Documente Academic
Documente Profesional
Documente Cultură
tineretului i sportului,
Daniel Petru Funeriu
Ministrul finanelor publice,
Gheorghe Ialomiianu
Bucureti, 19 ianuarie 2011.
Nr. 38.
ANEXA 1
NORME METODOLOGICE
de aplicare a prevederilor Legii nr. 277/2010 privind alocaia pentru susinerea
familiei
ART. 1
(1) Beneficiaz de alocaia pentru susinerea familiei, denumit n continuare
alocaie, prevzut de Legea nr. 277/2010 privind alocaia pentru susinerea
familiei, denumit n continuare lege, familiile ai cror membri sunt ceteni
romni care locuiesc n Romnia.
(2) Alocaia se acord i familiilor i persoanelor singure care nu au cetenie
romn, dac se afl n una dintre urmtoarele situaii:
a) sunt ceteni ai unui stat membru al Uniunii Europene, ai Spaiului Economic
European, ai Confederaiei Elveiene sau ai altor state, pe perioada n care au
domiciliul sau, dup caz, reedina n Romnia, n condiiile legii;
b) sunt ceteni strini sau apatrizi crora li s-a acordat, n condiiile legii, o
form de protecie;
c) sunt apatrizi care au domiciliul sau, dup caz, reedina n Romnia, n
condiiile legii.
ART. 2
(1) Beneficiaz de alocaie familiile care ndeplinesc condiiile prevzute la art.
2 din lege.
(2) n perioada n care unul dintre soi este detaat pe perioad determinat n
interes de serviciu ori efectueaz serviciul militar pe baz de voluntariat, condiia
de a locui mpreun se consider ndeplinit.
(3) Sunt considerai copii aflai n ntreinerea familiilor definite la art. 2 din
lege, copiii naturali ai soilor sau ai unuia dintre acetia ori, dup caz, ai persoanei
singure, copiii adoptai, copiii ncredinai n vederea adopiei, copiii aflai n
plasament sau n plasament n regim de urgen ori pentru care s-a instituit tutela n
(3) n cazul n care nu este eliberat livretul de familie sau situaia familiei nu este
evideniat n livretul de familie, reprezentantul familiei prezint, dup caz, n
copie certificat sau, dup caz, autentificat pentru conformitate cu originalul,
urmtoarele documente:
a) certificatele de natere ale copiilor aflai n ntreinerea familiilor definite la
art. 2 din lege;
b) certificatul de cstorie;
c) hotrrea judectoreasc de ncredinare n vederea adopiei, potrivit legii;
d) hotrrea judectoreasc de ncuviinare a adopiei, potrivit legii;
e) hotrrea judectoreasc sau, dup caz, hotrrea comisiei pentru protecia
copilului pentru msura plasamentului, potrivit legii;
f) decizia directorului general al direciei generale de asisten social i
protecia copilului sau, dup caz, hotrrea judectoreasc pentru msura
plasamentului n regim de urgen, potrivit legii;
g) hotrrea judectoreasc de instituire a tutelei sau, dup caz, dispoziia
autoritii tutelare, potrivit legii;
h) actul doveditor care atest calitatea de reprezentant legal al persoanei minore
lipsite de capacitate deplin de exerciiu al drepturilor civile, pentru situaia
prevzut la art. 12 alin. (3), respectiv printe, tutore, curator, alt persoan
desemnat reprezentant legal prin decizia directorului general al direciei generale
de asisten social i protecia copilului sau, dup caz, prin hotrre
judectoreasc;
i) hotrrea judectoreasc prin care soul/soia este declarat/declarat
disprut/disprut;
j) hotrrea judectoreasc prin care soul/soia este arestat/arestat preventiv pe
o perioad mai mare de 30 de zile sau execut o pedeaps privativ de libertate i
nu particip la ntreinerea copiilor;
k) dup caz, alte acte doveditoare privind componena familiei.
(4) Pentru situaiile prevzute la art. 1 alin. (2) nu se solicit livretul de familie.
Componena familiei, filiaia copiilor i situaia lor juridic fa de reprezentantul
legal se dovedesc cu documentele eliberate de autoritile din ara de origine,
traduse i legalizate, precum i cu alte documente eliberate de autoritile romne
competente.
ART. 7
(1) La stabilirea venitului mediu net lunar pe membru de familie se iau n
considerare toate veniturile pe care membrii acesteia le realizeaz sau, dup caz, leau realizat n luna anterioar solicitrii dreptului, aa cum sunt acestea prevzute la
art. 8 alin. (1) - (7) din Legea nr. 416/2001 privind venitul minim garantat, cu
modificrile i completrile ulterioare.
(5) Pentru familiile care au n ntreinere copii cu handicap grav sau accentuat,
de vrst colar i care nu frecventeaz o form legal de nvmnt, alocaia se
acord cu condiia prezentrii certificatului de ncadrare ntr-un grad de handicap i
a dovezilor prevzute la art. 8 alin. (2) din lege.
(6) n aplicarea art. 28 alin. (2) din lege, diminuarea cu 20% a cuantumului
alocaiei se calculeaz pentru un numr de 10 absene nemotivate i se menine
pn la nregistrarea unui numr de 20 de absene nemotivate pentru care se aplic
diminuarea cu 50%.
(7) n situaia n care mai muli copii nregistreaz absene nemotivate,
diminuarea prevzut la art. 28 alin. (2) din lege se aplic pentru fiecare copil n
parte n funcie de numrul de absene nemotivate nregistrate de acesta, de fiecare
dat raportnd diminuarea la cuantumul alocaiei.
(8) Cuantumul acordat n condiiile prevzute la alin. (7) se calculeaz ca
diferen ntre cuantumul alocaiei prevzut de lege, stabilit prin dispoziie a
primarului, i valoarea rezultat prin nsumarea diminurilor.
(9) Formula de calcul pentru determinarea cuantumului diminuat potrivit alin.
(8) este urmtoarea:
Exemplu:
Familie format din so i soie i 2 copii de vrst colar.
Cuantumul alocaie stabilit prin dispoziia primarului: 60 lei
Primul copil a nregistrat 10 absene colare nemotivate.
Al doilea copil a nregistrat 20 de absene colare nemotivate.
Calculul diminurii:
Pentru primul copil: 60 lei x 20% = 12 lei
Pentru al doilea copil: 60 lei x 50% = 30 lei
Diminuarea total pentru absenele nemotivate nregistrate: 12 lei + 30 lei = 42
lei
Cuantumul diminuat rezultat: 60 lei - 42 lei = 18 lei.
ART. 9
(1) n vederea soluionrii cererii pentru acordarea alocaiei, primarul dispune, n
mod obligatoriu, verificarea prin anchet social, la domiciliul sau, dup caz, la
reedina solicitantului, a situaiei ce rezult din datele nscrise n actele
doveditoare.
(2) n cazul familiilor prevzute la art. 3 alin. (2), verificarea prevzut la alin.
(1) se va efectua la locul indicat de solicitant, de ctre o comisie format din cel
puin dou persoane.
(3) Ancheta social se efectueaz, n termenul prevzut la art. 16 alin. (1) din
lege, de la data nregistrrii cererii, de ctre personalul serviciului public de
asisten social din subordinea consiliului local sau, dup caz, de ctre personalul
ART. 15
(1) Dreptul la alocaie, respectiv plata acesteia se suspend n luna urmtoare
celei n care se constat una dintre situaiile prevzute la art. 29 alin. (1) din lege.
(2) Reluarea plii drepturilor de alocaie suspendate se face dup cum urmeaz:
a) cu luna urmtoare ncetrii msurii plasamentului sau plasamentului n regim
de urgen ntr-un serviciu de tip rezidenial, n situaia revenirii n familia pentru
care s-a stabilit dreptul iniial la alocaie, pentru situaia prevzut la art. 29 alin.
(1) lit. a) din lege;
b) cu luna urmtoare celei n care, dup verificarea prevzut la art. 29 alin. (2)
din lege, primarul comunic ageniei teritoriale ndeplinirea de ctre beneficiari a
condiiilor de acordare, pentru situaiile prevzute la art. 29 alin. (1) lit. b) i c) din
lege;
c) cu luna urmtoare celei n care s-a primit evidena electronic prevzut la art.
12 alin. (1), pentru situaia prevzut la art. 29 alin. (1) lit. d) din lege.
(3) Plata alocaiei n condiiile prevzute la alin. (2) se face n cuantumul stabilit
prin dispoziia primarului sau, dup caz, n cuantumul diminuat conform art. 28
alin. (2) din lege.
(4) n situaia prevzut la art. 29 alin. (1) lit. a) din lege, n cazul n care
copilul/copiii pentru care s-a stabilit msura plasamentului sau a plasamentului n
regim de urgen ntr-un serviciu de tip rezidenial nu revine/revin n familia pentru
care s-a stabilit dreptul iniial la alocaie, dreptul nceteaz pentru familia n cauz.
ART. 16
(1) Modificarea cuantumului alocaiei i ncetarea dreptului n condiiile
prevzute la art. 24, 26, respectiv 30 din lege se fac prin dispoziie a primarului.
(2) Dispoziiile primarului prevzute la alin. (1) se transmit ageniei teritoriale,
pe baz de borderou, n termenul prevzut la art. 10 alin. (3). Modelul borderoului
este prevzut n anexa nr. 4.
(3) Pe baza dispoziiei primarului, directorul ageniei teritoriale emite decizia de
modificare a cuantumului, respectiv de ncetare a plii.
ART. 17
(1) Pentru situaiile n care numrul beneficiarilor este mai mare de 10, att
dispoziia primarului, ct i decizia directorului ageniei teritoriale pot fi emise
colectiv, comunicarea acestora fiind realizat individual.
(2) Modelul deciziilor emise de directorul ageniei teritoriale se stabilete prin
ordin al preedintelui Ageniei Naionale pentru Prestaii Sociale.
ART. 18
(1) Fondurile necesare pentru plata alocaiei, precum i a cheltuielilor de
transmitere se asigur din bugetul de stat, prin bugetul Ministerului Muncii,
Familiei i Proteciei Sociale.
CERERE
i
DECLARAIE PE PROPRIA RSPUNDERE
pentru acordarea unor drepturi de asisten social
Subsemnata(ul),
_____________________________________________________________________________
_
| A1. DATE PERSONALE ALE SOLICITANTULUI
|
| _
_
|
| |_| Dl.
|_| Dna.
|
|
|
| Nume
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
|
|
| Prenume |_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
|
|
|
| CNP |_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
|
|
_
_
|
|
_
|_| UE
|
|
| Cetenie |_|
Romn sau
_
> i anume (ara) ................
|
|
|_| Non UE _|
|
|
|
| Act identitate* |_|_|_| Seria |_|_| Nr. |_|_|_|_|_|_|
|
|
|
| eliberat de |_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| la date de
|__|__|__|__|__|__| |
|
(z z) (l l) (a a)
|
|
|
| (*) n cazul cetenilor romni se va Pentru ceteni strini sau
apatrizi: |
| specifica tipul de act de identitate: PST - permis de edere temporar
|
| BI - buletin de identitate
PSP - permis de edere permanent
|
| CI - carte de identitate
DI - document de identitate
|
| CIP - carte de identitate provizorie
CR - carte de reziden
|
| P - paaport
CR - carte de reziden permanent
|
|____________________________________________________________________________
__|
_____________________________________________________________________________
_
| A2. DATE DE CONTACT ALE SOLICITANTULUI
|
|
|
| Strada
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
|
|
| Nr. |_|_|_|_| Bl. |_|_|_|_|_| Sc. |_|_|_| Apart. |_|_|_|_| Sector |_|_|
|
|
|
| Localitatea |_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
|
|
|
| Jude |_|_|_|_|_|_|_|_|_|_|_|_|_|_| Telefon |_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
|
|
|
| Mobil |_|_|_|_|_|_|_|_|_|_|_|_|_|_| Fax |_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
|
|
|
| E-mail
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
|____________________________________________________________________________
__|
_____________________________________________________________________________
_
| A3. SOLICITANTUL ARE REEDINA (locul de edere obinuit) N AFARA
ROMNIEI:|
|
|
| /\
|
| \/ NU
|
|
|
| /\
|
| \/ DA, n localitatea ______________________ ara
_________________________ |
|____________________________________________________________________________
__|
_____________________________________________________________________________
_
| A4. STAREA CIVIL A SOLICITANTULUI
|
| _
_
_
|
| |_| Cstorit()
|_| Necstorit()
|_| Vduv()
|
| _
_
_
|
| |_| Divorat()
|_| Desprit n fapt
|_| Uniune consensual
|
|
|
| Altele ...........................................
|
|____________________________________________________________________________
__|
_____________________________________________________________________________
_
| A5. SITUAIA COLAR A SOLICITANTULUI
|
| _
_
_
_
|
| (_) Fr studii
(_) Generale
(_) Medii
(_) Superioare
|
|____________________________________________________________________________
__|
_____________________________________________________________________________
_
| B. DAC BENEFICIAZ DE UNELE DREPTURI DE ASISTEN SOCIAL
|
| _
_
|
| |_| NU |_| DA, din Romnia (se vor ataa actele doveditoare: mandat potal/
|
|
extras de cont/decizie/adeverin)
|
|
_
|
|
|_| DA, din alte ri (se vor ataa actele doveditoare: mandat
potal/|
|
extras de cont/decizie/adeverin)
|
|____________________________________________________________________________
__|
_____________________________________________________________________________
_
| C1. SITUAIA PROFESIONAL A SOLICITANTULUI
|
| _
_
_
_
_
|
|(_) Elev*
(_) Student* (_) Lucrtor agricol (_) Independent (_) Fr loc
|
|
de munc
|
| _
_
_
_
_
|
|(_) Salariat* (_) omer*
(_) Lucrtor
(_) Pensionar* (_)
Casnic() |
|
ocazional
|
| Altele ..........................................................
