HG 778 2013 PDF

HOTRRE Nr.
778 din 9 octombrie 2013

pentru modificarea i completarea Normelor metodologice de aplicare a prevederilor Legii nr.
416/2001 privind venitul minim garantat, aprobate prin Hotrrea Guvernului nr. 50/2011, a
Normelor metodologice de aplicare a prevederilor Legii nr. 277/2010 privind alocaia pentru
susinerea familiei, aprobate prin Hotrrea Guvernului nr. 38/2011, i a Normelor
metodologice de aplicare a prevederilor Ordonanei de urgen a Guvernului nr. 70/2011 privind
msurile de protecie social n perioada sezonului rece, aprobate prin Hotrrea Guvernului nr.
920/2011
EMITENT:
GUVERNUL ROMNIEI
PUBLICAT N: MONITORUL OFICIAL NR. 631 din 11 octombrie 2013
n temeiul art. 108 din Constituia Romniei, republicat,
Guvernul Romniei adopt prezenta hotrre.
ART. I
Normele metodologice de aplicare a prevederilor Legii nr. 416/2001 privind venitul minim
garantat, aprobate prin Hotrrea Guvernului nr. 50/2011, publicat n Monitorul Oficial al
Romniei, Partea I, nr. 76 din 28 ianuarie 2011, cu modificrile i completrile ulterioare, se
modific i se completeaz dup cum urmeaz:
1. Articolul 8 se modific i va avea urmtorul cuprins:
"ART. 8
Ajutorul social se acord lunar, n completarea veniturilor nete lunare ale familiei sau ale
persoanei singure, pentru asigurarea venitului minim garantat, la nivelul prevzut la art. 4 din
lege, transformat n lei."
2. La articolul 11, alineatul (4) se modific i va avea urmtorul cuprins:
"(4) Potrivit prevederilor art. 7 din lege, persoanele apte de munc ce nu realizeaz venituri
din salarii sau din alte activiti prezint adeverin c sunt nregistrate n evidena ageniilor
pentru ocuparea forei de munc judeene, respectiv a municipiului Bucureti, denumite n
continuare agenii teritoriale pentru ocuparea forei de munc, pentru ncadrare n munc i c
nu au refuzat un loc de munc sau participarea la serviciile pentru stimularea ocuprii forei de
munc i de formare profesional oferite de aceste agenii."
"(1) Cuantumul ajutorului social se stabilete ca diferen ntre nivelurile prevzute la art. 4
din lege, transformate n lei, i venitul net lunar al familiei sau persoanei singure, rezultat din
fia de calcul. Dac din calculul n lei rezult fraciuni n bani, acestea se rotunjesc la un leu n
favoarea beneficiarului."
4. La articolul 17, dup alineatul (1) se introduce un nou alineat, alineatul (1^1), cu
urmtorul cuprins:
"(1^1) n situaia n care veniturile realizate de membrii familiei sau de persoana singur sunt
anuale sau periodice, pentru stabilirea venitului net lunar se calculeaz media lunar a acestora
n raport cu perioada pentru care au fost acordate."
5. La articolul 18, dup alineatul (1) se introduc patru noi alineate, alineatele (2) - (5),
cu urmtorul cuprins:
"(2) Lista bunurilor ce conduc la excluderea acordrii ajutorului social, prevzut la alin. (1),
cuprinde cldiri i alte bunuri mobile, precum i suprafee de teren, animale i psri a cror
valoare net de producie anual depete cumulat suma de 1.000 euro pentru persoana
singur, respectiv suma de 2.500 euro pentru familie.
(3) Pentru determinarea sumelor menionate la alin. (2), Ministerul Agriculturii i Dezvoltrii
Rurale, prin structurile locale din subordine, pune la dispoziia primarilor, pe baz de protocol,
elementele tehnice necesare stabilirii valorii nete de producie pentru suprafee de teren, animale
i psri.
(4) Documentul rezultat n urma stabilirii valorii nete prevzute la alin. (3) se listeaz i se
anexeaz la fia de calcul prevzut n anexa nr. 3.
(5) n situaia n care suprafeele de teren deinute de solicitant, indiferent de calitatea
acestora, nu sunt cultivate, pentru evaluarea acestora se va lua n calcul cea mai mic valoare
net ce poate rezulta n urma aplicrii elementelor prevzute la alin. (3)."
6. La articolul 20, dup alineatul (1) se introduce un nou alineat, alineatul (2), cu
urmtorul cuprins:
"(2) n situaia n care unul sau mai multe bunuri cuprinse n anexa nr. 4, aflate n
proprietatea persoanei singure/familiei beneficiare de ajutor social, este dat n
nchiriere/arend/concesiune sau alt form legal de cedare a folosinei bunurilor, acest bun va
fi luat n calcul pentru persoana/familia care l are n nchiriere/arend/concesiune, iar pentru
proprietarul de drept se va lua n calcul valoarea obinut n urma cedrii dreptului de folosin
a bunului."
7. La articolul 24, alineatele (5) i (6) se modific i vor avea urmtorul cuprins:
"(5) Dispoziia primarului de acordare a dreptului la ajutorul social, nsoit de copia cererii
de acordare a ajutorului social i a declaraiei pe propria rspundere, certificat de primar,
precum i de copia fiei de calcul, se transmite pe baz de borderou la ageniile pentru pli i
inspecie social judeene, respectiv a municipiului Bucureti, denumite n continuare agenii
teritoriale. Modelul borderoului este prevzut n anexa nr. 5.
(6) Primarul are obligaia de a transmite ageniei teritoriale documentele prevzute la alin.
(5), precum i situaia centralizatoare privind titularii ajutorului social i sumele de plat, pn
la data de 5 a fiecrei luni, pentru luna anterioar. Modelul situaiei centralizatoare este prevzut
n anexa nr. 6."
"(2) Emiterea deciziei prevzute la alin. (1) are la baz documentele prevzute la art. 24 alin.
(5) i (6). Pentru situaiile n care numrul beneficiarilor este mai mare de 10 persoane, decizia
poate fi emis colectiv, comunicarea acesteia fiind realizat individual. Modelul deciziei este
prevzut n anexa nr. 7."
9. La articolul 27, partea introductiv a alineatului (2) se modific i va avea urmtorul
cuprins:
"(2) Persoanele apte de munc pentru care se acord ajutorul social i care nu realizeaz
venituri din salarii sau din alte activiti, potrivit legii, au obligaia s dovedeasc, din 3 n 3
luni, cu adeverin eliberat de agenia teritorial pentru ocuparea forei de munc,
urmtoarele:".

