k t ngy c giao Quyt nh
x pht l ngy . thng . nm ., tr trng hp c hon chp hnh theo
quy nh ca php lut v (81): .Qu
thi hn nu trn, nu khng t nguyn chp hnh th b cng ch thi hnh theo
quy nh ca php lut.
S tin pht quy nh ti iu 1 phi np ngay cho ngi ra Quyt nh x
pht v c nhn bin lai thu tin pht hoc np ti Kho bc Nh nc ( 82) .
trong vng 10 (mi) ngy, k t ngy c giao Quyt nh x pht.
ng (b)/t chc c tn ti iu 1 c quyn khiu ni hoc khi kin i vi
Quyt nh x pht vi phm hnh chnh ny theo quy nh ca php lut.
iu 3. Quyt nh ny c hiu lc thi hnh k t ngy k v c lp thnh 03
bn c ni dung v gi tr nh nhau, 01 bn giao cho ngi vi phm hoc i din t
chc vi phm, 01 bn giao cho Kho bc Nh nc ni thu tin pht, 01 bn lu h
s c quan x l vi phm hnh chnh.
Quyt nh ny gm . trang, c ng du gip lai gia cc trang./.
Ngi ra quyt nh
(K, ghi r h tn v ng du) (83)

79

Nu c nhiu hnh vi th ghi c th tng hnh vi vi phm.

Ghi r a im xy ra hnh vi vi phm hnh chnh.
81
Ghi r l do.
82
Ghi r tn, a ch Kho bc.
83
Trng hp ngi ra Quyt nh x pht khng c s dng con du th Quyt nh phi c ng du treo.
80

Mu quyt nh s 02b

. (84)
. (85)

CNG HA X HI CH NGHA VIT NAM

c lp - T do - Hnh phc

_______

_____________________________________

S: ........ /Q-XPHC

Quyn s:

86

( ), ngy thng nm

QUYT NH X PHT VI PHM HNH CHNH

Trong lnh vc giao thng ng b
(Theo th tc n gin)
_________

Cn c Php lnh X l vi phm hnh chnh ngy 02 thng 7 nm 2002;

Cn c Ngh nh s 34/2010/N-CP ngy 02 thng 4 nm 2010 ca Chnh ph
quy nh x pht vi phm hnh chnh trong lnh vc giao thng ng b;
Xt hnh vi vi phm hnh chnh do ng (b)/t chc: ....... thc
hin v cc tnh tit gim nh, tnh tit tng nng (nu c): ..
Ti: .. Cp bc, chc v: ............
n v: ...................
QUYT NH:
iu 1. X pht vi phm hnh chnh i vi: ng (b)/t chc: .......
Sinh ngy: ..... / .... / ......
Ngh nghip (lnh vc hot ng): ....
S CMND hoc HC/Quyt nh thnh lp hoc KKD: ..
Ngy cp: ../.../ Ni cp: ...
Ni c tr (hoc a ch ca t chc): ........................
Bng hnh thc x pht chnh (cnh co, pht tin): ... Pht tin: ....... ng
(Ghi bng ch....)
L do: Hi .. gii .. ngy ../ ./ Ti (a im): ..
c hnh vi vi phm (nu iu khin xe th phi ghi r loi xe, bin s ng k):
.
..... im . khon .. iu .. Mc tin pht ...
..... im . khon .. iu .. Mc tin pht ...
..... im . khon .. iu .. Mc tin pht ...
Bin php khc phc hu qu, bo m vic x pht (nu c): .................................
84

Tn c quan ch qun; nu Quyt nh x pht ca Ch tch y ban nhn dn cc cp th khng cn ghi c quan
ch qun.
85
Tn c quan ra quyt nh.
86
Ghi a danh hnh chnh cp tnh.

iu 2. ng (b) hoc t chc c tn ti iu 1 c trch nhim chp hnh Quyt

nh x pht; nu pht tin c th np tin pht ti ch hoc ti Kho bc Nh nc v
c nhn bin lai thu tin pht. Nu khng t nguyn chp hnh th b cng ch thi
hnh theo quy nh ca php lut.
ng (b) hoc t chc vi phm c quyn khiu ni hoc khi kin i vi Quyt
nh x pht vi phm hnh chnh ny theo quy nh ca php lut.
iu 3. Quyt nh ny c hiu lc thi hnh k t ngy k v c lp thnh 02 bn
c ni dung v gi tr nh nhau, 01 bn giao cho ngi vi phm hoc i din t chc vi
phm, 01 bn lu h s c quan x l vi phm hnh chnh./.
Ngi ra quyt nh
(K, ghi r h tn v ng du) (87)

87

Trng hp ngi ra Quyt nh x pht khng c s dng con du th Quyt nh phi c ng du treo.