|
| * Se vor ataa adeverine, dup caz, de la unitatea colar, angajator,
talon|
| de pensie
|
|
_
_
|
|
|
| Strada
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
|
|
| Nr. |_|_|_|_| Bl. |_|_|_|_|_| Sc. |_|_|_| Apart. |_|_|_|_| Sector |_|_|
|
|
|
| Localitatea |_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
|
|
|
| Jude |_|_|_|_|_|_|_|_|_|_|_|_|_|_| Telefon |_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
|
|
|
| Mobil |_|_|_|_|_|_|_|_|_|_|_|_|_|_| Fax |_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
|
|
|
| E-mail
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
|____________________________________________________________________________
__|
_____________________________________________________________________________
_
| D3. PARTENERUL/PERSOANA NDREPTIT ARE REEDINA (locul de edere
|
| obinuit) N AFARA ROMNIEI:
|
| _
_
|
| |_| NU |_| DA, n localitatea
_____________________________________________ |
|
ara
____________________________________________________ |
|____________________________________________________________________________
__|
_____________________________________________________________________________
_
| D4. SITUAIA COLAR A PARTENERULUI/PERSOANEI NDREPTITE
|
| _
_
_
_
|
| (_) Fr studii
(_) Generale
(_) Medii
(_) Superioare
|
|____________________________________________________________________________
__|
_____________________________________________________________________________
_
| D5. PARTENERUL/PERSOANA NDREPTIT BENEFICIAZ DE UNELE DREPTURI DE
|
| ASISTEN SOCIAL
|
| _
_
|
| |_| NU |_| DA, din Romnia (se vor ataa actele doveditoare: mandat potal/
|
|
extras de cont/decizie/adeverin)
|
|
_
|
|
|_| DA, din alte ri (se vor ataa actele doveditoare: mandat
potal/|
|
extras de cont/decizie/adeverin)
|
|____________________________________________________________________________
__|
_____________________________________________________________________________
_
| D6. SITUAIA PROFESIONAL A PARTENERULUI/PERSOANEI NDREPTITE
|
| _
_
_
_
_
|
|(_) Elev*
(_) Student* (_) Lucrtor agricol (_) Independent (_) Fr loc
|
|
de munc
|
| _
_
_
_
_
|
|(_) Salariat* (_) omer*
(_) Lucrtor
(_) Pensionar* (_)
Casnic() |
|
ocazional
|
| Altele ..........................................................
|
| * Se vor ataa adeverine, dup caz, de la unitatea colar, angajator,
talon|
| de pensie
|
|
|
| D7. DAC PARTENERUL/PERSOANA NDREPTIT LUCREAZ N AFARA ROMNIEI?
|
| _
_
|
| |_| NU |_| DA
|
|____________________________________________________________________________
__|
_____________________________________________________________________________
_
| E1. COPIII FAMILIEI*
|
|
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
| 1. Numele i prenumele
|
|
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
|
|
| Cod numeric personal
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
|
|
| Act de identitate/act doveditor** |_|_|_| Seria |_|_|_| Nr.
|_|_|_|_|_|_|_| |
|
|
|
Unitatea colar
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
| Dac este elev nva la
|
|
Clasa |_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
|
|
|
| Dac beneficiaz de unele drepturi
Dac realizeaz
|
| de asisten social:
venituri din munc:
|
| _
_
|
| |_| NU
(se vor ataa acte
|_| NU
|
| _
doveditoare: mandat potal/
_
|
| |_| DA, din Romnia
extras de cont/decizie/
|_| DA
|
| _
adeverin)
|
| |_| DA, din alte ri
|
|____________________________________________________________________________
__|
_____________________________________________________________________________
_
|
|
|
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
| 2. Numele i prenumele
|
|
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
|
|
| Cod numeric personal
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
|
|
|
|
| Dac beneficiaz de unele drepturi
Dac realizeaz
|
| de asisten social:
venituri din munc:
|
| _
_
|
| |_| NU
(se vor ataa acte
|_| NU
|
| _
doveditoare: mandat potal/
_
|
| |_| DA, din Romnia
extras de cont/decizie/
|_| DA
|
| _
adeverin)
|
| |_| DA, din alte ri
|
|____________________________________________________________________________
__|
_____________________________________________________________________________
_
|
|
|
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
| 4. Numele i prenumele
|
|
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
|
|
| Cod numeric personal
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
|
|
| Act de identitate/act doveditor** |_|_|_| Seria |_|_|_| Nr.
|_|_|_|_|_|_|_| |
|
|
|
Unitatea colar
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
| Dac este elev nva la
|
|
Clasa |_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
|
|
|
| Dac beneficiaz de unele drepturi
Dac realizeaz
|
| de asisten social:
venituri din munc:
|
| _
_
|
| |_| NU
(se vor ataa acte
|_| NU
|
| _
doveditoare: mandat potal/
_
|
| |_| DA, din Romnia
extras de cont/decizie/
|_| DA
|
| _
adeverin)
|
| |_| DA, din alte ri
|
|____________________________________________________________________________
__|
(*) Se includ i copii care au mplinit vrsta de 18 ani i se afl n
ntreinerea familiei
_____________________________________________________________________________
_
| (**) n cazul cetenilor romni se va| Pentru cetenii strini sau
|
| specifica tipul de act de identitate: | apatrizi:
|
| - B.I. - buletin de identitate
| - P.S.T. - permis de edere
temporar|
| - C.I. - carte de identitate
| - P.S.P. - permis de edere
|
| - C.I.P. - carte de identitate
| permanent
|
| provizorie
| - D.I. - document de identitate
|
| - P - paaport
| - CR - carte de reziden
|
|
| - CRP - carte de reziden
permanent|
|_______________________________________|____________________________________
__|
| n cazul copiilor sub 14 ani sau care nu au act de identitate se vor
|
| specifica datele din certificatul de natere.
|
|____________________________________________________________________________
__|
| n toate cazurile de mai sus se vor ataa copii dup actele menionate
|
|____________________________________________________________________________
__|
_____________________________________________________________________________
_
| E2. COPIII FAMILIEI*
|
|
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
| 5. Numele i prenumele
|
|
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
|
|
|
Unitatea colar
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
| Dac este elev nva la
|
|
Clasa |_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
|
|
|
| Dac beneficiaz de unele drepturi
Dac realizeaz
|
| de asisten social:
venituri din munc:
|
| _
_
|
| |_| NU
(se vor ataa acte
|_| NU
|
| _
doveditoare: mandat potal/
_
|
| |_| DA, din Romnia
extras de cont/decizie/
|_| DA
|
| _
adeverin)
|
| |_| DA, din alte ri
|
|____________________________________________________________________________
__|
_____________________________________________________________________________
_
|
|
|
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
| 7. Numele i prenumele
|
|
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
|
|
| Cod numeric personal
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
|
|
| Act de identitate/act doveditor** |_|_|_| Seria |_|_|_| Nr.
|_|_|_|_|_|_|_| |
|
|
|
Unitatea colar
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
| Dac este elev nva la
|
|
Clasa |_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
|
|
|
| Dac beneficiaz de unele drepturi
Dac realizeaz
|
| de asisten social:
venituri din munc:
|
| _
_
|
| |_| NU
(se vor ataa acte
|_| NU
|
| _
doveditoare: mandat potal/
_
|
| |_| DA, din Romnia
extras de cont/decizie/
|_| DA
|
| _
adeverin)
|
| |_| DA, din alte ri
|
|____________________________________________________________________________
__|
_____________________________________________________________________________
_
|
|
|
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
| 8. Numele i prenumele
|
|
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
|
|
| Cod numeric personal
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
|
|
| Act de identitate/act doveditor** |_|_|_| Seria |_|_|_| Nr.
|_|_|_|_|_|_|_| |
|
|
|
Unitatea colar
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
| Dac este elev nva la
|
|
Clasa |_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
|
|
|
| Dac beneficiaz de unele drepturi
Dac realizeaz
|
| de asisten social:
venituri din munc:
|
| _
_
|
| |_| NU
(se vor ataa acte
|_| NU
|
| _
doveditoare: mandat potal/
_
|
| |_| DA, din Romnia
extras de cont/decizie/
|_| DA
|
| _
adeverin)
|
| |_| DA, din alte ri
|
|____________________________________________________________________________
__|
(*) Se includ i copii care au mplinit vrsta de 18 ani i se afl n
ntreinerea familiei
_____________________________________________________________________________
_
| (**) n cazul cetenilor romni se va| Pentru cetenii strini sau
|
| specifica tipul de act de identitate: | apatrizi:
|
| - B.I. - buletin de identitate
| - P.S.T. - permis de edere
temporar|
| - C.I. - carte de identitate
| - P.S.P. - permis de edere
|
| - C.I.P. - carte de identitate
| permanent
|
| provizorie
| - D.I. - document de identitate
|
| - P - paaport
| - CR - carte de reziden
|
|
| - CRP - carte de reziden
permanent|
|_______________________________________|____________________________________
__|
| n cazul copiilor sub 14 ani sau care nu au act de identitate se vor
|
| specifica datele din certificatul de natere.
|
|____________________________________________________________________________
__|
| n toate cazurile de mai sus se vor ataa copii dup actele menionate
|
|____________________________________________________________________________
__|
_____________________________________________________________________________
_
| F. STAREA LOCATIV A FAMILIEI/PERSOANEI NDREPTITE
|
|
____________________________________________________________________________
|
|| FAMILIA sau PERSOANA NDREPTIT gospodrete:
||
|| _
_
_
||
|| |_| singur
|_| mpreun cu alt(e)
|_| mpreun cu alt(e)
||
||
persoan(e) singur(e)
familie(i)
||
||___________________________________________________________________________
_||
|
____________________
|
| | Cas cu curte
| |
al |
| |__________________|_|
|
| | Cas fr curte | |
__________________ |
| |__________________|_|
||
| | Apartament la
| |
||
| | bloc
| |
|________________|_||
| |__________________|_|
||
| | Locuin social | |
||
| |__________________|_|
|________________|_||
| | Locuin de
| |
|
| | serviciu
| |
|
| |__________________|_|
|
| | Locuin de
| |
|
| | necesitate
| |
|
| |__________________|_|
|
| | Instituionalizat| |
__________________ |
| |__________________|_|
||
| | Nu are locuin | |
||
| |__________________|_|
||
|
|________________|_||
|
||
|
|________________|_||
|
||
|
||
|
||
|
|________________|_||
|
|
______________
_____________
Regimul juridic
|____________|_| |___________|_|
locuinei
| | |
| |
|____________|_| |___________|_|
| Nr. camere | | | Suprafaa | |
|
| | |
| | Alte situaii
| | |
| | Tipul de nclzire
| Energie termic|
| n sistem
| centralizat
| Gaze naturale
| Lemne, crbuni,|
| combustibili
| petrolieri
|
_
__________________________________________________________ |
|
| /\ | TIP A (construcia cu structura de rezisten din beton
||
|
| \/ |
armat, metal ori lemn sau cu perei exteriori din
||
| Tipul
|
|
piatr, crmid ars sau din orice alte
materiale||
| locuinei |
|
rezultate n urma unui tratament termic i/sau
||
|
<
|
chimic)
||
|
|
|__________________________________________________________||
|
| /\ | TIP B (construcia cu perei exteriori din crmid
||
|
| \/ |
nears sau din orice alte materiale nesupuse unui
||
|
|_
|
tratament termic i/sau chimic)
||
|
|__________________________________________________________||
|____________________________________________________________________________
__|
_____________________________________________________________________________
_
| G. FAMILIA/PERSOANA NDREPTIT DEINE N PROPRIETATE/FOLOSIN
|
|
____________________________________________________________________________
|
||
BUNURI IMOBILE
||
||___________________________________________________________________________
_||
|| 1 | Cldiri sau alte spaii locative n afara locuinei de domiciliu
|
||
||
| sau alte imobile aflate proprietate
|
||
||____|____________________________________________________________________|_
_||
||
BUNURI MOBILE
||
||___________________________________________________________________________
_||
|| 2 | Aparatur electronic*: camere video, amplificatoare audio,
|
||
||
| copiatoare.
