Verificat identitatea solicitantului

________________
Ofier de stare civil,
___________________________
L.S.

nregistrat

la

nr.

din

DOMNULE PRIMAR
Subsemnatul(a) _________________________________________________,
fiul(fiica)
lui
______________________________
i
al
______________________________,
domiciliat()
n
_______________________________, satul/str. __________________________ nr.
______,
ap.
_____,
judeul/sect.
_____________________
ara
____________________, posesor(oare) al(a) actului de identitate ____ seria ____ nr.
___________,
eliberat()
de
ctre
____________,
n
calitate
de
__________________________________________________________________,
V rog s binevoii a-mi elibera certificatul de NATERE privind pe
________________ ______________________________________________, n care
sens fac urmtoarele precizri:
- S-a nscut la data de ________________________ n
_________________
___________________________,
__________________________,
cu
numele
de
_____________________________________________________.

localitatea
judeul
familie

Vechiul certificat a fost _______________________________________ n

urmtoarele mprejurri:
(pierdut, furat, deteriorat, predat pentru anulare)
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
________________________
ANEXEZ PREZENTEI PROCURA SPECIAL N ORIGINAL/MPUTERNICIREA
AVOCAIAL N ORIGINAL
Nr. ________________ Din _________________
Data

SEMNTURA

________________________
________________________
C.N.P.-ul titularului care solicit certificatul

Eliberat certificat de :
Natere Seria ____ nr. _____________

Am primit certificatul

solicitat
Semntura,
Ofier de stare civil,
_____________________________
___________________