Mu quyt nh s 03a

TN C QUAN CH QUN (88)

TN C QUAN RA QUYT
NH
__________

S: ........ /Q-TGTVPT

CNG HA X HI CH NGHA VIT NAM

c lp - T do - Hnh phc
____________________________________

(89), ngy thng nm

QUYT NH
Tm gi tang vt, phng tin vi phm hnh chnh
trong lnh vc giao thng ng b
___________

Cn c iu 45, iu 46 ca Php lnh X l vi phm hnh chnh ngy 02 thng 7

nm 2002;
Cn c Ngh nh s 34/2010/N-CP ngy 02 thng 4 nm 2010 ca Chnh ph
quy nh x pht vi phm hnh chnh trong lnh vc giao thng ng b;

(90)

................

Ti (91): Cp bc/chc v: .
n v : ..........
QUYT NH:
iu 1. Tm gi tang vt, phng tin vi phm hnh chnh ca:
ng (b)/t chc (92): .........
a ch: ......................
Ngh nghip (lnh vc hot ng): . Nm sinh ( 93): ...
....
S CMND hoc h chiu/Quyt nh thnh lp hoc KKD: ..
Ngy cp: ../.../ Ni cp: ..
L do: c hnh vi vi phm quy nh ca Ngh nh s 34/2010/N-CP ti:
im
.
......

88

khon

iu

..(94)...

Nu Quyt nh tm gi tang vt, phng tin ca Ch tch y ban nhn dn x, th trn th ch cn ghi y
ban nhn dn x, th trn m khng cn ghi c quan ch qun.
89
Ghi a danh hnh chnh cp tnh.
90
Ghi r l do tm gi tang vt, phng tin vi phm hnh chnh nh xc minh tnh tit lm cn c quyt nh
x l vi phm hnh chnh hoc ngn chn ngay vi phm hnh chnh. Nu ngi tm gi khng phi l ngi c
thm quyn quy nh ti iu 45 ca Php lnh X l vi phm hnh chnh, th phi ghi r thm cn c cho
rng nu khng tm gi ngay th tang vt, phng tin vi phm hnh chnh c th b tu tn, tiu hu.
91
H tn ngi ra Quyt nh tm gi.
92
Ghi h tn ngi/i din t chc vi phm.
93
i vi c nhn vi phm.
94
Nu c nhiu hnh vi th ghi c th tng hnh vi vi phm.

Cc tang vt, phng tin b tm gi gm (95): .

.
Vic tm gi tang vt, phng tin vi phm hnh chnh c lp bin bn (km
theo Quyt nh ny).
iu 2. Tang vt, phng tin nu trn c tm gi ti (96): ...
iu 3. Thi hn tm gi l . ngy, k t ngy //. n ht ngy //.
iu 4. ng (b)/t chc c tn ti iu 1 phi nghim chnh chp hnh Quyt nh
ny. Quyt nh ny c hiu lc thi hnh k t ngy .../ ..../. v c lp
thnh bn c ni dung v gi tr nh nhau, 01 bn giao cho ngi vi phm hoc i
din t chc vi phm thc hin, 01 bn giao cho ngi c trch nhim bo qun, 01 bn
gi ..(97)..., 01 bn lu h s c quan x l vi phm hnh chnh.
Quyt nh ny gm . trang, c ng du gip lai gia cc trang./.
kin ca Th trng ngi ra Quyt nh (98)

Ngi ra quyt nh
(K, ghi r h tn)

95

Ghi r tn, s lng, chng loi tang vt, phng tin b tm gi.
Ghi a ch ni tm gi tang vt, phng tin.
97
Trng hp ngi ra Quyt nh tm gi tang vt, phng tin vi phm hnh chnh khng phi l ngi c thm
quyn quy nh ti iu 45 Php lnh X l vi phm hnh chnh th Quyt nh ny phi c gi bo co
cho Th trng ca ngi ra Quyt nh tm gi.
98
Th trng ca ngi ra Quyt nh tm gi (trng hp ngi tm gi khng c thm quyn theo quy nh ti
iu 45 Php lnh X l vi phm hnh chnh) c kin v vic tm gi, ng hoc khng ng .
96

Mu quyt nh s 03b

.... (99) .
.... (100)

