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Nr.

__________/_______________

CERERE
i
DECLARAIE PE PROPRIE RSPUNDERE
pentru acordarea contravalorii n lei a trusoului pentru nou-nscui
Domnului Director General al DGASPC ___________
________________________
I.

Subsemnata

Nume

|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|

Prenume

|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|

CNP

|___|___|___|___|___|___|___|___|___|___|___|___|___|

Adresa: Str

|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|

Bl.

|___|___|___| Sc . |___|___| Ap.

Sector/Judet

|___|___|___|

Localitatea

Nr.|___|___|___|

|___|___|___|___|___|___|___|___|___|___|___|

|___|___|___|___|___|___|___|___|___|___|___|___|___| Telefon

|___|___|___|___|___|___|___|___|___|___|

Act de identitate: |___|___|___| Seria: |___|___|___| Nr.:|___|___|___|___|___|___|___|___|___|


Eliberat de catre:

|___|___|___|___|___|___|___|___|___|___|

Avand calitatea de:


-

parinte natural

|___|

reprezentant legal al copilului

|___|

imputernicit

|___|

V rog s-mi aprobai cererea de acordare a contravalorii n lei a trusoului pentru nou-nscui
II.

Declar pe propria rspundere:


A.

Referitor la copilul pentru care solicit contravaloarea n lei a trusoului pentru nou-nscui

Nume/Prenume|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|

CNP:

|___|___|___|___|___|___|___|___|___|___|___|___|___|

Certificat de nastere: seria||___|___|Nr.|___|___|___|___|___|___|

B.

Declar ca nu am solicitat trusoul sau contravaloarea n lei a trusoului pentru nou-nscui in alt localitate

C.

Am luat la cunostin c urmeaz s m prezint n data _____ - ____ luna___________/20__, la casieria DGASPC
sector_____ cu actul de identitate, pentru a ridica contravaloarea n lei a trusoului pentru nou-nscui

Cunoscnd prevederile art 292.Cod Penal privind falsul in declaraii, declar pe propria rspundere c datele i informaiile
prezentate sunt reale
Data
____________________

Semnatura
___________________________

III.

DECLARAIE A CELUILALT PRINTE AL COPILULUI PENTRU CARE SE SOLICITA DREPTUL

I.

Subsemnatul

Nume

|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|

Prenume

|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|

CNP

|___|___|___|___|___|___|___|___|___|___|___|___|___|

Adresa: Str

|___|___|___|___|___|___|___|___|___|___|___|___|___|___|

Nr.|___|___|___|

Bl. |___|___|___| Sc. |___|___| Ap. |___|___|___| Localitatea |___|___|___|___|___|___|___|___|___|___|___|


Sector/Judet |___|___|___|___|___|___|___|___|___|___|___|
Act de identitate: |___|___|___| Seria: |___|___|___| Nr.:|___|___|___|___|___|___|___|___|___|
Eliberat de ctre:

|___|___|___|___|___|___|___|___|___|___|

Declar urmatoarele:
|___|

Am solicitat trusoul / contravaloarea in lei a trusoului nou-nscut

|___|

Nu am solicitat trusoul / contravaloarea in lei a trusoului nou-nscut

Cunoscnd prevederile art 292.Cod Penal privind falsul in declaraii, declar pe propria rspundere c datele i informaiile
prezentate sunt reale

Data
____________________

Semnatura
___________________________