"(7) Situaia lunar privind persoanele apte de munc din familiile beneficiare de ajutor
social, precum i activitile realizate de acetia, conform planului de aciuni prevzut la alin.
(3), se transmite ageniilor teritoriale n termenul prevzut la art. 13^1 alin. (3) din lege. Situaia
se va completa potrivit modelului prevzut n anexa nr. 8."
11. La articolul 29 alineatul (2), litera c) se modific i va avea urmtorul cuprins:
"c) certificatul medical de constatare a capacitii de munc, emis de medicul expert al
asigurrilor sociale din cadrul casei judeene de pensii i alte drepturi de asigurri sociale,
pentru persoanele cu afeciuni cronice invalidante i care nu sunt asigurate n sistemul public de
pensii, al crui model este prezentat n anexa nr. 9."
"ART. 30
(1) n aplicarea prevederilor art. 7 i art. 15 alin. (1) - (3) din lege, se procedeaz dup cum
urmeaz:
a) pentru verificarea ndeplinirii condiiei prevzute la art. 7 alin. (1) din lege, agenia
teritorial pentru ocuparea forei de munc transmite primarilor, n scris i n format electronic,
n prima zi lucrtoare a fiecrei luni, pentru luna anterioar, un tabel nominal cu persoanele care
sunt n cutarea unui loc de munc, nregistrate n evidena ageniei teritoriale pentru ocuparea
forei de munc, pentru care s-au eliberat adeverine potrivit art. 11 alin. (4), conform modelului
prevzut n anexa nr. 10;
b) n condiiile prevzute de art. 15 alin. (3) din lege, primarii transmit lunar, n format
electronic, n termenul prevzut la art. 13^1 alin. (3) din lege, lista persoanelor apte de munc
din familiile beneficiare de ajutor social, att la agenia teritorial pentru ocuparea forei de
munc i inspectoratul teritorial de munc, ct i la agenia teritorial, conform modelului
prevzut n anexa nr. 11;
c) pe baza listei prevzute la lit. b), agenia teritorial pentru ocuparea forei de munc
transmite n termen de 10 zile de la primirea listei, iar inspectoratul teritorial de munc, n
termen de 20 de zile lucrtoare, tabelul nominal cu persoanele din familiile beneficiare de ajutor
social care s-au ncadrat n munc, inclusiv cu cele care au plecat cu contract de munc n
strintate, au refuzat un loc de munc oferit sau un curs de calificare/recalificare/formare
profesional, conform modelelor prevzute n anexele nr. 12 i 13, att primarilor, ct i
ageniei teritoriale.
(2) n vederea asigurrii unei evidene centralizate la nivel naional, n termen de 5 zile
lucrtoare de la transmiterea tabelelor prevzute la alin. (1) lit. c), Agenia Naional pentru
Ocuparea Forei de Munc i Inspecia Muncii vor transmite n format electronic la Agenia
Naional pentru Pli i Inspecie Social tabelele centralizatoare cu persoanele din familiile
beneficiare de ajutor social care s-au ncadrat n munc, inclusiv cu cele care au plecat cu
contract de munc n strintate, au refuzat un loc de munc oferit sau un curs de
calificare/recalificare/formare profesional. Modalitatea de transmitere i formatul acestora se
stabilesc prin protocol."
"ART. 31
Datele prevzute la art. 30 alin. (1) lit. c) privind ncadrarea n munc, care se transmit de
agenia teritorial pentru ocuparea forei de munc, cuprind i informaiile furnizate, conform
legii, de furnizorii de servicii specializate pentru stimularea ocuprii forei de munc din
sectorul public sau privat, acreditai n condiiile Criteriilor de acreditare a furnizorilor de
servicii specializate pentru stimularea ocuprii forei de munc, aprobate prin Hotrrea
Guvernului nr. 277/2002, cu modificrile i completrile ulterioare."
14. La articolul 33 alineatul (1), litera a) se modific i va avea urmtorul cuprins:
"a) dac nu prezint adeverina eliberat de agenia teritorial pentru ocuparea forei de
munc, prevzut la art. 11 alin. (4);".
"a) dac veniturile nete lunare ale familiei sau ale persoanei singure depesc nivelurile
prevzute la art. 4 alin. (1) din lege, transformate n lei, sau dac familia sau persoana singur
deine cel puin unul din bunurile cuprinse n lista prevzut la art. 18;".
16. Dup articolul 36 se introduce un nou articol, articolul 36^1, cu urmtorul cuprins:
"ART. 36^1
(1) Pentru recuperarea sumelor ncasate necuvenit, cu titlu de ajutor social, n condiiile art.
21 din lege se procedeaz dup cum urmeaz:
a) dac beneficiarul primete n continuare ajutor social, se vor face reineri ealonat din
drepturile aferente lunilor urmtoare, dar nu mai mult de 1/3 din aceste drepturi;
b) dac beneficiarul nu mai primete drepturi n perioada urmtoare constatrii debitului i
titularul consimte, prin angajament scris, s restituie suma ncasat necuvenit, acesta va achita
suma respectiv n contul ageniei teritoriale deschis la Trezoreria Statului sau la sediul acesteia
prin casierie, n termenul prevzut de decizia de recuperare;
c) dac titularul dreptului nu consimte la restituirea sumei i nu exist posibilitatea recuperrii
din alte drepturi, pe baza deciziei directorului executiv al ageniei teritoriale, care constituie titlu
executoriu conform art. 21 alin. (3) din lege, debitul se transmite la organele de executare silit
din cadrul unitilor administrativ-teritoriale, aceast instituie urmnd s confirme preluarea n
continuare a urmririi debitului respectiv;
d) debitorii declarai insolvabili se scad din activul ageniei teritoriale i se trec ntr-o
eviden special, cu respectarea procedurilor legale.
(2) n situaia n care beneficiarul ajutorului social este familia, iar titularul ajutorului social a
decedat, recuperarea sumelor ncasate necuvenit, cu titlu de ajutor social, n condiiile art. 21
din lege, se va face de la ceilali membri ai familiei, n calitate de beneficiari ai dreptului, cu
aplicarea corespunztoare a prevederilor alin. (1), precum i ale art. 32, dac situaia de fapt
impune schimbarea titularului i modificarea cuantumului ajutorului social.
(3) n situaia n care beneficiarul ajutorului social, persoan singur, a decedat, nu se mai
procedeaz la recuperarea sumelor ncasate necuvenit cu titlu de ajutor social."
17. La articolul 38, dup alineatul (2) se introduce un nou alineat, alineatul (2^1), cu
urmtorul cuprins:
"(2^1) n situaia n care se impune acordarea ajutorului de urgen n situaii deosebite care
afecteaz un numr mai mare de persoane, la efectuarea anchetei sociale se poate utiliza
modelul prevzut n anexa nr. 16a."
18. Anexele nr. 1, 2, 4 - 13 se modific i se nlocuiesc cu anexele nr. 1 - 12 la prezenta
hotrre.
19. Dup anexa nr. 16 se introduce o nou anex, anexa nr. 16a, al crei model este
prevzut n anexa nr. 13 la prezenta hotrre.
ART. II
Anexele nr. 1 i 2 la Normele metodologice de aplicare a prevederilor Legii nr. 277/2010
privind alocaia pentru susinerea familiei, aprobate prin Hotrrea Guvernului nr. 38/2011,
publicat n Monitorul Oficial al Romniei, Partea I, nr. 56 din 21 ianuarie 2011, cu
modificrile i completrile ulterioare, se modific i se nlocuiesc cu anexele nr. 1 i 2 la
prezenta hotrre.
ART. III
Normele metodologice de aplicare a prevederilor Ordonanei de urgen a Guvernului nr.
70/2011 privind msurile de protecie social n perioada sezonului rece, aprobate prin
Hotrrea Guvernului nr. 920/2011, publicat n Monitorul Oficial al Romniei, Partea I, nr.
678 din 23 septembrie 2011, cu modificrile ulterioare, se modific i se completeaz dup cum
urmeaz:
1. La articolul 1 alineatul (2), dup litera b) se introduce o nou liter, litera b^1), cu
urmtorul cuprins:
"b^1) ajutor pentru nclzirea locuinei cu energie electric, denumit n continuare ajutor
pentru energie electric;".
"ART. 3
(1) Ajutoarele prevzute la art. 1 se acord pe baz de cerere i declaraie pe propria
rspundere privind componena familiei i veniturile acesteia, precum i bunurile mobile i
imobile deinute.
(2) Pentru ajutoarele prevzute la art. 1 alin. (2) lit. a), formularele de cerere i declaraie pe
propria rspundere sunt transmise de ctre primrii furnizorilor, cu respectarea termenului
prevzut la art. 15 alin. (1) din ordonana de urgen, iar pentru ajutoarele prevzute la art. 1
alin. (2) lit. b), b^1) i c), formularele de cerere i declaraie sunt puse la dispoziia solicitanilor
direct de ctre primrii.
(3) Furnizorii prevzui la alin. (2) transmit formularele titularilor de contract, i anume
consumatorilor individuali i asociaiilor de proprietari/locatari, cu respectarea termenului
prevzut la art. 15 alin. (2) din ordonana de urgen.
(4) Formularul de cerere i declaraie pe propria rspundere va fi pus la dispoziia
solicitanilor i n format electronic, pe site-urile primriilor, al Ministerului Muncii, Familiei,
Proteciei Sociale i Persoanelor Vrstnice i Ageniei Naionale pentru Pli i Inspecie
Social, precum i pe site-urile ageniilor judeene pentru pli i inspecie social, respectiv a
municipiului Bucureti, denumite n continuare agenii teritoriale.
(5) Formularul de cerere i declaraie pe propria rspundere se completeaz potrivit
modelului prevzut n anexa nr. 1 la Normele metodologice de aplicare a prevederilor Legii nr.
416/2001 privind venitul minim garantat, aprobate prin Hotrrea Guvernului nr. 50/2011, cu
modificrile i completrile ulterioare."
"ART. 4
Familiile i persoanele singure care ndeplinesc condiiile pentru acordarea ajutoarelor
prevzute la art. 1 depun individual sau prin asociaiile de proprietari/locatari cererile i
declaraiile pe propria rspundere la primria comunei, oraului, municipiului sau, dup caz, a
sectorului municipiului Bucureti n a crei/crui raz teritorial se afl locuina de domiciliu