|
||
||____|____________________________________________________________________|_
_||
|| 3 | Obiecte de valoare: tablouri i obiecte de art, obiecte
|
||
||
| ornamentale, bijuterii sau monezi din metale preioase, obiecte de |
||
||
| cristal i porelan de mare valoare, blnuri de valoare mare, n
|
||
||
| stare vandabil
|
||
||____|____________________________________________________________________|_
_||
|| MIJLOACE TRANSPORT*
||
||___________________________________________________________________________
_||
|| 4 | Autoturisme cu o vechime mai mic de 10 ani
|
||
||____|____________________________________________________________________|_
_||
|| 5 | Autoutilitare
|
||
||____|____________________________________________________________________|_
_||
|| 6 | Autocamioane cu sau fr remorci
|
||
||____|____________________________________________________________________|_
_||
|| 7 | alupe
|
||
||____|____________________________________________________________________|_
_||
|| 8 | Brci cu motor
|
||
||____|____________________________________________________________________|_
_||
|| 9 | Scutere de ap
|
||
||____|____________________________________________________________________|_
_||
|| 10 | Iahturi
|
||
||____|____________________________________________________________________|_
_||
|| 11 | Autobuze
|
||
||____|____________________________________________________________________|_
_||
|| 12 | Microbuze
|
||
||____|____________________________________________________________________|_
_||
|| UTILAJE AGRICOLE*
||
||___________________________________________________________________________
_||
|| 13 | Tractor
|
||
||____|____________________________________________________________________|_
_||
|| 14 | Combin autopropulsat
|
||
||____|____________________________________________________________________|_
_||
|| UTILAJE DE PRELUCRARE AGRICOL*
||
||___________________________________________________________________________
_||
|| 15 | Pres de ulei
|
||
||____|____________________________________________________________________|_
_||
|| 16 | Moar de cereale
|
||
||____|____________________________________________________________________|_
_||
|| UTILAJE DE PRELUCRAT LEMNUL*
||
||___________________________________________________________________________
_||
|| 17 | Gater
|
||
||____|____________________________________________________________________|_
_||
|| 18 | Alte utilaje acionate hidraulic, mecanic sau electric
|
||
||____|____________________________________________________________________|_
_||
|| 19 | Depozite bancare cu valoare de peste 3000 lei
|
||
||____|____________________________________________________________________|_
_||
||
TERENURI
||
||___________________________________________________________________________
_||
|| 20 | Terenuri intravilane, inclusiv cel pe care se afl locuina de
|
||
||
| domiciliu, cu suprafaa mai mare de 1000 mp n zona urban i
|
||
||
| 2000 mp n zona rural
|
||
||____|____________________________________________________________________|_
_||
|| 21 | Terenuri extravilane n zona colinar, de es i de munte cu
|
||
||
| potenial productiv (exploatabile) cu suprafa mai mare de 1,5 ha |
||
||
| pentru familiile cu 1 - 3 membri i 2 ha pentru familiile cu
|
||
||
| peste 3 membri
|
||
||____|____________________________________________________________________|_
_||
||
CATEGORII DE ANIMALE/PSRI
||
||___________________________________________________________________________
_||
|| 22 | peste 3 bovine
|
||
||____|____________________________________________________________________|_
_||
|| 23 | peste 5 porcine
|
||
||____|____________________________________________________________________|_
_||
|| 24 | peste 20 ovine
|
||
||____|____________________________________________________________________|_
_||
|| 25 | peste 2 cabaline
|
||
||____|____________________________________________________________________|_
_||
|| 26 | peste 50 capete de iepuri de cas
|
||
||____|____________________________________________________________________|_
_||
|| 27 | peste 100 capete de psri
|
||
||____|____________________________________________________________________|_
_||
|| 28 | peste 15 familii de albine
|
||
||____|____________________________________________________________________|_
_||
|| 29 | cresctorii a cror producie se comercializeaz
|
||
||____|____________________________________________________________________|_
_||
|____________________________________________________________________________
__|
(*) n stare de funcionare
_____________________________________________________________________________
_
| H. REFERITOR LA VENITURILE REALIZATE DE FAMILIE SAU PERSOANA NDREPTIT:
|
|
_
|
|
| _
|
|
| |_| singur
|
|
FAMILIA sau PERSOANA NDREPTIT
| _
|
|
gospodrete
< |_| mpreun cu alt(e)
|
|
|
persoan(e) singur(e)
|
|
| _
|
|
| |_| mpreun cu alt(e)
familie(i) |
|
|_
|
|____________________________________________________________________________
__|
_____________________________________________________________________________
_
| VENITURI PERMANENTE NETE REALIZATE DE FAMILIE N LUNA:
| |
|
|________________________________________________________________________|__|
__|
| Cod|
Categoria de venituri
| Acte
| Venitul
|
|
|
| doveditoare* | realizat** lei
|
|____|_______________________________________|_______________|_______________
__|
| VENITURI DIN ACTIVITI INDEPENDENTE
|
|____________________________________________________________________________
__|
| 1 | Venituri din profesii libere,
| adeverin
| | | | | |
|
|
| veniturile obinute din exercitarea
| eliberat de | | | | | |
|
|
| profesiilor medicale, de avocat,
| Administraia | | | | | |
|
|
| notar, auditor financiar, consultant | financiar
| | | | | |
|
|
| fiscal, expert contabil, contabil
|
| | | | | |
|
|
| autorizat, consultant de plasament n |
| | | | | |
|
|
| valori mobiliare, arhitect sau a altor|
| | | | | |
|
|
| profesii reglementate, desfurate n |
| | | | | |
|
|
| mod independent, in condiiile legii |
| | | | | |
|
|____|_______________________________________|
|__|__|__|__|__|__|
| 2 | Venituri comerciale provenite din
|
| | | | | |
|
|
| fapte de comer ale contribuabililor, |
| | | | | |
|
|
| din prestri de servicii, precum i
|
| | | | | |
|
|
| din practicarea unei meserii
|
| | | | | |
|
|____|_______________________________________|
|__|__|__|__|__|__|
| 3 | Veniturile din valorificarea sub orice|
| | | | | |
|
|
| form a drepturilor de proprietate
|
| | | | | |
|
|
| intelectual provin din brevete de
|
| | | | | |
|
|
| invenie, desene i modele, mostre,
|
| | | | | |
|
|
| mrci de fabric i de comer,
|
| | | | | |
|
|
| procedee tehnice, know-how, din
|
| | | | | |
|
|
| drepturi de autor i drepturi conexe |
| | | | | |
|
|
| dreptului de autor i altele asemenea |
| | | | | |
|
|____|_______________________________________|_______________|__|__|__|__|__|
__|
_____________________________________________________________________________
_
| SALARIUL I ALTE DREPTURI SALARIALE
|
|____________________________________________________________________________
__|
| 4 | Salariul obinut pe baz de contract | adeverin
| | | | | |
|
|
| de munc/raport de serviciu
| eliberat de | | | | | |
|
|____|_______________________________________| angajator
|__|__|__|__|__|__|
| 5 | Salariul asistentului personal al
|
| | | | | |
|
|
| persoanei cu handicap
|
| | | | | |
|
|____|_______________________________________|
|__|__|__|__|__|__|
| 6 | Salariul asistentului maternal
|
| | | | | |
|
|____|_______________________________________|
|__|__|__|__|__|__|
| 7 | Salariul ngrijitorului la domiciliu |
| | | | | |
|
|
| al persoanei vrstnice dependente
|
| | | | | |
|
|____|_______________________________________|_______________|__|__|__|__|__|
__|
| 8 | Venitul lunar realizat ca membru
| adeverin
| | | | | |
|
|
| asociat sau persoan autorizat s
| eliberat de | | | | | |
|
|
| desfoare o activitate independent | Administraia | | | | | |
|
|
|
| financiar
| | | | | |
|
|____|_______________________________________|_______________|__|__|__|__|__|
__|
| 9 | Indemnizaia de omaj i/sau venit
| mandat potal/| | | | | |
|
|
| lunar de completare
| extras de
| | | | | |
|
|
|
| cont/
| | | | | |
|
|____|_______________________________________|_______________|__|__|__|__|__|
__|
| 10 | indemnizaiile din activiti
| adeverin
| | | | | |
|
|
| desfurate ca urmare a unei funcii | eliberat de | | | | | |
|
|
| de demnitate public, stabilite
| Administraia | | | | | |
|
|
| potrivit legii
| financiar
| | | | | |
|
|____|_______________________________________|
|__|__|__|__|__|__|
| 11 | indemnizaii din activiti
|
| | | | | |
|
|
| desfurate ca urmare a unei funcii |
| | | | | |
|
|
| alese n cadrul persoanelor juridice |
| | | | | |
|
|
| fr scop patrimonial
|
| | | | | |
|
|____|_______________________________________|
|__|__|__|__|__|__|
| 12 | drepturile de sold lunar,
|
| | | | | |
|
|
| indemnizaiile, primele, premiile,
|
| | | | | |
|
|
| sporurile i alte drepturi ale
|
| | | | | |
|
|
| personalului militar, acordate
|
| | | | | |
|
|
| potrivit legii
|
| | | | | |
|
|____|_______________________________________|
|__|__|__|__|__|__|
| 13 | indemnizaia lunar brut, precum i |
| | | | | |
|
|
| suma din profitul net, cuvenite
|
| | | | | |
|
|
| administratorilor la companii/
|
| | | | | |
|
|
| societi naionale, societi
|
| | | | | |
|
|
| comerciale la care statul sau o
|
| | | | | |
|
|
| autoritate a administraiei publice
|
| | | | | |
|
|
| locale este acionar majoritar, precum|
| | | | | |
|
|
| i la regiile autonome
|
| | | | | |
|
|____|_______________________________________|
|__|__|__|__|__|__|
| 14 | remuneraia obinut de directori n |
| | | | | |
|
|
| baza unui contract de mandat conform |
| | | | | |
|
|
| prevederilor legii societilor
|
|
|
| comerciale
|
|
|____|_______________________________________|
|__|__|__|__|__|__|
| 15 | remuneraia primit de preedintele
|
|
|
| asociaiei de proprietari sau de alte |
|
|
| persoane, n baza contractului de
|
|
|
| mandat, potrivit legii privind
|
|
|
| nfiinarea, organizarea i
|
|
|
| funcionarea asociaiilor de
|
|
|
| proprietari
|
|
|____|_______________________________________|
|__|__|__|__|__|__|
| 16 | sumele primite de membrii fondatori ai|
|
|
| societilor comerciale constituite
|
|
|
| prin subscripie public
|
|
|____|_______________________________________|
|__|__|__|__|__|__|
| 17 | sumele primite de reprezentanii n
|
|
|
| adunarea general a acionarilor, n |
|
|
| consiliul de administraie, membrii
|
|
|
| directoratului i ai consiliului de
|
|
|
| supraveghere, precum i n comisia de |
|
|
| cenzori
|
|
|____|_______________________________________|
|__|__|__|__|__|__|
| 18 | sumele primite de reprezentanii n
|
|
|
| organisme tripartite, potrivit legii |
|
|____|_______________________________________|
|__|__|__|__|__|__|
| 19 | indemnizaia lunar a asociatului
|
|
|
| unic, la nivelul valorii nscrise n |
|
|
| declaraia de asigurri sociale
|
|
|____|_______________________________________|
|__|__|__|__|__|__|
| 20 | sumele acordate de organizaii
|
| | | | | |
|
|
| nonprofit i de alte entiti
|
| | | | | |
|
|
| nepltitoare de impozit pe profit,
|
| | | | | |
|
|
| peste limita de 2,5 ori nivelul legal |
| | | | | |
|
|
| stabilit pentru indemnizaia primit |
| | | | | |
|
|
| pe perioada delegrii i detarii n |
| | | | | |
|
|
| alt localitate, n ar i n
|
| | | | | |
|
|
| strintate, n interesul serviciului,|
| | | | | |
|
|
| pentru salariaii din instituiile
|
| | | | | |
|
|
| publice
|
| | | | | |
|
|____|_______________________________________|_______________|__|__|__|__|__|
__|
| 21 | indemnizaia administratorilor, precum| adeverin
| | | | | |
|
|
| i suma din profitul net cuvenite
| eliberat de | | | | | |
|
|
| administratorilor societilor
| Administraia | | | | | |
|
|
| comerciale potrivit actului
| financiar
| | | | | |
|
|
| constitutiv sau stabilite de adunarea |
| | | | | |
|
|
| general a acionarilor
|
| | | | | |
|
|____|_______________________________________|
|__|__|__|__|__|__|
| 22 | sume reprezentnd salarii sau
|
| | | | | |
|
|
| diferene de salarii stabilite n baza|
| | | | | |
|
|
| unor hotrri judectoreti rmase
|
| | | | | |
|
|
| definitive i irevocabile, precum i |
| | | | | |
|
|
| actualizarea acestora cu indicele de |
| | | | | |
|
|
| inflaie
|
| | | | | |
|
|____|_______________________________________|
|__|__|__|__|__|__|
| 23 | indemnizaiile lunare pltite conform |
| | | | | |
|
|
| legii de angajatori pe perioada de
|
| | | | | |
|
|
| neconcuren, stabilite conform
|
| | | | | |
|
|
| contractului individual de munc
|
| | | | | |
|
|____|_______________________________________|
|__|__|__|__|__|__|
| 24 | orice alte sume sau avantaje de natur|
| | | | | |
|
|
| salariat ori asimilate salariilor n |
| | | | | |
|
|
| vederea impunerii
|
| | | | | |
|
|____|_______________________________________|_______________|__|__|__|__|__|
__|
_____________________________________________________________________________
_
| VENITURI DIN CEDAREA FOLOSINEI BUNURILOR
|
|____________________________________________________________________________
__|
| 25 | veniturile, n bani i/sau n natur, | adeverin
| | | | | |
|
|
| provenind din cedarea folosinei
| eliberat de | | | | | |
|
|
| bunurilor mobile i imobile, obinute | Administraia | | | | | |
|
|
| de ctre proprietar, uzufructuar
| financiar
| | | | | |
|
|
| sau alt deintor legal, altele dect |
| | | | | |
|
|
| veniturile din activiti independente|
| | | | | |
|
|____|_______________________________________|_______________|__|__|__|__|__|
__|
_____________________________________________________________________________
_
| VENITURI DIN INVESTIII
|
|____________________________________________________________________________
__|
| 26 | dividende
| adeverin
| | | | | |
|
|____|_______________________________________| eliberat de | | | | | |
|
| 27 | venituri impozabile din dobnzi
| Administraia | | | | | |
|
|____|_______________________________________| financiar
| | | | | |
|
| 28 | ctiguri din transferul titlurilor de|
| | | | | |
|
|
| valoare
|
| | | | | |
|
|____|_______________________________________|
| | | | | |
|
|____|_______________________________________|_______________|__|__|__|__|__|
__|
| PENSII MILITARE
|
|____________________________________________________________________________
__|
| 37 | pensie de serviciu
| mandat potal/| | | | | |
|
|____|_______________________________________| extras de
| | | | | |
|
| 38 | pensia de invaliditate
| cont/decizie | | | | | |
|
|____|_______________________________________|
| | | | | |
|
| 39 | pensia de urma
|
| | | | | |
|
|____|_______________________________________|
| | | | | |
|
| 40 | pensia I.O.V.R.