CNG HA X HI CH NGHA VIT NAM

c lp - T do - Hnh phc

________

S: ........ /Q-TGTVPT

_____________________________________

Quyn s:

101

( ), ngy thng nm

QUYT NH
Tm gi tang vt, phng tin vi phm hnh chnh
trong lnh vc giao thng ng b
___________

Cn c iu 45, iu 46 ca Php lnh X l vi phm hnh chnh ngy 02

thng 7 nm 2002;
Cn c Ngh nh s 34/2010/N-CP ngy 02 thng 4 nm 2010 ca Chnh
ph quy nh x pht vi phm hnh chnh trong lnh vc giao thng ng b;
Cn c Bin bn vi phm hnh chnh s. /BB-VPHC lp ngy ././..
Ti: Cp bc, chc v: ..
n v : ...........
QUYT NH:
iu 1. Tm gi tang vt, phng tin vi phm hnh chnh ca ng (b)/t
chc: ............. Sinh ngy: ../
../.
Ngh nghip (lnh vc hot ng): ..........
S CMND hoc HC/Quyt nh thnh lp hoc KKD: ....
Ngy cp: ../.../ Ni cp: ......
Ni c tr (hoc a ch ca t chc): ....
Cc tang vt, phng tin b tm gi gm (tn, s lng, chng loi):
.....
C bin bn tm gi tang vt, phng tin vi phm hnh chnh km theo.
iu 2. Tang vt, phng tin nu trn c tm gi ti ( 102): ..
...
99

Tn c quan ch qun; nu Quyt nh tm gi tang vt, phng tin ca Ch tch UBND x, th trn th
khng cn ghi c quan ch qun.
100
Tn c quan ra quyt nh.
101
Ghi a danh hnh chnh cp tnh.
102
Ghi a ch ni tm gi tang vt, phng tin.

......
iu 3. Thi hn tm gi l . ngy, k t ngy .. /.. /
iu 4. ng (b)/t chc c tn ti iu 1 phi nghim chnh chp hnh Quyt
nh ny. Quyt nh ny c hiu lc thi hnh k t ngy ../../.. v c lp
thnh bn c ni dung v gi tr nh nhau, 01 bn giao cho ngi vi phm hoc
i din t chc vi phm, 01 bn giao cho ngi c trch nhim bo qun, 01 bn lu
h s c quan x l vi phm hnh chnh, 01 bn gi (103)
...................................../.
kin ca
Th trng
ca ngi ra
quyt nh (104)

103

Quyt nh ny
giao cho ngi
(hoc i din t
chc) vi phm
(K, ghi r h tn)

Quyt nh ny
giao cho ngi (hoc
i din t chc) c
trch nhim
bo qun
(K, ghi r h tn)

Ngi ra
quyt nh
(K, ghi r h tn)

Trng hp ngi ra Quyt nh tm gi tang vt, phng tin vi phm hnh chnh khng phi l ngi
c thm quyn quy nh ti iu 45 Php lnh X l vi phm hnh chnh th Quyt nh ny phi c gi
bo co cho Th trng ca ngi ra Quyt nh tm gi.
104
Th trng ca ngi ra Quyt nh tm gi (trng hp ngi tm gi khng c thm quyn theo quy
nh ti iu 45 Php lnh X l vi phm hnh chnh) c kin v vic tm gi, ng hoc khng ng .

Mu quyt nh s 04

TN C QUAN CH QUN (105)

TN C QUAN RA QUYT
NH
__________

S: ........ /Q-KNCGTVPT

CNG HA X HI CH NGHA VIT NAM

c lp - T do - Hnh phc
_____________________________________

(106), ngy thng nm

QUYT NH
Khm ni ct giu tang vt, phng tin vi phm hnh
chnh
__________

Cn c iu 45, iu 49 ca Php lnh X l vi phm hnh chnh ngy 02 thng 7

nm 2002;
Cn c Ngh nh s 34/2010/N-CP ngy 02 thng 4 nm 2010 ca Chnh ph
quy nh x pht vi phm hnh chnh trong lnh vc giao thng ng b;
Xt
(107)...................
..
Ti (108): .. Cp bc/chc v: ............

n v: ...................
109

QUYT NH:
..