sau de reedin, cu respectarea termenului prevzut la art. 16 din ordonana de urgen."
"ART. 5
(1) Ajutoarele prevzute la art. 1 se acord n funcie de veniturile nete medii lunare pe
membru de familie, respectiv ale persoanei singure, n limitele, procentele i cuantumurile
stabilite la art. 8, 9, 10 i 11 din ordonana de urgen.
(2) La stabilirea venitului net mediu lunar pe membru de familie i, dup caz, al persoanei
singure se iau n calcul toate veniturile realizate de membrii acesteia n luna anterioar lunii n
care se solicit dreptul, potrivit prevederilor art. 18 din ordonana de urgen. n situaia n care
veniturile realizate de membrii familiei sau de persoana singur sunt anuale sau periodice,
pentru stabilirea venitului net lunar se calculeaz media lunar a acestora n raport cu perioada
pentru care au fost acordate.
(3) n cererea i declaraia pe propria rspundere solicitantul ajutorului prevzut la art. 1 are
obligaia de a meniona bunurile aflate n proprietate, nchiriere, concesiune, comodat sau alt
form de deinere, cuprinse n lista bunurilor ce conduc la excluderea acordrii ajutorului pentru
nclzirea locuinei. Persoanele care solicit ajutorul pentru energie termic au obligaia de a
completa numrul de camere ale locuinei.
(4) Lista menionat la alin. (3) este prevzut n anexa nr. 4 la Normele metodologice de
aplicare a prevederilor Legii nr. 416/2001 privind venitul minim garantat, aprobate prin
Hotrrea Guvernului nr. 50/2011, cu modificrile i completrile ulterioare.
(5) Pentru informarea solicitanilor, lista bunurilor ce conduc la excluderea acordrii
ajutorului pentru nclzirea locuinei, prevzut la alin. (4), se afieaz ntr-un loc vizibil la
sediul consiliului local al comunei, oraului, municipiului sau, dup caz, al sectorului
municipiului Bucureti."
"(1) Pe baza datelor cuprinse n cererea i declaraia pe propria rspundere, a actelor
doveditoare, precum i a informaiilor sau, dup caz, a documentelor obinute potrivit art. 14
alin. (5) din ordonana de urgen, primarul stabilete dreptul la ajutoarele prevzute la art. 1,
prin dispoziie scris. Dispoziia se emite o singur dat, pentru toat perioada sezonului rece."
6. La articolul 6, dup alineatul (1) se introduc trei noi alineate, alineatele (1^1) - (1^3),
cu urmtorul cuprins:
"(1^1) n cazul stabilirii dreptului la ajutorul pentru energie electric, primarul dispune, n
mod obligatoriu, efectuarea anchetei sociale la domiciliul sau reedina titularului ajutorului,
pentru verificarea sistemului de nclzire utilizat.
(1^2) Ancheta social se realizeaz de ctre serviciul public de asisten social definit la art.
113 din Legea asistenei sociale nr. 292/2011, cu respectarea termenului prevzut la art. 14 alin.
(7) din ordonana de urgen. Modelul anchetei sociale este cel prevzut n anexa nr. 2 la
Normele metodologice de aplicare a prevederilor Legii nr. 416/2001 privind venitul minim
garantat, aprobate prin Hotrrea Guvernului nr. 50/2011, cu modificrile i completrile
ulterioare.
(1^3) n cazul beneficiarilor de ajutor social i/sau alocaie pentru susinerea familiei, care
solicit ajutorul pentru energie electric, ancheta social se efectueaz numai n situaia n care
au trecut mai mult de 3 luni de la ultima actualizare a informaiilor potrivit art. 14^1 din Legea
nr. 416/2001 privind venitul minim garantat, cu modificrile i completrile ulterioare, respectiv
art. 24 i 25 din Legea nr. 277/2010 privind alocaia pentru susinerea familiei, republicat, cu
modificrile ulterioare."
7. La articolul 6 alineatul (2), dup litera b) se introduce o nou liter, litera b^1), cu
urmtorul cuprins:
"b^1) pentru ajutorul pentru energie electric: numele i prenumele titularului, codul numeric
personal, adresa locuinei pentru care se solicit dreptul, cuantumul maxim al ajutorului calculat
n funcie de venitul net mediu lunar pe membru de familie, respectiv al persoanei singure,
inclusiv cel acordat din bugetul local, n condiiile art. 10 alin. (1) i (2) din ordonana de
urgen, i perioada de acordare a acestuia;".
"ART. 8
(1) n aplicarea prevederilor art. 17 alin. (3) din ordonana de urgen, primarii au obligaia de
a transmite furnizorilor, asociaiilor de proprietari/locatari i ageniilor teritoriale situaii
centralizatoare cuprinznd n mod obligatoriu titularii ajutoarelor prevzute la art. 1 alin. (2) lit.
a), b) i c), numrul dispoziiei prin care s-a stabilit dreptul, venitul net lunar pe membru de
familie i valoarea ajutorului calculat n condiiile art. 8, 9 i 11 din ordonana de urgen,
precum i codul furnizorului, respectiv al clientului, n scris i n format electronic, ntocmite
potrivit modelelor prevzute n anexele nr. 1a, 1b i 1c. Situaiile centralizatoare se transmit
lunar, actualizate cu beneficiarii care ndeplinesc condiiile de acordare a ajutorului social pe
parcursul sezonului rece.
(2) n aplicarea prevederilor art. 17 alin. (3^1) din ordonana de urgen, primarii au obligaia
de a transmite furnizorilor de energie electric i ageniilor teritoriale situaia centralizatoare
cuprinznd n mod obligatoriu titularii ajutorului prevzut la art. 1 alin. (2) lit. b^1), numrul
dispoziiei prin care s-a stabilit dreptul, venitul net lunar pe membru de familie i valoarea
ajutorului calculat n condiiile art. 10 din ordonana de urgen, precum i codul furnizorului,
respectiv al clientului, n scris i n format electronic, ntocmite potrivit modelului prevzute n
anexa nr. 1d. Situaia centralizatoare se transmite lunar, actualizat cu beneficiarii care
ndeplinesc condiiile de acordare a ajutorului social pe parcursul sezonului rece."
"(1) Autoritile administraiei publice locale, n baza art. 8 alin. (8), art. 9 alin. (2), art. 10
alin. (2) i art. 11 alin. (3) din ordonana de urgen, pot aproba din bugetele proprii ajutoare
dup cum urmeaz:
a) prin majorri ale gradului de compensare n acelai procent pentru toi beneficiarii de
ajutor pentru energie termic ce se regsesc n aceeai tran de venituri;
b) prin majorri ale ajutorului pentru gaze naturale, energie electric i combustibili solizi sau
petrolieri cu acelai cuantum pentru toi beneficiarii care se regsesc n aceeai tran de
venituri;
c) prin acordarea de ajutoare pentru familiile i persoanele singure cu venituri care depesc
tranele de venituri prevzute de ordonana de urgen."
10. La articolul 13 alineatul (4), sintagma "anexa nr. 6" se nlocuiete cu sintagma
"anexa nr. 2".
"anexa nr. 3".
"anexa nr. 4".
"anexa nr. 5".
"anexa nr. 6".
"(2) Pe baza facturilor prevzute la alin. (1), furnizorul de gaze naturale ntocmete borderoul
centralizator cuprinznd beneficiarii ajutorului pentru gaze naturale i cuantumul efectiv al
acestuia, potrivit modelului prevzut n anexa nr. 7."
16. Dup articolul 22 se introduce o nou seciune, seciunea a 2^1-a "Ajutorul pentru
energie electric", alctuit din articolele 22^1 - 22^4, cu urmtorul cuprins:
"SECIUNEA a 2^1-a
Ajutorul pentru energie electric
ART. 22^1
n aplicarea prevederilor art. 17 alin. (3^1) din ordonana de urgen, primarii au obligaia de
a transmite furnizorilor i ageniilor teritoriale situaia centralizatoare privind beneficiarii,
venitul net lunar pe membru de familie i cuantumul ajutoarelor pentru energie electric stabilit
n condiiile art. 10 din ordonana de urgen.
ART. 22^2
(1) Pe baza consumului efectiv nregistrat de consumatorii vulnerabili individuali, furnizorul
stabilete cuantumul ajutorului efectiv, dup cum urmeaz:
a) la nivelul cuantumului ajutorului stabilit prin dispoziie a primarului, dac valoarea
consumului este mai mare sau egal cu acest nivel;
b) la valoarea consumului, dac acesta este mai mic dect cuantumul ajutorului stabilit prin
dispoziie a primarului.
(2) n situaia n care modalitatea de facturare practicat de ctre furnizorul de energie
electric conduce la emiterea a mai mult de 5 facturi pentru perioada sezonului rece, cuantumul
ajutorului efectiv stabilit potrivit prevederilor alin. (1), nsumat pe aceast perioad, nu poate
depi cuantumul nsumat al ajutorului pentru energie electric stabilit prin dispoziia
primarului pentru aceeai perioad.
ART. 22^3
(1) Furnizorii de energie electric transmit consumatorilor vulnerabili individuali, titulari de
contracte individuale, factura reprezentnd consumul de energie electric, cu respectarea
prevederilor art. 23 alin. (3) i (4) din ordonana de urgen, n care se evideniaz ajutorul
pentru energie electric calculat n condiiile art. 22^2 alin. (1) i (2).
(2) Pe baza facturilor prevzute la alin. (1), furnizorul de energie electric ntocmete
borderoul centralizator cuprinznd beneficiarii ajutorului pentru energie electric i cuantumul
efectiv al acestuia, potrivit modelului prevzut n anexa nr. 8.
ART. 22^4
(1) Borderoul centralizator prevzut la art. 22^3 alin. (2) reprezint document de plat, se
ntocmete de furnizor n 3 exemplare i se transmite primarilor pentru certificare.
(2) n termen de 5 zile de la primire, primarii certific i transmit un exemplar ageniilor