|
| | | | | |
|
|____|_______________________________________|_______________|__|__|__|__|__|
__|
_____________________________________________________________________________
_
| INDEMNIZAII
|
|____________________________________________________________________________
__|
| 41 | Indemnizaia pt. persoanele care i-au| mandat potal/| | | | | |
|
|
| pierdut total sau parial capacitatea | extras de
| | | | | |
|
|
| de munc ca urmare a participrii la | cont/decizie | | | | | |
|
|
| revoluie i pt. urmaii acestora
|
| | | | | |
|
|____|_______________________________________|
|__|__|__|__|__|__|
| 42 | Indemnizaia de nsoitor pentru
|
| | | | | |
|
|
| pensionari gr. I invaliditate/
|
| | | | | |
|
|
| nevztori handicap grav
|
| | | | | |
|
|____|_______________________________________|_______________|__|__|__|__|__|
__|
| 43 | Indemnizaia pentru incapacitatea
| adeverin
| | | | | |
|
|
| temporar de munc
| eliberat de | | | | | |
|
|
|
| angajator
| | | | | |
|
|____|_______________________________________|_______________|__|__|__|__|__|
__|
| 44 | Indemnizaia lunar pentru activitatea|
| | | | | |
|
|
| de liber-profesionist a artitilor
|
| | | | | |
|
|
| interprei sau executani
|
| | | | | |
|
|____|_______________________________________|_______________|__|__|__|__|__|
__|
_____________________________________________________________________________
_
| INDEMNIZAII I STIMULENTE PENTRU CRETEREA COPILULUI
|
|____________________________________________________________________________
__|
| 45 | Indemnizaia pentru maternitate
| adeverin
| | | | | |
|
|
|
| eliberat de | | | | | |
|
|
|
| angajator
| | | | | |
|
|____|_______________________________________|_______________|__|__|__|__|__|
__|
| 46 | Indemnizaia pentru creterea
| mandat potal/| | | | | |
|
|
| copilului pn la vrsta de 1, 2 sau 3| extras de
| | | | | |
|
|
| ani
| cont/decizie | | | | | |
|
|____|_______________________________________|
| | | | | |
|
| 47 | Stimulent lunar/de inserie
|
| | | | | |
|
|____|_______________________________________|
| | | | | |
|
| 48 | Indemnizaia i ajutoare pentru
|
| | | | | |
|
|
| creterea copilului cu handicap
|
| | | | | |
|
|____|_______________________________________|_______________|__|__|__|__|__|
__|
_____________________________________________________________________________
_
| INDEMNIZAII CU CARACTER PERMANENT
|
|____________________________________________________________________________
__|
| 49 | Indemnizaia lunar acordat
| mandat potal/| | | | | |
|
|
| magistrailor nlturai din justiie | extras de
| | | | | |
|
|
| din considerente politice
| cont/decizie | | | | | |
|
|____|_______________________________________|
| | | | | |
|
| 50 | Indemnizaia lunar acordat
|
| | | | | |
|
|
| persoanelor persecutate din motive
|
| | | | | |
|
|
| politice sau etnice
|
| | | | | |
|
|____|_______________________________________|
| | | | | |
|
| 51 | Indemnizaia, sporul sau renta
|
| | | | | |
|
|
| acordat invalizilor, veteranilor i |
| | | | | |
|
|
| vduvelor de rzboi
|
| | | | | |
|
|____|_______________________________________|_______________|__|__|__|__|__|
__|
| 52 | Indemnizaia lunar pentru persoanele | mandat potal/| | | | | |
|
|
| care au efectuat stagiul militar n
| extras de
| | | | | |
|
|
| cadrul Direciei Generale a
| cont/decizie | | | | | |
|
|
| Serviciului Muncii n perioada 1950 - |
| | | | | |
|
|
| 1961
|
| | | | | |
|
|____|_______________________________________|
| | | | | |
|
| 53 | Indemnizaia lunar pentru pensionarii|
| | | | | |
|
|
| sistemului de pensii, membrii ai
|
| | | | | |
|
|
| uniunilor de creaie, legal
|
| | | | | |
|
|
| constituite i recunoscute ca persoane|
| | | | | |
|
|
| juridice de utilitate public
|
| | | | | |
|
|____|_______________________________________|
| | | | | |
|
| 54 | Indemnizaia lunar pentru persoanele |
| | | | | |
|
|
| cu handicap
|
| | | | | |
|
|____|_______________________________________|
| | | | | |
|
| 55 | Indemnizaia cuvenit revoluionarilor|
| | | | | |
|
|____|_______________________________________|
| | | | | |
|
| 56 | Indemnizaia de merit acordat n
|
| | | | | |
|
|
| temeiul Legii nr. 118/2002
|
| | | | | |
|
|____|_______________________________________|
| | | | | |
|
| 57 | Renta viager pentru sportivi
|
| | | | | |
|
|____|_______________________________________|_______________|__|__|__|__|__|
__|
_____________________________________________________________________________
_
| VENITURI DIN ACTIVITI AGRICOLE
|
|____________________________________________________________________________
__|
| 58 | Venituri din cultivarea i
| adeverin
| | | | | |
|
|
| valorificarea florilor, legumelor i | eliberat de | | | | | |
|
|
| zarzavaturilor, n sere i solarii
| Administraia | | | | | |
|
|
| special destinate acestor scopuri
| financiar
| | | | | |
|
|
| i/sau n sistem irigat
|
| | | | | |
|
|____|_______________________________________|
| | | | | |
|
| 59 | Venituri din cultivarea i
|
| | | | | |
|
|
| valorificarea arbutilor, plantelor
|
| | | | | |
|
|
| decorative i ciupercilor
|
| | | | | |
|
|____|_______________________________________|
| | | | | |
|
| 60 | Venituri din exploatarea pepinierelor |
| | | | | |
|
|
| viticole i pomicole i altele
|
| | | | | |
|
|
| asemenea
|
| | | | | |
|
|____|_______________________________________|
| | | | | |
|
| 61 | Venituri din valorificarea produselor |
| | | | | |
|
|
| agricole obinute dup recoltare, n |
| | | | | |
|
|
| stare natural, de pe terenurile
|
| | | | | |
|
|
| agricole proprietate privat sau luate|
| | | | | |
|
|
| n arend, ctre uniti specializate |
| | | | | |
|
|
| pentru colectare, uniti de procesare|
| | | | | |
|
|
| industrial sau ctre alte uniti,
|
| | | | | |
|
|
| pentru utilizare ca atare
|
| | | | | |
|
|____|_______________________________________|_______________|__|__|__|__|__|
__|
_____________________________________________________________________________
_
| VENITURI DIN PREMII I DIN JOCURI DE NOROC
|
|____________________________________________________________________________
__|
| 62 | Veniturile din premii ce cuprind
| adeverin
| | | | | |
|
|
| veniturile din concursuri
| eliberat de | | | | | |
|
|____|_______________________________________| Administraia | | | | | |
|
| 63 | Veniturile din jocuri de noroc ce
| financiar
| | | | | |
|
|
| cuprind ctigurile realizate ca
|
| | | | | |
|
|
| urmare a participrii la jocuri de
|
| | | | | |
|
|
| noroc, inclusiv cele de tip jack-pot |
| | | | | |
|
|____|_______________________________________|_______________|__|__|__|__|__|
__|
_____________________________________________________________________________
_
| VENITURI DIN TRANSFERUL PROPRIETILOR IMOBILIARE DIN PATRIMONIUL PERSONAL
I|
| AL DEZMEMBRMINTELOR ACESTUIA
|
|____________________________________________________________________________
__|
| 64 | Venituri din transferul dreptului de | adeverin
| | | | | |
|
|
| proprietate i al dezmembrmintelor
| eliberat de | | | | | |
|
|
| acestuia, altele dect cele cu titlu | Administraia | | | | | |
|
|
| de motenire
| financiar
| | | | | |
|
|____|_______________________________________|_______________|__|__|__|__|__|
__|
_____________________________________________________________________________
_
| VENITURI DIN ALTE SURSE
|
|____________________________________________________________________________
__|
| 65 | Prime de asigurri suportate de o
| adeverin
| | | | | |
|
|
| persoan fizic independent sau de
| eliberat de | | | | | |
|
|
| orice alt entitate, n cadrul unei
| Administraia | | | | | |
|
|
| activiti pentru o persoan fizic n| financiar
| | | | | |
|
|
| legtur cu care suportatorul nu are o|
| | | | | |
|
|
| relaie generatoare de venituri din
|
| | | | | |
|
|
| salarii
|
| | | | | |
|
|____|_______________________________________|
| | | | | |
|
| 66 | Ctiguri primite de la societile de|
| | | | | |
|
|
| asigurri, ca urmare a contractului de|
| | | | | |
|
|
| asigurare ncheiat ntre pri cu
|
| | | | | |
|
|
| ocazia tragerilor de amortizare
|
| | | | | |
|
|____|_______________________________________|
| | | | | |
|
| 67 | Venituri, sub forma diferenelor de
|
| | | | | |
|
|
| pre pentru anumite bunuri, servicii |
| | | | | |
|
|
| i alte drepturi, primite de
|
| | | | | |
|
|
| persoanele fizice pensionari, foti
|
| | | | | |
|
|
| salariai, potrivit clauzelor
|
| | | | | |
|
|
| contractului de munc sau n baza unor|
| | | | | |
|
|
| legi speciale
|
| | | | | |
|
|____|_______________________________________|
| | | | | |
|
| 68 | Venituri primite de persoanele fizice |
| | | | | |
|
|
| reprezentnd onorarii din activitatea |
| | | | | |
|
|
| de arbitraj comercial
|
| | | | | |
|
|____|_______________________________________|
| | | | | |
|
| 69 | Venituri din alte surse sunt orice
|
| | | | | |
|
|
| venituri identificate ca fiind
|
| | | | | |
|
|
| impozabile
|
| | | | | |
|
|____|_______________________________________|_______________|__|__|__|__|__|
__|
_____________________________________________________________________________
_
| VENITURI OBINUTE DIN STRINTATE
|
|____________________________________________________________________________
__|
|
| de munc n perioada efecturii unei | cont/decizie | | | | | |
|
|
| pedepse privative de libertate
|
| | | | | |
|
|____|_______________________________________|_______________|__|__|__|__|__|
__|
_____________________________________________________________________________
_
| ALTE SURSE DE VENIT
|
|____________________________________________________________________________
__|
| 77 | Depozite bancare
| adeverin
| | | | | |
|
|____|_______________________________________| eliberat de
|__|__|__|__|__|__|
| 78 | Rent viager agricol
| Administraia | | | | | |
|
|____|_______________________________________| financiar
|__|__|__|__|__|__|
| 79 | Alte venituri
|
| | | | | |
|
|____|_______________________________________|_______________|__|__|__|__|__|
__|
| 80 | Venituri poteniale obinute din
|
| | | | | |
|
|
| valorificarea unor bunuri mobile i
|
| | | | | |
|
|
| imobile (conform HCL)***
|
| | | | | |
|
|____|_______________________________________|_______________|__|__|__|__|__|
__|
_____________________________________________________________________________
_
| VENIT LUNAR TOTAL AL FAMILIEI
| | | | | |
|
|____________________________________________________________|__|__|__|__|__|
__|
_____________________________________________________________________________
_
| VENIT NET LUNAR PE MEMBRU DE FAMILIE
| | | | | |
|
|____________________________________________________________|__|__|__|__|__|
__|
_____________________________________________________________________________
_
| I. MODALITATEA DE PLAT A DREPTURILOR DE ASISTEN SOCIAL
|
|
_
|
| /
\ Mandat potal
|
| \ _ /
_
|
|
_
n
| Nume titular
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_||
| /
\ cont < cont
|
| \ _ / bancar | Numr cont
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_||
|
| deschis
|
|
| Deschis la
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_||
|
|_banca
|
|
_
|
| /
\ Casierie (numai pentru persoanele fr adpost)
|
| \ _ /
|
|____________________________________________________________________________
__|
_____________________________________________________________________________
_
| J. Declar pe propria rspundere c nu am solicitat dreptul la ajutor social
|
| sau alocaie pentru susinerea familiei de la alte primrii.
|
|
|
| K. Declar c m oblig s aduc la cunotina primarului orice modificare
|
| intervenit n componena familiei i a veniturilor realizate, inclusiv a
|
| bunurilor mobile i imobile deinute, precum i a informaiilor privitoare
la|
| domiciliu/reedin declarat, n termen de 15/10 zile de la data la care a
|
| intervenit modificarea.
|
|
|
| Prin semnarea prezentei, am luat la cunotin c cele declarate sunt
corecte|
| i complete, iar declararea necorespunztoare a adevrului se pedepsete
|
ANEXA 2 *1)
la normele metodologice
*1) Anexa nr. 2 este reprodus n facsimil.
_____________________________________________________________________________
_
|
CONSILIUL LOCAL
|
|
...........................................
|
|____________________________________________________________________________
__|
_____________________
| CERTIFICARE PRIMAR |
|
____
|
|
/
\
|
|
( L.S. )
|
|
\____/
|
|_____________________|
ANCHETA SOCIAL
pentru acordarea unor drepturi de asisten social
_____________________________________________________________________________
_
|
|
| Efectuat la data de |__|__|__|__|__|__| pentru acordarea
__________________ |
|
(z z) (l l) (a a)
|
|
|
| Urmare a cererii nregistrat sub nr. |_|_|_|_|_|_|_|
|
|
_
_
|
| la data de |__|__|__|__|__|__| a |_| Dlui. |_| Dnei.
|
|
(z z) (l l) (a a)
|
|
|
| A1. DATE PERSONALE ALE SOLICITANTULUI
|
|
|
| Nume
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
|
|
| Prenume |_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
|
|
|
| CNP |_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
|
|
_
_
|
|
_
|_| UE
|
|
| Cetenie |_|
Romn sau
_
> i anume (ara) ................
|
|
|_| Non UE _|
|
|
|
| Act identitate* |_|_|_| Seria |_|_| Nr. |_|_|_|_|_|_|
|
|
|
| Eliberat de |_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| la date de
|__|__|__|__|__|__| |
|
(z z) (l l) (a a)
|
|
|
| (*) n cazul cetenilor romni se va Pentru ceteni strini sau
apatrizi: |
| specifica tipul de act de identitate: PST - permis de edere temporar
|
| BI - buletin de identitate
PSP - permis de edere permanent
|
| CI - carte de identitate
DI - document de identitate
|
| CIP - carte de identitate provizorie
CR - carte de reziden
|
| P - paaport
CR - carte de reziden permanent
|
|____________________________________________________________________________
__|
_____________________________________________________________________________
_
| A2. DATE DE CONTACT ALE SOLICITANTULUI
|
|
|
| Strada
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
|
|
| Nr. |_|_|_|_| Bl. |_|_|_|_|_| Sc. |_|_|_| Apart. |_|_|_|_| Sector |_|_|
|
|
|
| Localitatea |_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
|
|
|
| Jude |_|_|_|_|_|_|_|_|_|_|_|_|_|_| Telefon |_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
|
|
|
| Mobil |_|_|_|_|_|_|_|_|_|_|_|_|_|_| Fax |_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
|
|
|
| E-mail
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
|____________________________________________________________________________
__|
_____________________________________________________________________________
_
| A3. SOLICITANTUL ARE REEDINA (locul de edere obinuit) N AFARA
ROMNIEI:|
|
|
| /\
|
| \/ NU
|
|
|
| /\
|
| \/ DA, n localitatea ______________________ ara
_________________________ |
|____________________________________________________________________________
__|
_____________________________________________________________________________
_
| A4. STAREA CIVIL A SOLICITANTULUI
|
| _
_
_
|
| |_| Cstorit()
|_| Necstorit()
|_| Vduv()
|
| _
_
_
|
| |_| Divorat()
|_| Desprit n fapt
|_| Uniune consensual
|
|
|
| Altele ...........................................
|
|____________________________________________________________________________
__|
_____________________________________________________________________________
_
| A5. SITUAIA COLAR A SOLICITANTULUI
|
| _
_
_
_
|
| (_) Fr studii
(_) Generale
(_) Medii
(_) Superioare
|
|____________________________________________________________________________
__|
_____________________________________________________________________________
_
| B. DAC BENEFICIAZ DE UNELE DREPTURI DE ASISTEN SOCIAL
|
| _
_
|
| |_| NU |_| DA, din Romnia (se vor ataa actele doveditoare: mandat potal/
|
|
extras de cont/decizie/adeverin)
|
|
_
|
|
|_| DA, din alte ri (se vor ataa actele doveditoare: mandat
potal/|
|
extras de cont/decizie/adeverin)
|
|____________________________________________________________________________
__|
_____________________________________________________________________________
_
| C1. SITUAIA PROFESIONAL A SOLICITANTULUI
|
| _
_
_
_
_
|
|(_) Elev*
(_) Student* (_) Lucrtor agricol (_) Independent (_) Fr loc
|
|
de munc
|
| _
_
_
_
_
|
|(_) Salariat* (_) omer*
(_) Lucrtor
(_) Pensionar* (_)
Casnic() |
|
ocazional
|
| Altele ..........................................................