Khm
( ):
.
Ch
ni
b
khm
l:
ng
(b)/t
chc
(110):

a ch: ......................
Ngh nghip (lnh vc hot ng): ........
S CMND hoc h chiu/Quyt nh thnh lp hoc KKD: ..
Ngy cp: ../.../ Ni cp: ....
L do: .
(Vic khm ni ct giu tang vt, phng tin vi phm hnh chnh c lp bin
bn km theo Quyt nh ny).
Quyt nh ny c: ...
1. Giao cho ng (b)/i din t chc chp hnh
2. Gi: ...
Quyt nh ny gm trang, c ng du gip lai gia cc trang.
105

Nu Quyt nh khm ni ct giu tang vt, phng tin vi phm hnh chnh ca Ch tch y ban nhn dn
x, th trn th ch cn ghi y ban nhn dn x, th trn m khng cn ghi c quan ch qun.
106
Ghi a danh hnh chnh cp tnh.
107
Ghi r cn c cho rng ni b khm c ct giu tang vt, phng tin vi phm hnh chnh.
108
H v tn ngi ra Quyt nh khm ni ct giu tang vt, phng tin vi phm hnh chnh.
109
Ghi r a im b khm.
110

Nu khng c ngi ch ni b khm th ghi r ngi thnh nin trong gia nh h l ..

Ngi ra quyt nh
(K, ghi r h tn v ng du)

kin ng ca Ch tch y ban nhn dn cp huyn trc khi tin hnh khm
ni ct giu tang vt, phng tin l ni .
(K, ghi r h tn )

Mu quyt nh s 05

TN C QUAN CH QUN (111)

TN C QUAN RA QUYT
NH
________

S: ........ /Q-KN

CNG HA X HI CH NGHA VIT NAM

c lp - T do - Hnh phc
____________________________________

(112), ngy thng nm

QUYT NH
Khm ngi theo th tc hnh chnh
____________

Cn c iu 45, iu 47 ca Php lnh X l vi phm hnh chnh ngy 02

thng 7 nm 2002;
Cn c Ngh nh s 34/2010/N-CP ngy 02 thng 4 nm 2010 ca Chnh
ph quy nh x pht vi phm hnh chnh trong lnh vc giao thng ng b;
Xt
(113):
...
..
Ti
(114):

Cp
bc/chc
v:
...............
n v: .
QUYT NH:
Khm ngi ng (b): .......... tui: ..
a ch: ........................
Ngh nghip: ...
S CMND/HC: ... Ngy cp: ././ Ni cp: ..
Quyt nh khm ngi ny c thng bo cho ng (b) (115):
..
Vic khm ngi c ngi chng kin l ng (b) (116):
...
a ch: ........................
Ngh nghip: ...
S CMND/HC: ... Ngy cp: ././ Ni cp: ...
Quyt nh ny c gi cho:
1. ng (b): .. chp hnh;
2.
3.
Quyt nh ny gm: .. trang, c ng du gip lai gia cc trang./.
111

Nu Quyt nh khm ngi ca Ch tch y ban nhn dn x, th trn th ch cn ghi y ban nhn dn
x, th trn m khng cn ghi c quan ch qun.
112
Ghi a danh hnh chnh cp tnh.
113
Ghi r cn c khm ngi l ng (b) c ct giu trong ngi vt, ti liu, phng tin vi phm hnh chnh.
114
Ghi h tn ngi ra Quyt nh khm ngi.
115
Ghi h tn ngi b khm.
116
Ghi h tn ngi chng kin.

Ngi ra quyt nh
(K, ghi r h tn)

Mu quyt nh s 06

TN C QUAN CH QUN (117)

TN C QUAN RA QUYT
NH
__________

S: ........ /Q-TGN

CNG HA X HI CH NGHA VIT NAM

c lp - T do - Hnh phc
____________________________________

(118), ngy thng nm

QUYT NH
Tm gi ngi theo th tc hnh chnh
____________

Cn c iu 44, iu 45 ca Php lnh X l vi phm hnh chnh ngy 02

thng 7 nm 2002;
Cn c Ngh nh s 34/2010/N-CP ngy 02 thng 4 nm 2010 ca Chnh
ph quy nh x pht vi phm hnh chnh trong lnh vc giao thng ng b;
Xt thy cn phi p dng bin php tm gi ngi theo th tc hnh
chnh ( 119 ) ...............
Ti (120): Cp bc/chc v: .
n v : ..........
QUYT NH:
Tm gi ng (b):. Tui: .
a ch: ......................
Ngh nghip: .
S CMND/HC: ... Ngy cp: ././ Ni cp:
L do:
c hnh vi vi phm hnh chnh quy nh ti (121): im ... khon
. iu .. ca Ngh nh s .....................
Thi gian tm gi l: 12 gi k t thi im bt u gi l hi . gi
ngy thng nm
V l do (122): .. nn thi hn tm gi c ko di l .. gi.
Theo yu cu ca ng (b): .., vic tm gi c
thng bo cho gia nh, t chc, ni lm vic hoc hc tp l ( 123): ..
..
117