teritoriale, pe baza cruia acestea achit la furnizori sumele reprezentnd ajutoarele pentru
energie electric. Unul dintre celelalte dou exemplare certificate rmne la primar, iar cellalt
se remite furnizorului."
"(1) Ageniile teritoriale, pe baza situaiei centralizatoare prevzute la art. 24 alin. (2),
respectiv a borderourilor prevzute la art. 16 alin. (2), art. 21 alin. (2) i art. 22^3 alin. (2),
solicit Ageniei Naionale pentru Pli i Inspecie Social creditele bugetare corespunztoare
ajutoarelor prevzute la art. 1 alin. (2) suportate din bugetul de stat, conform art. 8 alin. (2) - (5),
art. 9 alin. (1), art. 10 alin. (1) i art. 11 alin. (1) din ordonana de urgen."
"a) n conturile de tip angajament scris n pstrarea unui ter, escrow, deschise de ctre
productorii i distribuitorii de energie termic, gaze naturale sau energie electric;".
19. La articolul 27, sintagma "anexele nr. 12 - 20" se nlocuiete cu sintagma "anexele
nr. 9 i 10".
"ART. 29
(1) Pentru recuperarea sumelor ncasate necuvenit, cu titlu de ajutor pentru nclzire, n
condiiile art. 30 alin. (4) din ordonana de urgen, se procedeaz dup cum urmeaz:
a) dac beneficiarul primete n continuare ajutor pentru nclzire, se vor face reineri
ealonat din drepturile aferente lunilor urmtoare;
b) dac beneficiarul nu mai primete drepturi n perioada urmtoare constatrii debitului i
titularul consimte, prin angajament scris, s restituie suma ncasat necuvenit, acesta va achita
suma respectiv la primrie, n termenul prevzut de dispoziia de recuperare;
c) dac titularul dreptului nu consimte la restituirea sumei i nu exist posibilitatea recuperrii
din alte drepturi, se transmite ntiinare la organele de executare silit din cadrul unitilor
administrativ-teritoriale, care vor confirma preluarea n continuare a urmririi debitului
respectiv;
d) sumele cu titlu de ajutor pentru nclzire diminuate n condiiile lit. a) nu se mai solicit
ageniilor teritoriale pentru decontare;
e) sumele ncasate n condiiile lit. b) se vireaz ageniilor teritoriale.
(2) n situaia n care beneficiarul este familia, iar titularul a decedat, recuperarea sumelor
ncasate necuvenit, cu titlu de ajutor, se va face de la ceilali membri ai familiei.
(3) n situaia n care beneficiarul, persoan singur, a decedat, nu se mai procedeaz la
recuperarea sumelor ncasate necuvenit."
21. Articolul 30 se abrog.
22. La articolul 33 alineatul (2) , sintagma "anexa nr. 23" se nlocuiete cu sintagma
"anexa nr. 11".
"ART. 34
Anexele nr. 1a - 1d i 2 - 11 fac parte integrant din prezentele norme metodologice."
24. Anexele nr. 1 - 23 se abrog i se nlocuiesc cu anexele nr. 1a - 1d i 2 - 11, al cror
model este prevzut n anexele nr. 14 - 27 la prezenta hotrre.
ART. IV
(1) Pentru drepturile de ajutor social acordat n baza Legii nr. 416/2001 privind venitul
minim garantat, cu modificrile i completrile ulterioare, precum i de alocaie pentru
susinerea familiei acordate n baza Legii nr. 277/2010, republicat, cu modificrile ulterioare,
stabilite anterior intrrii n vigoare a prezentei hotrri, primarii au obligaia s reevalueze
ndeplinirea condiiilor de acordare, precum i cuantumul dreptului, conform anexei nr. 3 la
prezenta hotrre, pn cel trziu la 31 martie 2014, cu excepia situaiei n care, n aceast
perioad, titularii acestor drepturi solicit acordarea ajutorului pentru nclzirea locuinei
prevzut de Ordonana de urgen a Guvernului nr. 70/2011 privind msurile de protecie
social n perioada sezonului rece, aprobat prin Legea nr. 92/2012, cu modificrile i
completrile ulterioare, caz n care, odat cu stabilirea acestui drept, se reevalueaz i drepturile
de ajutor social, respectiv de alocaie pentru susinerea familiei.
(2) Modificrile, suspendrile, ncetrile drepturilor menionate la alin. (2) se stabilesc prin
dispoziie a primarului care se comunic ageniilor pentru pli i inspecie social judeene,
respectiv a municipiului Bucureti conform procedurilor i n termenele prevzute de lege
pentru aceste drepturi.
(3) n situaia n care formularul cuprinznd cererea i declaraia pe propria rspundere n
vederea solicitrii ajutorului pentru nclzirea locuinei cu energie termic n sistem centralizat,
gaze naturale sau lemne, crbuni, combustibili petrolieri a fost completat potrivit modelului
aprobat n anexa nr. 1 la Normele metodologice de aplicare a prevederilor Ordonanei de
urgen a Guvernului nr. 70/2011 privind msurile de protecie social n perioada sezonului
rece, aprobate prin Hotrrea Guvernului nr. 920/2011, cu modificrile ulterioare, nainte de
modificrile aduse prin prezenta hotrre, ajutorul se va acorda pe baza acestui formular, sub
rezerva stabilirii dreptului conform modificrilor i completrilor aduse prin prezenta hotrre,
Normelor metodologice de aplicare a prevederilor Ordonanei de urgen a Guvernului nr.
70/2011 privind msurile de protecie social n perioada sezonului rece, aprobate prin
Hotrrea Guvernului nr. 920/2011, cu modificrile ulterioare.
ART. V
(1) Protocolul prevzut la art. 18 alin. (3) din Normele metodologice de aplicare a
prevederilor Legii nr. 416/2001 privind venitul minim garantat, aprobate prin Hotrrea
Guvernului nr. 50/2011, cu modificrile i completrile ulterioare, se ncheie n termen de
maximum 10 zile de la publicarea prezentei hotrri n Monitorul Oficial al Romniei, Partea I.
(2) O copie a protocolului va fi transmis ageniilor judeene pentru pli i inspecie social,
respectiv a municipiului Bucureti.
ART. VI
(1) Hotrrea Guvernului nr. 50/2011 pentru aprobarea Normelor metodologice de aplicare a
prevederilor Legii nr. 416/2001 privind venitul minim garantat, publicat n Monitorul Oficial
al Romniei, Partea I, nr. 76 din 28 ianuarie 2011, cu modificrile i completrile ulterioare,
precum i cu cele aduse prin prezenta hotrre, se va republica n Monitorul Oficial al
Romniei, Partea I, dndu-se textelor o nou numerotare.
(2) Hotrrea Guvernului nr. 920/2011 pentru aprobarea Normelor metodologice de aplicare
a prevederilor Ordonanei de urgen a Guvernului nr. 70/2011 privind msurile de protecie
social n perioada sezonului rece, publicat n Monitorul Oficial al Romniei, Partea I, nr. 678
din 23 septembrie 2011, cu modificrile ulterioare, precum i cu cele aduse prin prezenta
hotrre, se va republica n Monitorul Oficial al Romniei, Partea I, dndu-se textelor o nou