|
| * Se vor ataa adeverine, dup caz, de la unitatea colar, angajator,
talon|
| de pensie
|
|
_
_
|
| C2. DAC LUCREAZ N AFARA ROMNIEI?
|_| NU
|_| DA
|
|____________________________________________________________________________
__|
_
_
n calitate de reprezentant
|_| familiei
|_| persoanei
ndreptite
legal al
n numele creia se
face cererea
_____________________________________________________________________________
_
| D1. DATE PERSONALE ALE PARTENERULUI/PERSOANEI NDREPTITE
|
|
|
| Nume
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
|
|
| Prenume |_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
|
|
|
| CNP |_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
|
|
_
_
|
|
_
|_| UE
|
|
| Cetenie |_|
Romn sau
_
> i anume (ara) ................
|
|
|_| Non UE _|
|
|
|
| Act identitate* |_|_|_| Seria |_|_| Nr. |_|_|_|_|_|_|
|
|
|
| eliberat de |_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| la date de
|__|__|__|__|__|__| |
|
(z z) (l l) (a a)
|
|____________________________________________________________________________
__|
_____________________________________________________________________________
_
| D2. DATE DE CONTACT ALE PARTENERULUI/PERSOANEI NDREPTITE
|
|
|
| Strada
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
|
|
| Nr. |_|_|_|_| Bl. |_|_|_|_|_| Sc. |_|_|_| Apart. |_|_|_|_| Sector |_|_|
|
|
|
| Localitatea |_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
|
|
|
| Jude |_|_|_|_|_|_|_|_|_|_|_|_|_|_| Telefon |_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
|
|
|
| Mobil |_|_|_|_|_|_|_|_|_|_|_|_|_|_| Fax
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
|
|
|
| E-mail
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
|____________________________________________________________________________
__|
_____________________________________________________________________________
_
| D3. PARTENERUL/PERSOANA NDREPTIT ARE REEDINA (locul de edere
|
| obinuit) N AFARA ROMNIEI:
|
| _
_
|
| |_| NU
|_| DA,
n localitatea _________________________________________
|
|
ara ___________________________________________________
|
|____________________________________________________________________________
__|
_____________________________________________________________________________
_
| D4. SITUAIA COLAR A PARTENERULUI/PERSOANEI NDREPTITE
|
| _
_
_
_
|
| (_) Fr studii
(_) Generale
(_) Medii
(_) Superioare
|
|____________________________________________________________________________
__|
_____________________________________________________________________________
_
| D5. PARTENERUL/PERSOANA NDREPTIT BENEFICIAZ DE UNELE DREPTURI DE
|
| ASISTEN SOCIAL
|
| _
_
|
| |_| NU |_| DA, din Romnia (se vor ataa actele doveditoare: mandat potal/
|
|
extras de cont/decizie/adeverin)
|
|
_
|
|
|_| DA, din alte ri (se vor ataa actele doveditoare: mandat
potal/|
|
extras de cont/decizie/adeverin)
|
|____________________________________________________________________________
__|
_____________________________________________________________________________
_
| D6. SITUAIA PROFESIONAL A PARTENERULUI/PERSOANEI NDREPTITE
|
| _
_
_
_
_
|
|(_) Elev*
(_) Student* (_) Lucrtor agricol (_) Independent (_) Fr loc
|
|
de munc
|
| _
_
_
_
_
|
|(_) Salariat* (_) omer*
(_) Lucrtor
(_) Pensionar* (_)
Casnic() |
|
ocazional
|
| Altele ..........................................................
|
| * Se vor ataa adeverine, dup caz, de la unitatea colar, angajator,
talon|
| de pensie
|
|
|
| D7. DAC PARTENERUL/PERSOANA NDREPTIT LUCREAZ N AFARA ROMNIEI?
|
| _
_
|
| |_| NU |_| DA
|
|____________________________________________________________________________
__|
_____________________________________________________________________________
_
| E1. COPIII FAMILIEI*
|
|
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
| 1. Numele i prenumele
|
|
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
|
|
| Cod numeric personal
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
|
|
| Act de identitate/act doveditor** |_|_|_| Seria |_|_|_| Nr.
|_|_|_|_|_|_|_| |
|
|
|
Unitatea colar
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
| Dac este elev nva la
|
|
Clasa
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
|
|
| Dac beneficiaz de unele drepturi
Dac realizeaz
|
| de asisten social:
venituri din munc:
|
| _
_
|
| |_| NU
(se vor ataa acte
|_| NU
|
| _
doveditoare: mandat potal/
_
|
| |_| DA, din Romnia
extras de cont/decizie/
|_| DA
|
| _
adeverin)
|
| |_| DA, din alte ri
|
|____________________________________________________________________________
__|
_____________________________________________________________________________
_
|
|
|
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
| 2. Numele i prenumele
|
|
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
|
|
| Cod numeric personal
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
|
|
|
|
| Dac beneficiaz de unele drepturi
Dac realizeaz
|
| de asisten social:
venituri din munc:
|
| _
_
|
| |_| NU
(se vor ataa acte
|_| NU
|
| _
doveditoare: mandat potal/
_
|
| |_| DA, din Romnia
extras de cont/decizie/
|_| DA
|
| _
adeverin)
|
| |_| DA, din alte ri
|
|____________________________________________________________________________
__|
_____________________________________________________________________________
_
|
|
|
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
| 4. Numele i prenumele
|
|
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
|
|
| Cod numeric personal
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
|
|
| Act de identitate/act doveditor** |_|_|_| Seria |_|_|_| Nr.
|_|_|_|_|_|_|_| |
|
|
|
Unitatea colar
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
| Dac este elev nva la
|
|
Clasa
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
|
|
| Dac beneficiaz de unele drepturi
Dac realizeaz
|
| de asisten social:
venituri din munc:
|
| _
_
|
| |_| NU
(se vor ataa acte
|_| NU
|
| _
doveditoare: mandat potal/
_
|
| |_| DA, din Romnia
extras de cont/decizie/
|_| DA
|
| _
adeverin)
|
| |_| DA, din alte ri
|
|____________________________________________________________________________
__|
(*) Se includ i copii care au mplinit vrsta de 18 ani i se afl n
ntreinerea familiei
_____________________________________________________________________________
_
| (**) n cazul cetenilor romni se va| Pentru ceteni strini sau
apatrizi:|
| specifica tipul de act de identitate: | - P.S.T. - permis de edere
temporar|
| - B.I. - buletin de identitate
| - P.S.P. - permis de edere
|
| - C.I. - carte de identitate
| permanent
|
| - C.I.P. - carte de identitate
| - D.I. - document de identitate
|
| provizorie
| - CR - carte de reziden
|
| - P - paaport
| - CRP - carte de reziden
permanent|
|_______________________________________|____________________________________
__|
| n cazul copiilor sub 14 ani sau care nu au act de identitate se vor
|
| specifica datele din certificatul de natere.
|
|____________________________________________________________________________
__|
| n toate cazurile de mai sus se vor ataa copii dup actele menionate
|
|____________________________________________________________________________
__|
_____________________________________________________________________________
_
| E2. COPIII FAMILIEI*
|
|
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
| 5. Numele i prenumele
|
|
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
|
|
| Cod numeric personal
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
|
|
| Act de identitate/act doveditor** |_|_|_| Seria |_|_|_| Nr.
|_|_|_|_|_|_|_| |
|
|
|
Unitatea colar
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
| Dac este elev nva la
|
|
Clasa
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
|
|
| Dac beneficiaz de unele drepturi
Dac realizeaz
|
| de asisten social:
venituri din munc:
|
| _
_
|
| |_| NU
(se vor ataa acte
|_| NU
|
| _
doveditoare: mandat potal/
_
|
| |_| DA, din Romnia
extras de cont/decizie/
|_| DA
|
| _
adeverin)
|
| |_| DA, din alte ri
|
|____________________________________________________________________________
__|
_____________________________________________________________________________
_
|
|
|
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
| 6. Numele i prenumele
|
|
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
|
|
| Cod numeric personal
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
|
|
| Act de identitate/act doveditor** |_|_|_| Seria |_|_|_| Nr.
|_|_|_|_|_|_|_| |
|
|
|
Unitatea colar
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
| Dac este elev nva la
|
|
Clasa
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
|
|
| Dac beneficiaz de unele drepturi
Dac realizeaz
|
| de asisten social:
venituri din munc:
|
| _
_
|
| |_| NU
(se vor ataa acte
|_| NU
|
| _
doveditoare: mandat potal/
_
|
| |_| DA, din Romnia
extras de cont/decizie/
|_| DA
|
| _
adeverin)
|
| |_| DA, din alte ri
|
|____________________________________________________________________________
__|
_____________________________________________________________________________
_
|
|
|
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
| 7. Numele i prenumele
|
|
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
|
|
| Cod numeric personal
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
|
|
| Act de identitate/act doveditor** |_|_|_| Seria |_|_|_| Nr.
|_|_|_|_|_|_|_| |
|
|
|
Unitatea colar
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
| Dac este elev nva la
|
|
Clasa
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
|
|
| Dac beneficiaz de unele drepturi
Dac realizeaz
|
| de asisten social:
venituri din munc:
|
| _
_
|
| |_| NU
(se vor ataa acte
|_| NU
|
| _
doveditoare: mandat potal/
_
|
| |_| DA, din Romnia
extras de cont/decizie/
|_| DA
|
| _
adeverin)
|
| |_| DA, din alte ri
|
|____________________________________________________________________________
__|
_____________________________________________________________________________
_
|
|
|
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
| 8. Numele i prenumele
|
|
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
|
|
| Cod numeric personal
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
|
|
| Act de identitate/act doveditor** |_|_|_| Seria |_|_|_| Nr.
|_|_|_|_|_|_|_| |
|
|
|
Unitatea colar
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
| Dac este elev nva la
|
|
Clasa
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
|
|
| Dac beneficiaz de unele drepturi
Dac realizeaz
|
| de asisten social:
venituri din munc:
|
| _
_
|
| |_| NU
(se vor ataa acte
|_| NU
|
| _
doveditoare: mandat potal/
_
|
| |_| DA, din Romnia
extras de cont/decizie/
|_| DA
|
| _
adeverin)
|
| |_| DA, din alte ri
|
|____________________________________________________________________________
__|
(*) Se includ i copii care au mplinit vrsta de 18 ani i se afl n
ntreinerea familiei
_____________________________________________________________________________
_
| (**) n cazul cetenilor romni se va| Pentru cetenii strini sau
|
| specifica tipul de act de identitate: | apatrizi:
|
| - B.I. - buletin de identitate
| - P.S.T. - permis de edere
temporar|
| - C.I. - carte de identitate
| - P.S.P. - permis de edere
|
| - C.I.P. - carte de identitate
| permanent
|
| provizorie
| - D.I. - document de identitate
|
| - P - paaport
| - CR - carte de reziden
|
|
| - CRP carte de reziden permanent
|
|_______________________________________|____________________________________
__|
| n cazul copiilor sub 14 ani sau care nu au act de identitate se vor
|
| specifica datele din certificatul de natere.
|
|____________________________________________________________________________
__|
| n toate cazurile de mai sus se vor ataa copii dup actele menionate
|
|____________________________________________________________________________
__|
_____________________________________________________________________________
_
| F. STAREA LOCATIV A FAMILIEI/PERSOANEI NDREPTITE
|
|
____________________________________________________________________________
|
|| FAMILIA sau PERSOANA NDREPTIT gospodrete:
||
|| _
_
_
||
|| |_| singur
|_| mpreun cu alt(e)
|_| mpreun cu alt(e)
||
||
persoan(e) singur(e)
familie(i)
||
||___________________________________________________________________________
_||
|
____________________
______________
_____________
|
| | Cas cu curte
| | | Nr. camere | | | Suprafaa | |
al |
| |__________________|_| |____________|_| |___________|_|
|
| | Cas fr curte | | | Nr. camere | | | Suprafaa | |
__________________ |
| |__________________|_| |____________|_| |___________|_|
||
| | Apartament la
| | | Nr. camere | | | Suprafaa | |
||
| | bloc
| | |
| | |
| |
|________________|_||
| |__________________|_| |____________|_| |___________|_|
||
| | Locuin social | | | Nr. camere | | | Suprafaa | |
||
| |__________________|_| |____________|_| |___________|_|
|________________|_||
| | Locuin de
| | | Nr. camere | | | Suprafaa | |
|
| | serviciu
| | |
| | |
| |
|
| |__________________|_| |____________|_| |___________|_|
|
| | Locuin de
| | | Nr. camere | | | Suprafaa | |
|
| | necesitate
| | |
| | |
| |
|
| |__________________|_| |____________|_| |___________|_|
|
| | Instituionalizat| |
__________________ |
| |__________________|_|
||
| | Nu are locuin | |
||
| |__________________|_|
||
|
|________________|_||
|
||
|
|________________|_||
|
||
|
||
|
||
|
|________________|_||
|
|
|
_
__________________________________________________________
Regimul juridic
locuinei
| Proprietate
| personal
| n nchiriere
| public/privat
Alte situaii
...............
