Mu s 16/K

CNG HO X HI CH NGHA VIT NAM

c lp - T do - Hnh phc

N XIN TCH THA T, HP THA T

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)

I- K KHAI CA NGI S DNG T

(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 bn
a ch tha t
S pht hnh
t s
s
Giy chng nhn

S vo s cp giy
chng nhn

3. L do tch, hp tha
t...................................................................................................... .........................................
............................................................................................................
4. Giy t np km theo n ny gm c:
- 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);
.....................................................................................................................................
Ti xin cam oan ni dung k khai trn n l ng.
, ngy .... thng ... nm ......
Ngi vit n
(k, ghi r h tn)
II- KIN CA C QUAN TI NGUYN V MI TRNG

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

Ngy.. thng. nm ..
Ngi thm tra
(K, ghi r h tn, chc v)

Ngy.. thng. nm ..
Th trng c quan ti nguyn v mi trng
(K tn, ng du)

Hng dn vit n:
- n ny dng trong trng hp ngi s sng t xin tch mt tha t thnh nhiu tha t mi hoc xin hp
nhiu tha t thnh mt tha t;
- gi n: H gia nh, c nhn, cng ng dn c th gi U ban nhn dn cp huyn ni c t; t chc,
c s tn gio, t chc v c nhn nc ngoi, ngi Vit Nam nh c nc ngoi th gi U ban nhn dn
cp tnh ni c t;

- im 1 ghi tn v a ch ca ngi s dng t nh trn giy chng nhn quyn s dng t gm

cc thng tin nh sau: 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 cng s dng t;
trng hp quyn s dng t l ti sn chung ca c v 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;
- im 2 ghi cc thng tin v tha t nh trn giy chng nhn quyn s dng t;
- 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.