numerotare.
PRIM-MINISTRU
VICTOR-VIOREL PONTA
Contrasemneaz:
Ministrul muncii, familiei, proteciei sociale
i persoanelor vrstnice,
Mariana Cmpeanu
Viceprim-ministru, ministrul dezvoltrii
regionale i administraiei publice,
Nicolae-Liviu Dragnea
Viceprim-ministru,
ministrul finanelor publice,
Daniel Chioiu
p. Ministrul delegat pentru buget,
Gheorghe Gherghina,
secretar de stat
p. Ministrul economiei,
Bogdan Nicolae Badea,
secretar de stat
Ministrul delegat pentru energie,
Constantin Ni
Ministrul agriculturii i dezvoltrii rurale,
Daniel Constantin
Bucureti, 9 octombrie 2013.

Nr. 778.
ANEXA 1*)
(Anexa nr. 1 la normele metodologice)
*) Anexa nr. 1 este reprodus n facsimil.
______________________________________________________________________________
| UNITATEA ADMINISTRATIV
AGENIA NAIONAL PENTRU
|
| TERITORIAL .......
PLI I INSPECIE SOCIAL |
|______________________________________________________________________________|
CERERE - DECLARAIE PE PROPRIA RSPUNDERE

pentru acordarea unor drepturi de asisten social
Stimai ceteni, Statul romn, n conformitate cu prevederile constituionale, dorete s v
ajute s depii momentele speciale prin care trecei, dvs. i familia dvs. Pentru aceasta v
adresm rugmintea s citii cu foarte mult atenie formularul i s completai cu sinceritate
toate datele solicitate, conform indicaiilor de mai jos.
Cu sperana c situaia dvs. personal se va schimba n bine ct mai curnd, v mulumim
pentru nelegere!
CAP. 1
Acest capitol al cererii se completeaz de ctre solicitant. Dac solicitantul este persoana
ndreptit sau reprezentantul familiei, datele se vor repeta la cap. 2.
______________________________________________________________________________
| A. Subsemnatul(a):
|
| _______________
|
|| Numele
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
||
|
|| Prenumele
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
||_______________
|
| ______________________
|
|| Cod numeric personal
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
||______________________
|
| ____________________________________________________________________________ |
||
_
_
|
|| Cetenia?
|_| UE
|
|
||
_
_
> i anume (ara) ..................... |
||
|_| Romn
|_| Non-UE _|
|
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
||
|
|| Act de identitate/doveditor*) |_|_|_|_| Seria |_|_|_| Nr. |_|_|_|_|_|_|_|
|
|| (copie ataat)
|
|| Eliberat de |_|_|_|_|_|_|_|_|_|_|_|
La data de |__|__|__|__|__|__|__|__| |
||
(z z) (l l) (a a a a) |
||
|
|| *) Pentru cetenii romni:
Pentru cetenii strini Pentru cetenii
|
||
sau apatrizi:
UE, SEE sau
|
||
Confed. Elveian: |
|| BI - buletin de P - paaport PST - permis de edere
CIN - certificat
|
||
identitate
temporar
nregistrare |
|| CI - carte de
DI - document de
CR - carte de
|
||
identitate
identitate
reziden
|
|| CIP - carte de
PSTL - permis de edere
|
||
identitate
pe termen lung
|
||
provizorie
|
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
|| Domiciliul/Date de contact:
|
||
|
|| Strada |_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
||
|
|| Nr. |_|_|_| Bl. |_|_|_| Sc. |_|_| Et. |_|_| Apart. |_|_| Sector |_|_| |
||
|
|| Localitatea |_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
||
|
|| Jude |_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
|
||
|
|| Telefon |_|_|_|_|_|_|_|_|_|_|_|_|_|
Mobil |_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
|| Reedina (loc de edere obinuit) este n afara Romniei?
|
||
_
_
|
|| |_| Nu
|_| Da, n localitatea ................. ara ................ |
||____________________________________________________________________________ |
|______________________________________________________________________________|
_
_
_
|_| n nume propriu |_| n calitate de reprezentant |_| n numele persoanei
al familiei mele
ndreptite
V rog s aprobai acordarea:
_
_
|_| Ajutorului
|_| Alocaiei pt.
social
susinerea familiei
_
|_| Ajutorului
pentru nclzire
Pentru
CAP. 2
Date despre persoana ndreptit
______________________________________________________________________________
| _______________
|
|| Numele
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
||
|
|| Prenumele
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
||_______________
|
| ______________________
|
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
||______________________
|
| ____________________________________________________________________________ |
||
_
_
|
|| Cetenia?
|_| UE
|
|
||
_
_
> i anume (ara) ..................... |
||
|_| Romn
|_| Non-UE _|
|
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
||
|
|
|| (copie ataat)
|
|| Eliberat de |_|_|_|_|_|_|_|_|_|_|_|
La data de |__|__|__|__|__|__|__|__| |
||
(z z) (l l) (a a a a) |
||
|
|
||
sau apatrizi:
UE, SEE sau
|
||
Confed. Elveian: |
|| CN - Certificat
PST - permis de edere
CIN - certificat
|
||
de natere
temporar
nregistrare
|| BI - buletin de
DI - document de
CR - carte de
||
identitate
identitate
reziden
|| CI - carte de
||
identitate
pe termen lung
|| CIP - carte de
||
identitate
||
provizorie
|| P - paaport
||____________________________________________________________________________
| ____________________________________________________________________________
||
|| Strada |_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
||
|| Nr. |_|_|_| Bl. |_|_|_| Sc. |_|_| Et. |_|_| Apart. |_|_| Sector |_|_|
||
|| Localitatea |_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
||
|| Jude |_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
||
|| Telefon |_|_|_|_|_|_|_|_|_|_|_|_|_|
Mobil |_|_|_|_|_|_|_|_|_|_|_|_|_|_|
||____________________________________________________________________________
| ____________________________________________________________________________
||
_
_
_
|| Starea civil?
|_| cstorit() |_| necstorit() |_| uniune
||
consensual
||
_
_
_
||
|_| vduv()
|_| divorat()
|_| desprit()
||
n fapt
||____________________________________________________________________________
| ____________________________________________________________________________