Tipul de nclzire
al locuinei
| Energie termic|
| n sistem
| centralizat
| Gaze naturale
| Lemne, crbuni,|
| combustibili
| petrolieri
|
| /\ | TIP A (construcia cu structura de rezisten din beton
||
|
| \/ |
armat, metal ori lemn sau cu perei exteriori din
||
| Tipul
|
|
piatr, crmid ars sau din orice alte
materiale||
| locuinei |
|
rezultate n urma unui tratament termic i/sau
||
|
<
|
chimic)
||
|
|
|__________________________________________________________||
|
| /\ | TIP B (construcia cu perei exteriori din crmid
||
|
| \/ |
nears sau din orice alte materiale nesupuse unui
||
|
|_
|
tratament termic i/sau chimic)
||
|
|__________________________________________________________||
|____________________________________________________________________________
__|
_____________________________________________________________________________
_
| G. FAMILIA/PERSOANA NDREPTIT DEINE N PROPRIETATE/FOLOSIN
|
|
____________________________________________________________________________
|
||
BUNURI IMOBILE
||
||___________________________________________________________________________
_||
|| 1 | Cldiri sau alte spaii locative n afara locuinei de domiciliu
|
||
||
| sau alte imobile aflate proprietate
|
||
||____|____________________________________________________________________|_
_||
||
BUNURI MOBILE
||
||___________________________________________________________________________
_||
|| 2 | Aparatura electronic*: camere video, amplificatoare audio,
|
||
||
| copiatoare.
|
||
||____|____________________________________________________________________|_
_||
|| 3 | Obiecte de valoare: tablouri i obiecte de art, obiecte
|
||
||
| ornamentale, bijuterii sau monezi din metale preioase, obiecte de |
||
||
| cristal i porelan de mare valoare, blnuri de valoare mare, n
|
||
||
| stare vandabil
|
||
||____|____________________________________________________________________|_
_||
|| MIJLOACE TRANSPORT*
||
||___________________________________________________________________________
_||
|| 4 | Autoturisme cu o vechime mai mic de 10 ani
|
||
||____|____________________________________________________________________|_
_||
|| 5 | Autoutilitare
|
||
||____|____________________________________________________________________|_
_||
|| 6 | Autocamioane cu sau fr remorci
|
||
||____|____________________________________________________________________|_
_||
|| 7 | alupe
|
||
||____|____________________________________________________________________|_
_||
|| 8 | Brci cu motor
|
||
||____|____________________________________________________________________|_
_||
|| 9 | Scutere de ap
|
||
||____|____________________________________________________________________|_
_||
|| 10 | Iahturi
|
||
||____|____________________________________________________________________|_
_||
|| 11 | Autobuze
|
||
||____|____________________________________________________________________|_
_||
|| 12 | Microbuze
|
||
||____|____________________________________________________________________|_
_||
|| UTILAJE AGRICOLE*
||
||___________________________________________________________________________
_||
|| 13 | Tractor
|
||
||____|____________________________________________________________________|_
_||
|| 14 | Combin autopropulsat
|
||
||____|____________________________________________________________________|_
_||
||____|____________________________________________________________________|_
_||
|| 23 | peste 5 porcine
|
||
||____|____________________________________________________________________|_
_||
|| 24 | peste 20 ovine
|
||
||____|____________________________________________________________________|_
_||
|| 25 | peste 2 cabaline
|
||
||____|____________________________________________________________________|_
_||
|| 26 | peste 50 capete de iepuri de cas
|
||
||____|____________________________________________________________________|_
_||
|| 27 | peste 100 capete de psri
|
||
||____|____________________________________________________________________|_
_||
|| 28 | peste 15 familii de albine
|
||
||____|____________________________________________________________________|_
_||
|| 29 | cresctorii a cror producie se comercializeaz
|
||
||____|____________________________________________________________________|_
_||
|____________________________________________________________________________
__|
(*) n stare de funcionare
_____________________________________________________________________________
_
| H. REFERITOR LA VENITURILE REALIZATE DE FAMILIE SAU PERSOANA NDREPTIT:
|
|
_
|
|
| _
|
|
| |_| singur
|
|
FAMILIA sau PERSOANA NDREPTIT
| _
|
|
gospodrete
< |_| mpreun cu alt(e)
|
|
|
persoan(e) singur(e)
|
|
| _
|
|
| |_| mpreun cu alt(e)
familie(i) |
|
|_
|
|____________________________________________________________________________
__|
_____________________________________________________________________________
_
| VENITURI PERMANENTE NETE REALIZATE DE FAMILIE N LUNA:
| |
|
|________________________________________________________________________|__|
__|
_____________________________________________________________________________
_
| Cod|
Categoria de venituri
| Acte
| Venitul
|
|
|
| doveditoare* | realizat** lei
|
|____|_______________________________________|_______________|_______________
__|
_____________________________________________________________________________
_
| VENITURI DIN ACTIVITI INDEPENDENTE
|
|____________________________________________________________________________
__|
| 1 | Venituri din profesii libere
| adeverin
| | | | | |
|
|
| veniturile obinute din exercitarea
| eliberat de | | | | | |
|
|
| profesiilor medicale, de avocat,
| Administraia | | | | | |
|
|
| notar, auditor financiar, consultant | financiar
| | | | | |
|
|
| fiscal, expert contabil, contabil
|
| | | | | |
|
|
| autorizat, consultant de plasament n |
| | | | | |
|
|
| valori mobiliare, arhitect sau a altor|
| | | | | |
|
|
| profesii reglementate, desfurate n |
| | | | | |
|
|
| mod independent, n condiiile legii |
| | | | | |
|
|____|_______________________________________|
|__|__|__|__|__|__|
| 2 | Venituri comerciale provenite din
|
| | | | | |
|
|
| fapte de comer ale contribuabililor, |
| | | | | |
|
|
| din prestri de servicii, precum i
|
| | | | | |
|
|
| din practicarea unei meserii
|
| | | | | |
|
|____|_______________________________________|
|__|__|__|__|__|__|
| 3 | Veniturile din valorificarea sub orice|
| | | | | |
|
|
| form a drepturilor de proprietate
|
| | | | | |
|
|
| intelectual provin din brevete de
|
| | | | | |
|
|
| invenie, desene i modele, mostre,
|
| | | | | |
|
|
| mrci de fabric i de comer,
|
| | | | | |
|
|
| procedee tehnice, know-how, din
|
| | | | | |
|
|
| drepturi de autor i drepturi conexe |
| | | | | |
|
|
| dreptului de autor i altele asemenea |
| | | | | |
|
|____|_______________________________________|_______________|__|__|__|__|__|
__|
_____________________________________________________________________________
_
| SALARIUL I ALTE DREPTURI SALARIALE
|
|____________________________________________________________________________
__|
| 4 | Salariul obinut pe baz de contract | adeverin
| | | | | |
|
|
| de munc/raport de serviciu
| eliberat de | | | | | |
|
|____|_______________________________________| angajator
|__|__|__|__|__|__|
| 5 | Salariul asistentului personal al
|
| | | | | |
|
|
| persoanei cu handicap
|
| | | | | |
|
|____|_______________________________________|
|__|__|__|__|__|__|
| 6 | Salariul asistentului maternal
|
| | | | | |
|
|____|_______________________________________|
|__|__|__|__|__|__|
| 7 | Salariul ngrijitorului la domiciliu |
| | | | | |
|
|
| al persoanei vrstnice dependente
|
| | | | | |
|
|____|_______________________________________|_______________|__|__|__|__|__|
__|
| 8 | Venitul lunar realizat ca membru
| adeverin
| | | | | |
|
|
| asociat sau persoan autorizat s
| eliberat de | | | | | |
|
|
| desfoare o activitate independent | Administraia | | | | | |
|
|
|
| financiar
| | | | | |
|
|____|_______________________________________|_______________|__|__|__|__|__|
__|
| 9 | Indemnizaia de omaj i/sau venit
| mandat potal/| | | | | |
|
|
| lunar de completare
| extras de
| | | | | |
|
|
|
| cont/
| | | | | |
|
|____|_______________________________________|_______________|__|__|__|__|__|
__|
| 10 | indemnizaiile din activiti
| adeverin
| | | | | |
|
|
| desfurate ca urmare a unei funcii | eliberat de | | | | | |
|
|
| de demnitate public, stabilite
| Administraia | | | | | |
|
|
| potrivit legii
| financiar
| | | | | |
|
|____|_______________________________________|
|__|__|__|__|__|__|
| 11 | indemnizaii din activiti
|
| | | | | |
|
|
| desfurate ca urmare a unei funcii |
| | | | | |
|
|
| alese n cadrul persoanelor juridice |
| | | | | |
|
|
| fr scop patrimonial
|
| | | | | |
|
|____|_______________________________________|
|__|__|__|__|__|__|
| 12 | drepturile de sold lunar,
|
| | | | | |
|
|
| indemnizaiile, primele, premiile,
|
| | | | | |
|
|
| sporurile i alte drepturi ale
|
| | | | | |
|
|
| personalului militar, acordate
|
| | | | | |
|
|
| potrivit legii
|
| | | | | |
|
|____|_______________________________________|
|__|__|__|__|__|__|
| 13 | indemnizaia lunar brut, precum i |
| | | | | |
|
|
| suma din profitul net, cuvenite
|
| | | | | |
|
|
| administratorilor la companii/
|
| | | | | |
|
|
| societi naionale, societi
|
| | | | | |
|
|
| comerciale la care statul sau o
|
| | | | | |
|
|
| autoritate a administraiei publice
|
| | | | | |
|
|
| locale este acionar majoritar, precum|
| | | | | |
|
|
| i la regiile autonome
|
| | | | | |
|
|____|_______________________________________|
|__|__|__|__|__|__|
|
| unic, la nivelul valorii nscrise n |
| | | | | |
|
|
| declaraia de asigurri sociale
|
| | | | | |
|
|____|_______________________________________|
|__|__|__|__|__|__|
| 20 | sumele acordate de organizaii
|
| | | | | |
|
|
| nonprofit i de alte entiti
|
| | | | | |
|
|
| nepltitoare de impozit pe profit,
|
| | | | | |
|
|
| peste limita de 2,5 ori nivelul legal |
| | | | | |
|
|
| stabilit pentru indemnizaia primit |
| | | | | |
|
|
| pe perioada delegrii i detarii n |
| | | | | |
|
|
| alt localitate, n ar i n
|
| | | | | |
|
|
| strintate, n interesul serviciului,|
| | | | | |
|
|
| pentru salariaii din instituiile
|
| | | | | |
|
|
| publice
|
| | | | | |
|
|____|_______________________________________|_______________|__|__|__|__|__|
__|
| 21 | indemnizaia administratorilor, precum| adeverin
| | | | | |
|
|
| i suma din profitul net cuvenite
| eliberat de | | | | | |
|
|
| administratorilor societilor
| Administraia | | | | | |
|
|
| comerciale potrivit actului
| financiar
| | | | | |
|
|
| constitutiv sau stabilite de adunarea |
| | | | | |
|
|
| general a acionarilor
|
| | | | | |
|
|____|_______________________________________|
|__|__|__|__|__|__|
| 22 | sume reprezentnd salarii sau
|
| | | | | |
|
|
| diferene de salarii stabilite n baza|
| | | | | |
|
|
| unor hotrri judectoreti rmase
|
| | | | | |
|
|
| definitive i irevocabile, precum i |
| | | | | |
|
|
| actualizarea acestora cu indicele de |
| | | | | |
|
|
| inflaie
|
| | | | | |
|
|____|_______________________________________|
|__|__|__|__|__|__|
|
| valoare
|
| | | | | |
|
|____|_______________________________________|
|__|__|__|__|__|__|
| 29 | venituri din operaiuni de vnzare|
| | | | | |
|
|
| cumprare de valut la termen, pe baz|
| | | | | |
|
|
| de contract, precum i orice alte
|
| | | | | |
|
|
| operaiuni similare
|
| | | | | |
|
|____|_______________________________________|
|__|__|__|__|__|__|
| 30 | venituri din lichidarea unei persoane |
| | | | | |
|
|
| juridice
|
| | | | | |
|
|____|_______________________________________|_______________|__|__|__|__|__|
__|
_____________________________________________________________________________
_
| PENSII
|
|____________________________________________________________________________
__|
| PENSII DE STAT
|
|____________________________________________________________________________
__|
| 31 | pensia pentru limit de vrst
| mandat potal/| | | | | |
|
|____|_______________________________________| extras de
|__|__|__|__|__|__|
| 32 | pensia anticipat
| cont/decizie | | | | | |
|
|____|_______________________________________|
|__|__|__|__|__|__|
| 33 | pensia anticipat parial
|
| | | | | |
|
|____|_______________________________________|
|__|__|__|__|__|__|
| 34 | pensia de invaliditate
|
| | | | | |
|
|____|_______________________________________|
|__|__|__|__|__|__|
| 35 | pensia de urma
|
| | | | | |
|
|____|_______________________________________|_______________|__|__|__|__|__|
__|
| PENSII AGRICULTORI
|
|____________________________________________________________________________
__|
| 36 | pensie agricultor
| mandat potal/| | | | | |
|
|
|
| extras de
| | | | | |
|
|
|
| cont/decizie | | | | | |
|
|____|_______________________________________|_______________|__|__|__|__|__|
__|
| PENSII MILITARE
|
|____________________________________________________________________________
__|
| 37 | pensie de serviciu
| mandat potal/| | | | | |
|
|____|_______________________________________| extras de
|__|__|__|__|__|__|
| 38 | pensia de invaliditate
| cont/decizie | | | | | |
|
|____|_______________________________________|
|__|__|__|__|__|__|
| 39 | pensia de urma
|
| | | | | |
|
|____|_______________________________________|
|__|__|__|__|__|__|
| 40 | pensia I.O.V.R.
