CATRE,

CASA DE ASIGURARI DE SANATATE CLUJ

Subsemnatul ( a)_______________________ reprezentantul legal al

(Denumire, adresa, telefon;)
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
Prin prezenta cunoscand prevederile articolului 292 din CODUL PENAL
( sau articolul 474 din noul Cod penal) privind falsul in declaratii , declar pe
proprie raspundere , ca cele prezentate mai jos sunt conforme cu realitatea .
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________

Data
_________________

Semnatura si
stampila