CNG HO X HI CH NGHA VIT NAM

c lp - T do - Hnh phc
MU NG K NGI PH THUC GIM TR GIA CNH
[01] Ln u:

Mu s: 16/K-TNCN
(Ban hnh km theo Thng t
s 28/2011/TT-BTC ngy
28/02/2011 ca B Ti chnh)

[02] B sung ln th:

[03] H v tn c nhn c thu nhp: .....

[04] M s thu:
[05] Tn ca t chc, c nhn tr thu nhp:...........................................................................
[06] M s thu:
Stt

H v tn

Ngy sinh

M s thu

S CMND/
H chiu

[07]

[08]

[09]

[10]

[11]

Quan h vi
TNT
[12]

Thi im tnh
gim tr
(thng/nm)
[13]

1
2
3
...
...

Ti cam oan nhng ni dung k khai l ng v chu trch nhim trc php lut v nhng ni dung khai./.
Ngy thng nm ...
C NHN C THU NHP
(K v ghi r h tn)