|
| | | | | |
|
|____|_______________________________________|_______________|__|__|__|__|__|
__|
_____________________________________________________________________________
_
| INDEMNIZAII
|
|____________________________________________________________________________
__|
| 41 | Indemnizaia pt. persoanele care i-au| mandat potal/| | | | | |
|
|
| pierdut total sau parial capacitatea | extras de
| | | | | |
|
|
| de munc ca urmare a participrii la | cont/decizie | | | | | |
|
|
| revoluie i pt. urmaii acestora
|
| | | | | |
|
|____|_______________________________________|
|__|__|__|__|__|__|
| 42 | Indemnizaia de nsoitor pentru
|
| | | | | |
|
|
| pensionari gr. I invaliditate/
|
| | | | | |
|
|
| nevztori handicap grav
|
| | | | | |
|
|____|_______________________________________|_______________|__|__|__|__|__|
__|
| 43 | Indemnizaia pentru incapacitatea
| adeverin
| | | | | |
|
|
| temporar de munc
| eliberat de | | | | | |
|
|
|
| angajator
| | | | | |
|
|____|_______________________________________|_______________|__|__|__|__|__|
__|
| 44 | Indemnizaia lunar pentru activitatea|
| | | | | |
|
|
| de liber-profesionist a artitilor
|
| | | | | |
|
|
| interprei sau executani
|
| | | | | |
|
|____|_______________________________________|_______________|__|__|__|__|__|
__|
_____________________________________________________________________________
_
| INDEMNIZAII I STIMULENTE PENTRU CRETEREA COPILULUI
|
|____________________________________________________________________________
__|
| 45 | Indemnizaia pentru maternitate
| adeverin
| | | | | |
|
|
|
| eliberat de | | | | | |
|
|
|
| angajator
| | | | | |
|
|____|_______________________________________|_______________|__|__|__|__|__|
__|
| 46 | Indemnizaia pentru creterea
| mandat potal/| | | | | |
|
|
| copilului pn la vrsta de 1, 2 sau 3| extras de
| | | | | |
|
|
| ani
| cont/decizie | | | | | |
|
|____|_______________________________________|
|__|__|__|__|__|__|
| 47 | Stimulent lunar/de inserie
|
| | | | | |
|
|____|_______________________________________|
|__|__|__|__|__|__|
| 48 | Indemnizaia i ajutoare pentru
|
| | | | | |
|
|
| creterea copilului cu handicap
|
| | | | | |
|
|____|_______________________________________|_______________|__|__|__|__|__|
__|
_____________________________________________________________________________
_
| INDEMNIZAII CU CARACTER PERMANENT
|
|____________________________________________________________________________
__|
| 49 | Indemnizaia lunar acordat
| mandat potal/| | | | | |
|
|
| magistrailor nlturai din justiie | extras de
| | | | | |
|
|
| din considerente politice
| cont/decizie | | | | | |
|
|____|_______________________________________|
|__|__|__|__|__|__|
| 50 | Indemnizaia lunar acordat
|
| | | | | |
|
|
| persoanelor persecutate din motive
|
| | | | | |
|
|
| politice sau etnice
|
| | | | | |
|
|____|_______________________________________|
|__|__|__|__|__|__|
| 51 | Indemnizaia, sporul sau renta
|
| | | | | |
|
|
| acordat invalizilor, veteranilor i |
| | | | | |
|
|
| vduvelor de rzboi
|
| | | | | |
|
|____|_______________________________________|_______________|__|__|__|__|__|
__|
| 52 | Indemnizaia lunar pentru persoanele | mandat potal/| | | | | |
|
|
| care au efectuat stagiul militar n
| extras de
| | | | | |
|
|
| cadrul Direciei Generale a
| cont/decizie | | | | | |
|
|
| Serviciului Muncii n perioada 1950 - |
| | | | | |
|
|
| 1961
|
| | | | | |
|
|____|_______________________________________|
|__|__|__|__|__|__|
| 53 | Indemnizaia lunar pentru pensionarii|
| | | | | |
|
|
| sistemului de pensii, membrii ai
|
| | | | | |
|
|
| uniunilor de creaie, legal
|
| | | | | |
|
|
| constituite i recunoscute ca persoane|
| | | | | |
|
|
| juridice de utilitate public
|
| | | | | |
|
|____|_______________________________________|
|__|__|__|__|__|__|
| 54 | Indemnizaia lunar pentru persoanele |
| | | | | |
|
|
| cu handicap
|
| | | | | |
|
|____|_______________________________________|
|__|__|__|__|__|__|
| 55 | Indemnizaia cuvenit revoluionarilor|
| | | | | |
|
|____|_______________________________________|
|__|__|__|__|__|__|
| 56 | Indemnizaia de merit acordat n
|
| | | | | |
|
|
| temeiul Legii nr. 118/2002
|
| | | | | |
|
|____|_______________________________________|
|__|__|__|__|__|__|
| 57 | Renta viager pentru sportivi
|
| | | | | |
|
|____|_______________________________________|_______________|__|__|__|__|__|
__|
_____________________________________________________________________________
_
| VENITURI DIN ACTIVITI AGRICOLE
|
|____________________________________________________________________________
__|
| 58 | Venituri din cultivarea i
| adeverin
| | | | | |
|
|
| valorificarea florilor, legumelor i | eliberat de | | | | | |
|
|
| zarzavaturilor, n sere i solarii
| Administraia | | | | | |
|
|
| special destinate acestor scopuri
| financiar
| | | | | |
|
|
| i/sau n sistem irigat
|
| | | | | |
|
|____|_______________________________________|
|__|__|__|__|__|__|
| 59 | Venituri din cultivarea i
|
| | | | | |
|
|
| valorificarea arbutilor, plantelor
|
| | | | | |
|
|
| decorative i ciupercilor
|
| | | | | |
|
|____|_______________________________________|
|__|__|__|__|__|__|
| 60 | Venituri din exploatarea pepinierelor |
| | | | | |
|
|
| viticole i pomicole i altele
|
| | | | | |
|
|
| asemenea
|
| | | | | |
|
|____|_______________________________________|
|__|__|__|__|__|__|
| 61 | Venituri din valorificarea produselor |
| | | | | |
|
|
| agricole obinute dup recoltare, n |
| | | | | |
|
|
| stare natural, de pe terenurile
|
| | | | | |
|
|
| agricole proprietate privat sau luate|
| | | | | |
|
|
| n arend, ctre uniti specializate |
| | | | | |
|
|
| pentru colectare, uniti de procesare|
| | | | | |
|
|
| industrial sau ctre alte uniti,
|
| | | | | |
|
|
| pentru utilizare ca atare
|
| | | | | |
|
|____|_______________________________________|_______________|__|__|__|__|__|
__|
_____________________________________________________________________________
_
| VENITURI DIN PREMII I DIN JOCURI DE NOROC
|
|____________________________________________________________________________
__|
| 62 | Veniturile din premii ce cuprind
| adeverin
| | | | | |
|
|
| veniturile din concursuri
| eliberat de | | | | | |
|
|____|_______________________________________| Administraia
|__|__|__|__|__|__|
| 63 | Veniturile din jocuri de noroc ce
| financiar
| | | | | |
|
|
| cuprind ctigurile realizate ca
|
| | | | | |
|
|
| urmare a participrii la jocuri de
|
| | | | | |
|
|
| noroc, inclusiv cele de tip jack-pot |
| | | | | |
|
|____|_______________________________________|_______________|__|__|__|__|__|
__|
_____________________________________________________________________________
_
| VENITURI DIN TRANSFERUL PROPRIETILOR IMOBILIARE DIN PATRIMONIUL PERSONAL
I|
| AL DEZMEMBRMINTELOR ACESTUIA
|
|____________________________________________________________________________
__|
| 64 | Venituri din transferul dreptului de | adeverin
| | | | | |
|
|
| proprietate i al dezmembrmintelor
| eliberat de | | | | | |
|
|
| acestuia, altele dect cele cu titlu | Administraia | | | | | |
|
|
| de motenire
| financiar
| | | | | |
|
|____|_______________________________________|_______________|__|__|__|__|__|
__|
_____________________________________________________________________________
_
| VENITURI DIN ALTE SURSE
|
|____________________________________________________________________________
__|
| 65 | Prime de asigurri suportate de o
| adeverin
| | | | | |
|
|
| persoan fizic independent sau de
| eliberat de | | | | | |
|
|
| orice alt entitate, n cadrul unei
| Administraia | | | | | |
|
|
| activiti pentru o persoan fizic n| financiar
| | | | | |
|
|
| legtur cu care suportatorul nu are o|
| | | | | |
|
|
| relaie generatoare de venituri din
|
| | | | | |
|
|
| salarii
|
| | | | | |
|
|____|_______________________________________|
|__|__|__|__|__|__|
| 66 | Ctiguri primite de la societile de|
| | | | | |
|
|
| asigurri, ca urmare a contractului de|
| | | | | |
|
|
| asigurare ncheiat ntre pri cu
|
| | | | | |
|
|
| ocazia tragerilor de amortizare
|
| | | | | |
|
|____|_______________________________________|
|__|__|__|__|__|__|
| 67 | Venituri, sub forma diferenelor de
|
| | | | | |
|
|
| pre pentru anumite bunuri, servicii |
| | | | | |
|
|
| i alte drepturi, primite de
|
| | | | | |
|
|
| persoanele fizice pensionari, foti
|
| | | | | |
|
|
| salariai, potrivit clauzelor
|
| | | | | |
|
|
| contractului de munc sau n baza unor|
| | | | | |
|
|
| legi speciale
|
| | | | | |
|
|____|_______________________________________|
|__|__|__|__|__|__|
| 68 | Venituri primite de persoanele fizice |
| | | | | |
|
|
| reprezentnd onorarii din activitatea |
| | | | | |
|
|
| de arbitraj comercial
|
| | | | | |
|
|____|_______________________________________|
|__|__|__|__|__|__|
| 69 | Venituri din alte surse sunt orice
|
| | | | | |
|
|
| venituri identificate ca fiind
|
| | | | | |
|
|
| impozabile
|
| | | | | |
|
|____|_______________________________________|_______________|__|__|__|__|__|
__|
_____________________________________________________________________________
_
| VENITURI OBINUTE DIN STRINTATE
|
|____________________________________________________________________________
__|
| 70 | Venituri obinute din strintate
| Contract de
| | | | | |
|
|
|
| munc
| | | | | |
|
|____|_______________________________________|_______________|__|__|__|__|__|
__|
_____________________________________________________________________________
_
| ALOCAII
|
|____________________________________________________________________________
__|
| 71 | Alocaia de stat pentru copii
| mandat potal/| | | | | |
|
|____|_______________________________________| extras de
|__|__|__|__|__|__|
| 72 | Alocaia lunar de plasament
| cont/decizie | | | | | |
|
|____|_______________________________________|_______________|__|__|__|__|__|
__|
| 73 | Alocaia de ntreinere
| Hotrre
| | | | | |
|
|
|
| judectoreasc| | | | | |
|
|____|_______________________________________|_______________|__|__|__|__|__|
__|
_____________________________________________________________________________
_
| BURSE*
|
|____________________________________________________________________________
__|
| 74 | pentru elevi
| adeverin
| | | | | |
|
|____|_______________________________________| instituie
|__|__|__|__|__|__|
| 75 | pentru studeni
| nvmnt
| | | | | |
|
|
|
|
| | | | | |
|
|____|_______________________________________|_______________|__|__|__|__|__|
__|
* Cu excepia burselor de studiu i a burselor sociale precum i a
sprijinului financiar prevzut de H.G. nr. 1488/2004
_____________________________________________________________________________
_
| AJUTOARE
|
|____________________________________________________________________________
__|
| 76 | Ajutorul bnesc lunar pentru
| mandat potal/| | | | | |
|
|
| persoanele care au devenit incapabile | extras de
| | | | | |
|
|
| de munc n perioada efecturii unei | cont/decizie | | | | | |
|
|
| pedepse privative de libertate
|
| | | | | |
|
|____|_______________________________________|_______________|__|__|__|__|__|
__|
_____________________________________________________________________________
_
| ALTE SURSE DE VENIT
|
|____________________________________________________________________________
__|
| 77 | Depozite bancare
| adeverin
| | | | | |
|
|____|_______________________________________| eliberat de
|__|__|__|__|__|__|
| 78 | Rent viager agricol
| Administraia | | | | | |
|
|____|_______________________________________| financiar
|__|__|__|__|__|__|
| 79 | Alte venituri
|
| | | | | |
|
|____|_______________________________________|_______________|__|__|__|__|__|
__|
| 80 | Venituri poteniale obinute din
|
| | | | | |
|
|
| valorificarea unor bunuri mobile i
|
| | | | | |
|
|
| imobile (conform HCL)***
|
| | | | | |
|
|____|_______________________________________|_______________|__|__|__|__|__|
__|
_____________________________________________________________________________
_
| VENIT LUNAR TOTAL AL FAMILIEI
| | | | | |
|
|____________________________________________________________|__|__|__|__|__|
__|
_____________________________________________________________________________
_
| VENIT NET LUNAR PE MEMBRU DE FAMILIE
| | | | | |
|
|____________________________________________________________|__|__|__|__|__|
__|
_____________________________________________________________________________
_
| I. STAREA DE SNTATE A PERSOANEI SINGURE/MEMBRILOR FAMILIEI SAU PERSOANEI
|
| NDREPTITE
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|____________________________________________________________________________
__|
_____________________________________________________________________________
_
| J. NEVOI SPECIALE A PERSOANEI SINGURE/MEMBRILOR FAMILIEI SAU PERSOANEI
|
| NDREPTITE
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|____________________________________________________________________________
__|
_____________________________________________________________________________
_
| K. ALTE ASPECTE
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|____________________________________________________________________________
__|
_____________________________________________________________________________
_
| L. CONCLUZII
|
|
_
|
| Se propune |_| acordarea
__________________________________________
|
|
_
|
|
|_| neacordarea __________________________________________
|
|
|
| MOTIVAIA:
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| AM LUAT LA CUNOTIN
NTOCMIT __________________
|
| SOLICITANT ___________________
|
| SEMNTURA ___________________
SEMNTURA __________________
|
|____________________________________________________________________________
__|
ANEXA 3 *1)
la normele metodologice
*1) Anexa nr. 3 este reprodus n facsimil.
- model BORDEROU
DOCUMENTE STABILIRE PLI DREPTURI NOI
_______________________
| PRIMRIA
|
|
|____________|__________|
| JUDEUL
|
|
|____________|__________|
| ADRESA
|
|
|____________|__________|
| CUI
|
|
|____________|__________|
| COD POTAL
|
|_______________________|
| OFICIUL POTAL
|
|_______________________|
__________________
| DELEGAT PRIMRIE |
|__________________|
| Nume
|
|
|_________|________|
| Prenume |
|
|_________|________|
| CNP
|
|
|_________|________|
Nr.