||
_
|| Dac a locuit n afara rii n ultimii 2 ani? |_| Nu
||
_
|| _
| n perioada anilor ............... ara .....................
|| |_| Da <
||
|_ n perioada anilor ............... ara .....................
||____________________________________________________________________________
| ____________________________________________________________________________
||
_
_
_
_
|| Situaia colar? |_| fr studii |_| generale |_| medii
|_| superioare
||____________________________________________________________________________
| ____________________________________________________________________________
||
_
_
_
_
|| Situaia
|_| salariat
|_| pensionar |_| omer
|_| student
|| profesional?
_
_
_
_
||
|_| independent |_| lucrtor |_| lucrtor |_| elev
||
agricol
ocazional
||
||
Altele ..................................................
||____________________________________________________________________________
| ____________________________________________________________________________
||
_
|| Dac a lucrat n afara rii n ultimii 2 ani? |_| Nu
||
_
|| _
|| |_| Da <
||
||____________________________________________________________________________
|| Venituri totale realizate n luna
|| anterioar depunerii cererii?
|_|_|_|_| lei
||____________________________________________________________________________
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| ____________________________________________________________________________ |
|| Grad de dizabilitate?
|
|| _
_
|
|| |_| Nu
|_| Da (se vor ataa acte doveditoare)
|
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
|| Dac beneficiaz sau a beneficiat de unele drepturi de asisten social?
|
|| (se vor ataa acte doveditoare)
|
|| _
|
|| |_| Nu
|
|| _
_ _
_
|
|| |_| Da, din alte ri | |_| Ajutor Social
| Drepturi|
|| _
|
_
>n curs |
|| |_| Da, din Romnia <
|_| Alocaia pentru Susinerea Familiei _|
|
||
|
_
|
||
|_ |_| Ajutorul pentru nclzirea Locuinei
|
||
(pentru sezonul rece anterior)
|
||
_____________________________/\______________________
|
||
|
|
|
|| _________________________________________________________________________ |
|| | | Energie termic | | Gaze naturale | | Energie
| | Lemne, crbuni | |
|| | |
| |
| | electric
| |
| |
|| |_|_________________|_|_______________|_|______________|_|________________| |
||____________________________________________________________________________ |
|______________________________________________________________________________|
CAP. 3
Date despre familia persoanei ndreptite format din ....... persoane majore (inclusiv
persoana ndreptit) i ........ copii:
a) Date despre partenerul/partenera persoanei ndreptite:
______________________________________________________________________________
| _______________
|
|| Numele
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
||
|
|| Prenumele
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
||_______________
|
| ______________________
|
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
||______________________
|
| ____________________________________________________________________________ |
||
_
_
|
|| Cetenia?
|_| UE
|
|
||
_
_
> i anume (ara) .................... |
||
|_| Romn
|_| Non-UE _|
|
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
||
|
|
|| (copie ataat)
|
|| Eliberat de |_|_|_|_|_|_|_|_|_|_|_|
La data de |__|__|__|__|__|__|__|__| |
||
(z z) (l l) (a a a a) |
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
||
_
|
|
||
_
|
|| _
|
|| |_| Da <
|
||
|
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
||
_
_
_
_
|
|_| superioare |
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
||
_
_
_
_
|
|| Situaia
|_| salariat
|_| student |
|| profesional?
_
_
_
_
|
||
|
||
agricol
ocazional
|
||
|
||
Altele .................................................. |
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
||
_
|
|
||
_
|
|| _
|
|| |_| Da <
|
||
|
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
|
|_|_|_|_| lei
|
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
|
|| _
_
|
|| |_| Nu
|
||____________________________________________________________________________ |
|______________________________________________________________________________|
b) Date despre copiii persoanei ndreptite:

______________________________________________________________________________
| ________________________
|
||
Numele
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
|| 1.
|
||
Prenumele
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
||________________________
|
| ________________________
|
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
||________________________
|
| ______________________________
|
|| Act de identitate/doveditor*)
|
|| (copie ataat)
|
||_______________________________|_|_|_|_| Seria |_|_|_| Nr. |_|_|_|_|_|_|_|
|
| ____________________________________________________________________________ |
|| Relaia de rudenie
_
_
_
|
|| cu persoana
|_| copil
|_| copil
|_| copil n plasament |
|| ndreptit?
natural
adoptat
familial
|
||
_
_
_
|
||
|_| copil n
|_| copil n |_| copil ncredinat
|
||
tutel
curatel
spre adopie
|
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
||
_
_
_
_
|
|| Situaia colar? |_| precolar
|_| elev
| | coala nr. ..... |
||
cls. I - VIII | |
|
||
_
_
><
|
||
|_| fr studii |_| elev
| | Loc. ........... |
||
cls. IX - XII _| |_
|
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
|
|| _
_
|
|| |_| Nu
|
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
|| Dac beneficiaz de unele drepturi de asisten social?
|
|
|| _
_
_
|
|| |_| Nu
|_| Da, din alte ri
|_| Da, din Romnia
|
||____________________________________________________________________________ |
|______________________________________________________________________________|
*) Pentru cetenii romni:
Pentru cetenii strini

sau apatrizi:
CN - certificat
de natere
BI - buletin de
identitate
CI - carte de
identitate
CIP - carte de
identitate
provizorie
P - paaport

