Nr.

__________/_______________

CERERE
i
DECLARAIE PE PROPRIE RSPUNDERE
pentru acordarea contravalorii n lei a trusoului pentru nou-nscui
Domnului Director General al DGASPC sector 6
Marius Lctu
I.

Subsemnata

Nume

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

Prenume

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

CNP

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

Adresa: Str

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

Bl.

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

|___|___|___|

Localitatea

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

Sector/Judet |___|___|___|___|___|___|___|___|___|___|___|___|___| Telefon

Act de identitate: |___|___|___| Seria: |___|___|___|

Nr.|___|___|___|

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

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___________/2009, la casieria DGASPC s.6 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
___________________________