CNG HO X HI CH NGHA VIT NAM

c lp - T do - Hnh phc

Mu s: 01/LPTB
(Ban hnh km theo Thng t
s 60/2007/TT-BTC ngy
14/6/2007 ca B Ti chnh)

T KHAI L PH TRC B NH, T

[01] Ngi np thu: .....................................................................................
[02] M s thu: .............................................................................................
[03] a ch: ...................................................................................................
[04] Qun/huyn: ................... [05] Tnh/Thnh ph: .....................................
[06] in thoi: ..................... [06] Fax: .................. [08] Email: ..................
C IM NH T:
1. t:
1.1 a ch tha t:
1.2.
1.3.
1.4.
1.5.

V tr (mt tin ng ph hay ng, hm):

Mc ch s dng t:
Din tch (m2):
Ngun gc nh t: (t c Nh nc giao, cho thu; t nhn chuyn
nhng; nhn tha k, hoc nhn tng, cho):
a) Tn t chc, c nhn chuyn giao QSD:
a ch ngi giao QSD:
b) Thi im lm giy t chuyn giao QSD ngy.......... thng....... nm............
1.6. Gi tr t thc t chuyn giao (nu c):
2. Nh:
2.1. Cp nh:
Loi nh:
2.2. Din tch nh (m2 sn xy dng):
2.3. Ngun gc nh:
a) T xy dng:
- Nm hon cng (hoc nm bt u s dng nh):
b) Mua, tha k, cho, tng:
- Thi im lm giy t chuyn giao nh ngy ............. thng ............
nm..............
2.4. Gi tr nh (ng):
3. Tr gi tr nh, t thc t nhn chuyn nhng, nhn tha k, nhn
tng cho (ng):
4. Ti sn thuc din khng phi np l ph trc b (l do):
5. Giy t c lin quan, gm:
Ti cam oan s liu khai trn l ng v chu trch nhim trc php lut v s
liu khai./
..........................., ngy......... thng........... nm..........
NGI NP THU hoc
I DIN HP PHP CA NGI NP THU
K tn, ng du (ghi r h tn v chc v)