Nu Quyt nh tm gi ngi ca Ch tch y ban nhn dn x, th trn th ch cn ghi y ban nhn

dn x, th trn m khng cn ghi c quan ch qun.
118
Ghi a danh hnh chnh cp tnh.
119
Ghi r l do tm gi ngi nh: ngn chn, nh ch ngay hnh vi gy ri trt t cng cng, gy thng
tch cho ngi khc hoc thu thp, xc minh tnh tit quan trng lm cn c Quyt nh x l vi phm
hnh chnh.
120
H tn ngi ra Quyt nh tm gi ngi.
121
Nu c nhiu hnh vi th ghi c th tng hnh vi vi phm.
122
Nu thi hn tm gi ko di hn 12 gi phi ghi r l do vic ko di thi hn tm gi.
123
Ghi r tn, a ch ngi c thng bo.

V ng (b) . l ngi cha thnh nin v tm gi vo ban

m/thi hn tm gi trn 6 gi, vic tm gi c thng bo vo hi . gi .
ngy . thng . nm cho cha m/ngi gim h l: . a ch:
Quyt nh ny c giao cho:
1. ng (b): . chp hnh.
2. ..
Quyt nh ny gm . trang, c ng du gip lai gia cc trang./.
Ngi ra quyt nh
(K, ghi r h tn)

Mu quyt nh s 07

TN C QUAN CH QUN (124)

TN C QUAN RA QUYT
NH
________

S: ........ /Q-KPHQ

CNG HA X HI CH NGHA VIT NAM

c lp - T do - Hnh phc
_____________________________________

(125), ngy thng nm

QUYT NH
p dng cc bin php khc phc hu qu do vi phm
hnh chnh gy ra trong trng hp khng p dng x
pht
trong lnh vc giao thng ng b
__________

Cn c iu (126) Php lnh X l vi phm hnh chnh ngy 02 thng 7

nm 2002;
Cn c Ngh nh s 34/2010/N-CP ngy 02 thng 4 nm 2010 ca Chnh
ph quy nh x pht vi phm hnh chnh trong lnh vc giao thng ng b;
Cn c Bin bn vi phm hnh chnh ( 127) s. /BB-VPHC
do... lp hi gi ngy .. thng . nm
ti.....;
khc phc trit hu qu do vi phm hnh chnh gy ra;
Ti
(128):
..
....

Cp

bc/chc

v:

n v: ......
QUYT NH:
iu 1. p dng bin php khc phc hu qu do vi phm hnh chnh i vi:
ng
(b)/t
chc
.....................................................................................

(129):

a ch: .......................
Ngh nghip (lnh vc hot ng): . Nm sinh
( ): .....
130

124

Nu Quyt nh khc phc hu qu ca Ch tch y ban nhn dn cc cp th ch cn ghi y ban nhn dn

tnh,
thnh ph trc thuc Trung ng, huyn, thnh ph thuc tnh, x m khng cn ghi c quan ch qun.
125
Ghi a danh hnh chnh cp tnh.
126
Trong trng hp ht thi hiu x pht th ghi cn c vo iu 10, trong trng hp ht thi hn ra
Quyt
nh x pht th ghi cn c vo iu 56 ca Php lnh X l vi phm hnh chnh.
127
Nu c bin bn vi phm hnh chnh, ghi c th s k hiu, ngy lp, ngi lp bin bn.
128
H tn ngi ra Quyt nh p dng cc bin php khc phc hu qu.
129
Ghi h tn ngi/i din t chc vi phm.
130
i vi c nhn vi phm.

S CMND hoc h chiu/Quyt nh thnh lp hoc KKD: .

