CNG HO X HI CH NGHA VIT NAM

c lp - T do - Hnh phc
N XIN CP GIY CHNG NHN
QUYN S DNG T
Knh gi: UBND TNH TY NINH.

Mu s 04a/K
PHN GHI CA NGI NHN H S
Vo s tip nhn h s:
.....Gi.pht, ngy / /
Quyn s , S th t..
Ngi nhn h s
(K v ghi r h, tn)

I. PHN K KHAI CA NGI S DNG T *

(Xem hng dn cui n ny trc khi k khai; khng ty xo, sa cha trn n)

1. Ngi s dng t:
1.1 Tn ngi s dng t (Vit ch in hoa) : CNG TY TNHH CNG NGHIP FEDERAL BAY
1.2 a ch (h gia nh, c nhn ghi a ch ng k h khu, t chc ghi a ch tr s): p Phc c B,
x Phc ng, huyn G Du, tnh Ty Ninh.
2. Tha t xin cp giy chng nhn quyn s dng t
2.1 th t s: 259; 2.2. T bn s: 07;
2.3. a ch ti: p Phc c B, x Phc ng, huyn G Du, tnh Ty Ninh.
2.4. Din tch: 46.684,3 m2; Hnh thc s dng: + S dng chung: Khng m2
+ S dng ring: 46.684,3 m2
2.5. Mc ch s dng t: SKC ; 2.6. Thi hn s dng t: n ngy 14/04/2008
2.7. Ngun gc s dng t: Nh nc cho thu t tr tin hng nm.
3. Ti sn gn lin vi t:
3.1. Loi ti sn (ghi loi nh hoc loi cng trnh, loi cy):..................................................;
3.2. Din tch chim t (ghi xy dng ca nh, cng trnh hoc din tch c cy): .................m2;
3.3. Thng tin khc (i vi nh) gm : S tng : ... , Kt cu :.............................................. ;
i vi cn h chung c gm : Cn h s : ... , tng s : ... , din tch s dng :......... m2;
4. Nhng giy t np km theo :

.............................................................................................................................................
.................................................................................................................................................
5. Nhu cu ghi n i vi loi ngha v ti chnh: ...
Ti xin cam oan ni dung k khai trn n l ng.

....., ngy .... thng ... nm ......

Ngi vit n
(K v ghi r h tn, i vi t chc phi ng du)

Hng dn vit n: Tn ngi s dng t: 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;
trng hp quyn s dng t l ti sn chung ca hai 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; i vi tha t c nhiu c nhn, h gia nh, t chc cng s dng
(tr trng hp tha t c nh chung c) th ghi cc thng tin v ngi xin cp GCN v lp danh sch nhng ngi cng s dng t khc
theo Mu 04b/K km theo.

II. XC NHN CA U BAN NHN DN X, PHNG, TH TRN I VI C QUAN, T

CHC
- Ngun gc s dng t:.............................................................................................................;
- Thi im s dng t vo mc ch hin ti:...;
- Tnh trng tranh chp, khiu ni v t ai: ...............................................................................
- S ph hp vi quy hoch s dng t : ....................................................................................
Ngy.. thng. nm ..
Cn b a chnh
(K, ghi r h, tn)

Ngy.. thng. nm ..
TM. U ban nhn dn
Ch tch
(K tn, ng du)

III. KT QU THM TRA CA VN PHNG NG K QUYN S DNG T

..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
................................................................................................................................
..............
Ngy.. thng. nm ..
Ngy.. thng. nm ..
Ngi thm tra h s
Gim c Vn phng ng k quyn s dng t
(K, ghi r h, tn v chc v)
(K tn, ng du)

IV. KIN CA C QUAN TI NGUYN MI TRNG

(Thuc U ban nhn dn cp c thm quyn cp giy chng nhn quyn s dng t)
.......................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
Ngy ... thng ... nm ...
Th trng c quan
(K tn, ng du)

Hng dn (tip theo): - im 2.5 ghi mc ch s dng t theo quyt nh giao t, cho thu t, chuyn mc ch s dng
t ca c quan c thm quyn cp; trng hp khng c quyt nh giao t, cho thu t, chuyn mc ch s dng t th ghi
theo hin trng ang s dng;
- im 2.6 ghi thi hn s dng t theo quyt nh giao t, cho thu t ca c quan nh nc c thm quyn (nu c).Trng hp
s dng t c thi hn phi ghi r ngy thng nm ht hn s dng, nu s dng n nh lu di th ghi Lu di;
- im 2.7 ghi ngun gc s dng t nh sau: nu c Nh nc giao t c thu tin s dng t th ghi t giao c thu
tin, nu khng thu tin th ghi t giao khng thu tin, nu c Nh nc cho thu t th ghi t thu tr tin hng
nm hoc "t thu tr tin mt ln"; trng hp nhn chuyn i, nhn chuyn nhng, c tha k, c tng cho hoc
ngun gc khc th ghi c th ngun gc v thi im bt u s dng t.
- Trng hp ngi s dng t xin cp mt GCN chung cho nhiu tha t th ti cc im 2.1, 2.2, 2.3, 2.5, 2.6, 2.7 b trng
khng ghi; im 2.4 ghi tng din tch cc tha; im 4 ghi ch "- Danh sch cc tha t nng nghip cp cng mt GCN"