Data
NSUIT PRIMAR
____
/
\
( LS
)
\____/
_____________________________________________________________________________
_
|Nr. |
Titular
|
|crt.|_______________________________________________________________________
__|
|
|
Nume
|
Prenume
|
CNP
|
|____|______________________|_________________________|______________________
__|
|
|
|
|
|
|____|______________________|_________________________|______________________
__|
|
|
|
|
|
|____|______________________|_________________________|______________________
__|
|
|
|
|
|
|____|______________________|_________________________|______________________
__|
|
|
|
|
|
|____|______________________|_________________________|______________________
__|
|
|
|
|
|
|____|______________________|_________________________|______________________
__|
|
|
|
|
|
|____|______________________|_________________________|______________________
__|
|
|
|
|
|
|____|______________________|_________________________|______________________
__|
|
|
|
|
|
|____|______________________|_________________________|______________________
__|
|
|
|
|
|
|____|______________________|_________________________|______________________
__|
|
|
|
|
|
|____|______________________|_________________________|______________________
__|
|
|
|
|
|
|____|______________________|_________________________|______________________
__|
|
|
|
|
|
|____|______________________|_________________________|______________________
__|
|
|
|
|
|
|____|______________________|_________________________|______________________
__|
|
|
|
|
|
|____|______________________|_________________________|______________________
__|
|
|
|
|
|
|____|______________________|_________________________|______________________
__|
|
|
|
|
|
|____|______________________|_________________________|______________________
__|
|
|
|
|
|
|____|______________________|_________________________|______________________
__|
|
|
|
|
|
|____|______________________|_________________________|______________________
__|
|
|
|
|
|
|____|______________________|_________________________|______________________
__|
|
|
|
|
|
|____|______________________|_________________________|______________________
__|
|
|
|____________________________________________________________________________
__|
- continuare _____________________________________________________________________________
_
|Nr. |
Adresa
|
|crt.|_______________________________________________________________________
__|
|
| Str.
| Nr.| Bl.| Sc.| Et.| Ap.| Sectorul| Localitatea| Oficiul| Cod
|
|
|
|
|
|
|
|
|
|
| potal |
potal|
|____|________|____|____|____|____|____|_________|____________|________|_____
__|
|
|
|
|
|
|
|
|
|
|
|
|
|____|________|____|____|____|____|____|_________|____________|________|_____
__|
|
|
|
|
|
|
|
|
|
|
|
|
|____|________|____|____|____|____|____|_________|____________|________|_____
__|
|
|
|
|
|
|
|
|
|
|
|
|
|____|________|____|____|____|____|____|_________|____________|________|_____
__|
|
|
|
|
|
|
|
|
|
|
|
|
|____|________|____|____|____|____|____|_________|____________|________|_____
__|
|
|
|
|
|
|
|
|
|
|
|
|
|____|________|____|____|____|____|____|_________|____________|________|_____
__|
|
|
|
|
|
|
|
|
|
|
|
|
|____|________|____|____|____|____|____|_________|____________|________|_____
__|
|
|
|
|
|
|
|
|
|
|
|
|
|____|________|____|____|____|____|____|_________|____________|________|_____
__|
|
|
|
|
|
|
|
|
|
|
|
|
|____|________|____|____|____|____|____|_________|____________|________|_____
__|
|
|
|
|
|
|
|
|
|
|
|
|
|____|________|____|____|____|____|____|_________|____________|________|_____
__|
|
|
|
|
|
|
|
|
|
|
|
|
|____|________|____|____|____|____|____|_________|____________|________|_____
__|
|
|
|
|
|
|
|
|
|
|
|
|
|____|________|____|____|____|____|____|_________|____________|________|_____
__|
|
|
|
|
|
|
|
|
|
|
|
|
|____|________|____|____|____|____|____|_________|____________|________|_____
__|
|
|
|
|
|
|
|
|
|
|
|
|
|____|________|____|____|____|____|____|_________|____________|________|_____
__|
|
|
|
|
|
|
|
|
|
|
|
|
|____|________|____|____|____|____|____|_________|____________|________|_____
__|
|
|
|
|
|
|
|
|
|
|
|
|
|____|________|____|____|____|____|____|_________|____________|________|_____
__|
|
|
|
|
|
|
|
|
|
|
|
|
|____|________|____|____|____|____|____|_________|____________|________|_____
__|
|
|
|
|
|
|
|
|
|
|
|
|
|____|________|____|____|____|____|____|_________|____________|________|_____
__|
|
|
|
|
|
|
|
|
|
|
|
|
|____|________|____|____|____|____|____|_________|____________|________|_____
__|
|
|
|
|
|
|
|
|
|
|
|
|
|____|________|____|____|____|____|____|_________|____________|________|_____
__|
|
|
|
|
|
|
|
|
|
|
|
|
|____|________|____|____|____|____|____|_________|____________|________|_____
__|
|
|
|____________________________________________________________________________
__|
- continuare _____________________________________________________________________________
_
|Nr. |Nr. |Tip
|Venit
|Nr.
|Nr.
|Cuantum |
Documente
|
|crt.|copii|familie|net/
|nregistrare|dispoziie|lunar
|
transmise**
|
|
|
|*
|persoan|cerere
|
|alocaie|_________________|
|
|
|
|
|
|
|
|dispoziie|cerere|
|____|_____|_______|________|____________|__________|________|__________|____
__|
|
|
|
|
|
|
|
|
|
|
|____|_____|_______|________|____________|__________|________|__________|____
__|
|
|
|
|
|
|
|
|
|
|
|____|_____|_______|________|____________|__________|________|__________|____
__|
|
|
|
|
|
|
|
|
|
|
|____|_____|_______|________|____________|__________|________|__________|____
__|
|
|
|
|
|
|
|
|
|
|
|____|_____|_______|________|____________|__________|________|__________|____
__|
|
|
|
|
|
|
|
|
|
|
|____|_____|_______|________|____________|__________|________|__________|____
__|
|
|
|
|
|
|
|
|
|
|
|____|_____|_______|________|____________|__________|________|__________|____
__|
|
|
|
|
|
|
|
|
|
|
|____|_____|_______|________|____________|__________|________|__________|____
__|
|
|
|
|
|
|
|
|
|
|
|____|_____|_______|________|____________|__________|________|__________|____
__|
|
|
|
|
|
|
|
|
|
|
|____|_____|_______|________|____________|__________|________|__________|____
__|
|
|
|
|
|
|
|
|
|
|
|____|_____|_______|________|____________|__________|________|__________|____
__|
|
|
|
|
|
|
|
|
|
|
|____|_____|_______|________|____________|__________|________|__________|____
__|
|
|
|
|
|
|
|
|
|
|
|____|_____|_______|________|____________|__________|________|__________|____
__|
|
|
|
|
|
|
|
|
|
|
|____|_____|_______|________|____________|__________|________|__________|____
__|
|
|
|
|
|
|
|
|
|
|
|____|_____|_______|________|____________|__________|________|__________|____
__|
|
|
|
|
|
|
|
|
|
|
|____|_____|_______|________|____________|__________|________|__________|____
__|
|
|
|
|
|
|
|
|
|
|
|____|_____|_______|________|____________|__________|________|__________|____
__|
|
|
|
|
|
|
|
|
|
|
|____|_____|_______|________|____________|__________|________|__________|____
__|
|
|
|
|
|
|
|
|
|
|
|____|_____|_______|________|____________|__________|________|__________|____
__|
|
|
|
|
|
|
|
|
|
|
|____|_____|_______|________|____________|__________|________|__________|____
__|
|
|
|
|
|
|
|
|
|
|
|____|_____|_______|________|____________|__________|________|__________|____
__|
|
|
|
|___________________________|________________________________________________
__|
_______________________
| PRIMRIA
|
|
|____________|__________|
| JUDEUL
|
|
|____________|__________|
| ADRESA
|
|
|____________|__________|
| CUI
|
|
|____________|__________|
| COD POTAL |
|
|____________|__________|
| OFICIUL POTAL
|
|_______________________|
__________________
| DELEGAT PRIMRIE |
|__________________|
| Nume
|
|
|_________|________|
| Prenume |
|
|_________|________|
| CNP
|
|
|_________|________|
Nr.
Data
NSUIT PRIMAR
____
/
\
( LS
)
\____/
_____________________________________________________________________________
_
|Nr. |
Titular
|
|crt.|_______________________________________________________________________
__|
|
|
Nume
|
Prenume
|
CNP
|
|____|______________________|_________________________|______________________
__|
|
|
|
|
|
|____|______________________|_________________________|______________________
__|
|
|
|
|
|
|____|______________________|_________________________|______________________
__|
|
|
|
|
|
|____|______________________|_________________________|______________________
__|
|
|
|
|
|
|____|______________________|_________________________|______________________
__|
|
|
|
|
|
|____|______________________|_________________________|______________________
__|
|
|
|
|
|
|____|______________________|_________________________|______________________
__|
|
|
|
|
|
|____|______________________|_________________________|______________________
__|
|
|
|
|
|
|____|______________________|_________________________|______________________
__|
|
|
|
|
|
|____|______________________|_________________________|______________________
__|
|
|
|
|
|
|____|______________________|_________________________|______________________
__|
|
|
|
|
|
|____|______________________|_________________________|______________________
__|
|
|
|
|
|
|____|______________________|_________________________|______________________
__|
|
|
|
|
|
|____|______________________|_________________________|______________________
__|
|
|
|
|
|
|____|______________________|_________________________|______________________
__|
|
|
|
|
|
|____|______________________|_________________________|______________________
__|
|
|
|
|
|
|____|______________________|_________________________|______________________
__|
|
|
|
|
|
|____|______________________|_________________________|______________________
__|
|
|
|
|
|
|____|______________________|_________________________|______________________
__|
|
|
|
|
|
|____|______________________|_________________________|______________________
__|
|
|
|
|
|
|____|______________________|_________________________|______________________
__|
|
|
|____________________________________________________________________________
__|
- continuare _____________________________________________________________________________
_
|Nr. |
Adresa
|
|crt.|_______________________________________________________________________
__|
|
| Str.
| Nr.| Bl.| Sc.| Et.| Ap.| Sectorul| Localitatea| Oficiul| Cod
|
|
|
|
|
|
|
|
|
|
| potal |
potal|
|____|________|____|____|____|____|____|_________|____________|________|_____
__|
|
|
|
|
|
|
|
|
|
|
|
|
|____|________|____|____|____|____|____|_________|____________|________|_____
__|
|
|
|
|
|
|
|
|
|
|
|
|
|____|________|____|____|____|____|____|_________|____________|________|_____
__|
|
|
|
|
|
|
|
|
|
|
|
|
|____|________|____|____|____|____|____|_________|____________|________|_____
__|
|
|
|
|
|
|
|
|
|
|
|
|
|____|________|____|____|____|____|____|_________|____________|________|_____
__|
|
|
|
|
|
|
|
|
|
|
|
|
|____|________|____|____|____|____|____|_________|____________|________|_____
__|
|
|
|
|
|
|
|
|
|
|
|
|
|____|________|____|____|____|____|____|_________|____________|________|_____
__|
|
|
|
|
|
|
|
|
|
|
|
|
|____|________|____|____|____|____|____|_________|____________|________|_____
__|
|
|
|
|
|
|
|
|
|
|
|
|
|____|________|____|____|____|____|____|_________|____________|________|_____
__|
|
|
|
|
|
|
|
|
|
|
|
|
|____|________|____|____|____|____|____|_________|____________|________|_____
__|
|
|
|
|
|
|
|
|
|
|
|
|
|____|________|____|____|____|____|____|_________|____________|________|_____
__|
|
|
|
|
|
|
|
|
|
|
|
|
|____|________|____|____|____|____|____|_________|____________|________|_____
__|
|
|
|
|
|
|
|
|
|
|
|
|
|____|________|____|____|____|____|____|_________|____________|________|_____
__|
|
|
|
|
|
|
|
|
|
|
|
|
|____|________|____|____|____|____|____|_________|____________|________|_____
__|
|
|
|
|
|
|
|
|
|
|
|
|
|____|________|____|____|____|____|____|_________|____________|________|_____
__|
|
|
|
|
|
|
|
|
|
|
|
|
|____|________|____|____|____|____|____|_________|____________|________|_____
__|
|
|
|
|
|
|
|
|
|
|
|
|
|____|________|____|____|____|____|____|_________|____________|________|_____
__|
|
|
|
|
|
|
|
|
|
|
|
|
|____|________|____|____|____|____|____|_________|____________|________|_____
__|
|
|
|
|
|
|
|
|
|
|
|
|
|____|________|____|____|____|____|____|_________|____________|________|_____
__|
|
|
|
|
|
|
|
|
|
|
|
|
|____|________|____|____|____|____|____|_________|____________|________|_____
__|
|
|
|
|
|
|
|
|
|
|
|
|
|____|________|____|____|____|____|____|_________|____________|________|_____
__|
|
|
|____________________________________________________________________________
__|
- continuare _____________________________________________________________________________
_
|Nr. | Nr.
| Tip
| Nr.
|
Tip dispoziie
|
|crt.| copii | familie* | dispoziie
|_________________________________________|
|
|
|
|
|
Modificare cuantum
| ncetare
|
|
|
|
|
|_____________________________| drept
|
|
|
|
|
| Cuantum vechi | Cuantum nou |
|
|
|
|
|
| (lei)
| (lei)
|
|
|____|_______|__________|____________|_______________|_____________|_________
__|
|
|
|
|
|
|
|
|
|____|_______|__________|____________|_______________|_____________|_________
__|
|
|
|
|
|
|
|
|
|____|_______|__________|____________|_______________|_____________|_________
__|
|
|
|
|
|
|
|
|
|____|_______|__________|____________|_______________|_____________|_________
__|
|
|
|
|
|
|
|
|
|____|_______|__________|____________|_______________|_____________|_________
__|
|
|
|
|
|
|
|
|
|____|_______|__________|____________|_______________|_____________|_________
__|
|
|
|
|
|
|
|
|
|____|_______|__________|____________|_______________|_____________|_________
__|
|
|
|
|
|
|
|
|
|____|_______|__________|____________|_______________|_____________|_________
__|
|
|
|
|
|
|
|
|
|____|_______|__________|____________|_______________|_____________|_________
__|
|
|
|
|
|
|
|
|
|____|_______|__________|____________|_______________|_____________|_________
__|
|
|
|
|
|
|
|
|
|____|_______|__________|____________|_______________|_____________|_________
__|
|
|
|
|
|
|
|
|
|____|_______|__________|____________|_______________|_____________|_________
__|
|
|
|
|
|
|
|
|
|____|_______|__________|____________|_______________|_____________|_________
__|
|
|
|
|
|
|
|
|
|____|_______|__________|____________|_______________|_____________|_________
__|
|
|
|
|
|
|
|
|
|____|_______|__________|____________|_______________|_____________|_________
__|
|
|
|
|
|
|
|
|
|____|_______|__________|____________|_______________|_____________|_________
__|
|
|
|
|
|
|
|
|
|____|_______|__________|____________|_______________|_____________|_________
__|
|
|
|
|
|
|
|
|
|____|_______|__________|____________|_______________|_____________|_________
__|
|
|
|
|
|
|
|
|
|____|_______|__________|____________|_______________|_____________|_________
__|
|
|
|
|
|
|
|
|
|____|_______|__________|____________|_______________|_____________|_________
__|
|
|
|
|
|
|
|
|
|____|_______|__________|____________|_______________|_____________|_________
__|
|
|
|
|_______________________|____________________________________________________
__|