Ngy cp: ../.../ Ni cp: ...
L do: c hnh vi vi phm hnh chnh ( 131): ..................
..............
Quy nh ti im khon iu .. ca Ngh nh s 34/2010/N-CP.
Nhng tnh tit lin quan n vic gii quyt v vi phm (nu c): .
L do khng p dng hnh thc x pht ( 132): ........
..
Bin php khc phc hu qu bao gm (133): .
....
iu 2. ng (b)/t chc c tn ti iu 1 phi nghim chnh chp hnh
Quyt nh ny trong thi hn 10 (mi) ngy, k t ngy c giao Quyt nh l
ngy . thng .nm tr trng hp (134) .. Qu thi
hn nu trn, nu khng t nguyn chp hnh th b cng ch thi hnh theo quy
nh ca php lut.
ng (b)/t chc c tn ti iu 1 c quyn khiu ni hoc khi kin i vi
Quyt nh ny theo quy nh ca php lut.
iu 3. Quyt nh ny c hiu lc thi hnh k t ngy .. thng .. nm ....
( ).... v c lp thnh 02 bn c ni dung v gi tr nh nhau, 01 bn giao cho
ngi vi phm hoc i din t chc vi phm, 01 bn lu h s c quan x l vi
phm hnh chnh.
135

Quyt nh ny gm . trang, c ng du gip lai gia cc trang./.

Ngi ra quyt nh
(K, ghi r h tn v ng du)

131

Nu c nhiu hnh vi th ghi c th tng hnh vi.

Ghi r l do khng p dng hnh thc x pht vi phm hnh chnh.
133
Ghi c th tng bin php khc phc hu qu.
134
Ghi r l do.
132

135

Ngy k Quyt nh hoc ngy do ngi c thm quyn quyt nh.

TN C QUAN CH QUN (136)

TN C QUAN RA QUYT
NH
_________

Mu quyt nh s 08

CNG HA X HI CH NGHA VIT NAM

c lp - T do - Hnh phc
______________________________________

(137), ngy thng nm

S: ........ /Q-CC

QUYT NH
Cng ch thi hnh quyt nh x pht vi phm hnh
chnh
trong lnh vc giao thng ng b
______________

Cn c Php lnh X l vi phm hnh chnh ngy 02 thng 7 nm 2002;

bo m thi hnh Quyt nh x pht vi phm hnh chnh trong lnh vc
giao thng ng b s .. .. ngy /../ ca..
Ti
(138):

...............

Cp

bc/chc

v:

n v: ...
QUYT NH:
iu 1. p dng bin php cng ch thi hnh Quyt nh x pht vi phm
hnh chnh s ngy /../ ca.... v ..
i vi:
ng
(b)/t
......

chc

(139):

......

a ch: ........................
Ngh nghip (lnh vc hot ng): . Nm sinh
(140): .....
S CMND hoc h chiu/Quyt nh thnh lp hoc KKD: ....
Ngy cp: ../.../ Ni cp: ......

136

Nu Quyt nh cng ch ca Ch tch y ban nhn dn cc cp th ch cn ghi y ban nhn dn tnh,

thnh
ph trc thuc Trung ng, huyn, thnh ph thuc tnh, x m khng cn ghi c quan ch qun.
137
Ghi a danh hnh chnh cp tnh.
138
Ghi h tn ngi ra Quyt nh cng ch.
139
Ghi h tn ngi/i din t chc vi phm.
140
i vi c nhn vi phm.

Bin php cng ch (141): ......................

.....
iu 2. ng (b)/t chc c tn ti iu 1 phi nghim chnh chp hnh
Quyt nh ny v phi chu mi chi ph v vic t chc thc hin cc bin php
cng ch.
iu 3. Quyt nh ny c hiu lc thi hnh k t ngy // v
c lp thnh bn c ni dung v gi tr nh nhau, 01 bn giao cho ngi vi
phm hoc i din t chc vi phm thc hin, 01 bn gi cho .
(142), 01 bn gi cho . (143), 01 bn lu h s c
quan x l vi phm hnh chnh.
Quyt nh ny gm . trang, c ng du gip lai gia cc trang./.
Ngi ra quyt nh
(K, ghi r h tn v ng du)

141

Ghi c th bin php cng ch, s tin cng ch, hoc cc bin php khc phc phi thc hin.

142

Nu bin php cng ch l khu tr lng hoc mt phn thu nhp, khu tr tin t ti khon ti ngn
hng th Quyt nh c gi cho c quan, t chc ni c nhn lm vic hoc ngn hng phi hp thc hin.

143

Nu bin php cng ch l k bin ti sn hoc cc bin php cng ch khc thc hin tch thu
tang vt, phng tin c s dng vi phm hnh chnh, buc khi phc li tnh trng ban u b
thay i do vi phm hnh chnh gy ra hoc buc tho d cng trnh xy dng tri php, buc thc hin
cc bin php khc phc tnh trng nhim mi trng, buc a ra khi lnh th Vit Nam, buc ti xut
phng tin th Quyt nh c gi cho Ch tch y ban nhn dn cp x ni thc hin vic cng ch
phi hp thc hin.