temporar
DI - document de
identitate
pe termen lung
Pentru cetenii
UE, SEE sau
Confed. Elveian:
CIN - certificat
nregistrare
CR - carte de
reziden
______________________________________________________________________________
| ________________________
|
||
Numele
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
|| 2.
|
||
Prenumele
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
||________________________
|
| ________________________
|
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
||________________________
|
| ______________________________
|
|
|| (copie ataat)
|
||_______________________________|_|_|_|_| Seria |_|_|_| Nr. |_|_|_|_|_|_|_|
|
| ____________________________________________________________________________ |
_
_
_
|
|| cu persoana
|_| copil
|_| copil
|| ndreptit?
natural
adoptat
familial
|
||
_
_
_
|
||
|_| copil n
|
||
tutel
curatel
spre adopie
|
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
||
_
_
_
_
|
|_| elev
| | coala nr. ..... |
||
cls. I - VIII | |
|
||
_
_
><
|
||
| | Loc. ........... |
||
cls. IX - XII _| |_
|
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
|
|| _
_
|
|| |_| Nu
|
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
|

|
|| _
_
_
|
|| |_| Nu
|_| Da, din alte ri
|_| Da, din Romnia
|
||____________________________________________________________________________ |
|______________________________________________________________________________|
______________________________________________________________________________
| ________________________
|
||
Numele
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
|| 3.
|
||
Prenumele
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
||________________________
|
| ________________________
|
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
||________________________
|
| ______________________________
|
|
|| (copie ataat)
|
||_______________________________|_|_|_|_| Seria |_|_|_| Nr. |_|_|_|_|_|_|_|
|
| ____________________________________________________________________________ |
_
_
_
|
|| cu persoana
|_| copil
|_| copil
|| ndreptit?
natural
adoptat
familial
|
||
_
_
_
|
||
|_| copil n
|
||
tutel
curatel
spre adopie
|
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
||
_
_
_
_
|
|_| elev
| | coala nr. ..... |
||
cls. I - VIII | |
|
||
_
_
><
|
||
| | Loc. ........... |
||
cls. IX - XII _| |_
|
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
|
|| _
_
|
|| |_| Nu
|
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
|
|
|| _
_
_
|
|| |_| Nu
|_| Da, din alte ri
|_| Da, din Romnia
|
||____________________________________________________________________________ |
|______________________________________________________________________________|
______________________________________________________________________________
| ________________________
|
||
Numele
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
|| 4.
|
||
Prenumele
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
||________________________
|
| ________________________
|
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
||________________________
|
| ______________________________
|
|
|| (copie ataat)
|
||_______________________________|_|_|_|_| Seria |_|_|_| Nr. |_|_|_|_|_|_|_|
|
| ____________________________________________________________________________ |
_
_
_
|
|| cu persoana
|_| copil
|_| copil
|| ndreptit?
natural
adoptat
familial
|
||
_
_
_
|
||
|_| copil n
|
||
tutel
curatel
spre adopie
|
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
||
_
_
_
_
|
|_| elev
| | coala nr. ..... |
||
cls. I - VIII | |
|
||
_
_
><
|
||
| | Loc. ........... |
||
cls. IX - XII _| |_
|
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
|
|| _
_
|
|| |_| Nu
|
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
|
|
|| _
_
_
|
|| |_| Nu
|_| Da, din alte ri
|_| Da, din Romnia
|
||____________________________________________________________________________ |
|______________________________________________________________________________|

sau apatrizi:
CN - certificat
de natere
BI - buletin de
identitate
CI - carte de
identitate
CIP - carte de
identitate
provizorie
P - paaport

temporar
DI - document de
identitate
pe termen lung
Pentru cetenii
UE, SEE sau
Confed. Elveian:
CIN - certificat
nregistrare
CR - carte de
reziden
c) Date despre celelalte persoane majore din familia persoanei ndreptite:

______________________________________________________________________________
| ________________________
|
||
Numele
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
|| 1.
|
||
Prenumele
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
||________________________
|
| ________________________
|
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
||________________________
|
| ____________________________________________________________________________ |
||
_
_
|
|| Cetenia?
|_| UE
|
|
||
_
_
> i anume (ara) ..................... |
||
|_| Romn
|_| Non-UE _|
|
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
||
|
|
|| (copie ataat)
|
|| Eliberat de |_|_|_|_|_|_|_|_|_|_|_|
La data de |__|__|__|__|__|__|__|__| |
||
(z z) (l l) (a a a a) |
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
||
_
|
|
||
_
|
|| _
|
|| |_| Da <
|
||
|
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
||
_
_
_
_
|
|_| superioare |
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
||
_
_
_
_
|
|| Situaia
|_| salariat
|_| student |
|| profesional?
_
_
_
_
|
||
|
||
agricol
ocazional
|
||
|
||
Altele .................................................. |
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
||
_
|
|
||
_
|
|| _
|
|| |_| Da <
|
||
|
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
|
|_|_|_|_| lei
|
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
|
|| _
_
|
|| |_| Nu
|
||____________________________________________________________________________ |
|______________________________________________________________________________|
______________________________________________________________________________
| ________________________
|
||
Numele
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
|| 2.
|
||
Prenumele
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
||________________________
|
| ________________________
|
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
||________________________
|
| ____________________________________________________________________________ |
||
_
_
|
|| Cetenia?
|_| UE
|
|
||
_
_
> i anume (ara) ..................... |
||
|_| Romn
|_| Non-UE _|
|
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
||
|
|
|| (copie ataat)
|
|| Eliberat de |_|_|_|_|_|_|_|_|_|_|_|
La data de |__|__|__|__|__|__|__|__| |
||
(z z) (l l) (a a a a) |
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
||
_
|

|
||
_
|
|| _
|
|| |_| Da <
|
||
|
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
||
_
_
_
_
|
|_| superioare |
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
||
_
_
_
_
|
|| Situaia
|_| salariat
|_| student |
|| profesional?
_
_
_
_
|
||
|
||
agricol
ocazional
|
||
|
||
Altele .................................................. |
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
||
_
|
|
||
_
|
|| _
|
|| |_| Da <
|
||
|
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
|
|_|_|_|_| lei
|
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
|
|| _
_
|
|| |_| Nu
|
||____________________________________________________________________________ |
|______________________________________________________________________________|
______________________________________________________________________________
| ________________________
|
||
Numele
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
|| 3.
|
||
Prenumele
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
||________________________
|
| ________________________
|
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
||________________________
|
| ____________________________________________________________________________ |
||
_
_
|
|| Cetenia?
|_| UE
|
|
||
_
_
> i anume (ara) ..................... |
||
|_| Romn
|_| Non-UE _|
|
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
||
|
|
|| (copie ataat)
|
|| Eliberat de |_|_|_|_|_|_|_|_|_|_|_|
La data de |__|__|__|__|__|__|__|__| |
||
(z z) (l l) (a a a a) |
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
||
_
|
|
||
_
|
|| _
|
|| |_| Da <
|
||
|
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
||
_
_
_
_
|
|_| superioare |
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
||
_
_
_
_
|
|| Situaia
|_| salariat
|_| student |
|| profesional?
_
_
_
_
|
||
|
||
agricol
ocazional
|
||
|
||
Altele .................................................. |
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
||
_
|
|
||
_
|
|| _
|
|| |_| Da <
|
||
|
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
|
|_|_|_|_| lei
|
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
|
|| _
_
|
|| |_| Nu
|
||____________________________________________________________________________ |
|______________________________________________________________________________|
______________________________________________________________________________
| ________________________
|
||
Numele
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
|| 4.
|
||
Prenumele
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
||________________________
|
| ________________________
|
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
||________________________
|
| ____________________________________________________________________________ |
||
_
_
|
|| Cetenia?
|_| UE
|
|
||
_
_
> i anume (ara) ..................... |
||
|_| Romn
|_| Non-UE _|
|
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
||
|
|
|| (copie ataat)
|
|| Eliberat de |_|_|_|_|_|_|_|_|_|_|_|
La data de |__|__|__|__|__|__|__|__| |
||
(z z) (l l) (a a a a) |
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
||
_
|
|
||
_
|
|| _
|
|| |_| Da <
|
||
|
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
||
_
_
_
_
|
|_| superioare |
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
||
_
_
_
_
|
|| Situaia
|_| salariat
|_| student |
|| profesional?
_
_
_
_
|
||
|
||
agricol
ocazional
|
||
|
||
Altele .................................................. |
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
||
_
|
|
||
_
|
|| _
|
|| |_| Da <
|
||
|
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
|
|_|_|_|_| lei
|
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
|
|| _
_
|
|| |_| Nu
|
||____________________________________________________________________________ |
|______________________________________________________________________________|
CAP. 4
n continuare se vor completa date privind locuina familiei/persoanei singure ndreptit:
______________________________________________________________________________
| ____________________________________________________________________________ |
|| Familia/persoana singur ndreptit locuiete:
|
|| _
_
|
|| |_| singur
|_| mpreun cu alt persoan singur sau familie |
||____________________________________________________________________________ |
| ____________________________________________ ______________________________ |
|| Model locuin:
| Regimul juridic al locuinei |
|| _____________________
|
|
||| | Cas cu curte
|\
| _
|
|||_|___________________| |
||_| Proprietate personal
|
|| _____________________ |
|
|
||| | Cas fr curte
| |
| _
|
|||_|___________________| |
/ _____________ ||_| n nchiriere public/privat|
|| _____________________ | | | | 1 camer | |
|
||| | Apartament la bloc| | | |_|___________| |
|
|||_|___________________| | | _____________ | Altele ...................... |
|| _____________________ | | | | 2 camere | |______________________________ |
||| | Locuin social | | | |_|___________|
|
|||_|___________________| | | _____________
______________________________ |
|| _____________________ | | | | 3 camere | | Modul de dobndire al
|
||| | Locuin de
| >< |_|___________| | locuinei
|
||| | serviciu
| | | _____________ |
|
|||_|___________________| | | | | 4 camere | | _
|
|| _____________________ | | |_|___________| ||_| Cumprare
|
||| | Locuin de
| | | _____________ |
|
||| | necesitate
| | | | | > 4 camere| | _
|
|||_|___________________| | | |_|___________| ||_| Motenire
|
|| _____________________ |
\
|
|
||| | Instituionalizat/| |
|
|
||| | nu are locuin
| |
| Altele ...................... |
|||_|___________________|/
|
|
||____________________________________________ |______________________________ |
| ____________________________________________________________________________ |
|| Tipul locuinei
|
||
________________________________________________________________________ |
|| _ | TIP A | construcia cu structura de rezisten din beton armat, metal, ||
||| ||
| lemn, piatr, crmid ars sau din orice alte materiale
||
|||_||
| 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
||
||
|_______|________________________________________________________________||
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
|| Dac are ncheiat poli de asigurare a locuinei?
|
|| _
_
|
|| |_| Nu
|_| Da, la societatea ....................................... |
||
|
|| Nr. poli .............. Valabil de la ........... La ................... |
||
|
|| Dac polia acoper riscurile obligatorii (cutremur, alunecri de teren,
|
|| inundaii)
|
|| _
_
|
|| |_| Nu
|_| Da
|
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
|| Familia/persoana singur ndreptit se nclzete cu:
|
|| _
|
|||_| ENERGIE TERMIC
Denumire furnizor |_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
||
|
||
Codul titularului de contract |_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
|| _
|
|||_| GAZE NATURALE
||
|
||
Codul client |_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
|| _
|
|||_| COMBUSTIBILI SOLIZI I LICHIZI (lemne, crbuni, combustibili petrolieri) |
|| _
|
|||_| ENERGIE ELECTRIC Denumire furnizor |_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
||
|
||
Codul client |_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
||____________________________________________________________________________ |
|______________________________________________________________________________|
CAP. 5
n acest Capitol se vor completa datele privind toate veniturile i bunurile familiei/persoanei
singure ndreptite n luna ....................
______________________________________________________________________________
| ____________________________________________________________________________ |
||Cod|
Categoria de venituri
| Acte
|Venitul
||
||
|
| doveditoare*) |realizat**)||
||
|
|
|lei
||
||___|____________________________________________|_______________|___________||
| ____________________________________________________________________________ |
|| VENITURI DIN ACTIVITI INDEPENDENTE

||
||____________________________________________________________________________||
|| 1| Venituri din profesii libere veniturile
| adeverin
| | | | | | ||
||
| obinute din exercitarea profesiilor
| eliberat de | | | | | | ||
||
| medicale, de avocat, notar, auditor
| Administraia | | | | | | ||
||
| financiar, consultant fiscal, expert
| financiar
| | | | | | ||
||
| 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 de
| adeverina
| | | | | | ||
||
| 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 asociat
| adeverin
| | | | | | ||
||
| sau persoan autorizat s desfoare o
| eliberat de | | | | | | ||
||
| activitate independent
| Adm.
| | | | | | ||
||
|
| financiar
| | | | | | ||
||___|____________________________________________|_______________|_|_|_|_|_|_||
|| 9| Indemnizaia de omaj i/sau venit lunar de| mandat potal/| | | | | | ||
||
| completare
| extras de
| | | | | | ||
||
|
| cont/decizie | | | | | | ||
||___|____________________________________________|_______________|_|_|_|_|_|_||
|| 10| Indemnizaiile din activiti desfurate | adeverin
| | | | | | ||
||
| ca urmare a unei funcii de demnitate
| eliberat de | | | | | | ||
||
| public, stabilite potrivit legii
| Adm.
| | | | | | ||
||___|____________________________________________| 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
|
| | | | | | ||
||___|____________________________________________|
|_|_|_|_|_|_||
|
| | | | | | ||
||
| 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 i | adeverin
| | | | | | ||
||
| suma din profitul net cuvenite
| eliberat de | | | | | | ||
||
| administratorilor societilor comerciale | Adm.
| | | | | | ||
||
| potrivit actului constitutiv sau stabilite | financiar
| | | | | | ||
||
| 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
|
| | | | | | ||
||
| salarial ori asimilate salariilor n
|
| | | | | | ||
||
| vederea impunerii
|
| | | | | | ||
||___|____________________________________________|_______________|_|_|_|_|_|_||
| ____________________________________________________________________________ |
|| VENITURI DIN CEDAREA FOLOSINEI BUNURILOR
||
||____________________________________________________________________________||
|| 25| Veniturile, n bani i/sau n natur,
| adeverin
| | | | | | ||
||
| provenind din cedarea folosinei bunurilor | eliberat de | | | | | | ||
||
| mobile i imobile, obinute de ctre
| Adm.
| | | | | | ||
||
| proprietar, uzufructuar sau alt deintor | financiar
| | | | | | ||
||
| legal, altele dect veniturile din
|
| | | | | | ||
||
| activiti independente
|
| | | | | | ||
||___|____________________________________________|_______________|_|_|_|_|_|_||
| ____________________________________________________________________________ |
|| VENITURI DIN INVESTIII
||
||____________________________________________________________________________||
|| 26| Dividende
| adeverin
| | | | | | ||
||___|____________________________________________| eliberat de |_|_|_|_|_|_||
|| 27| Venituri impozabile din dobnzi
| Adm.
| | | | | | ||
||___|____________________________________________| financiar
|_|_|_|_|_|_||
|| 28| Ctiguri din transferul titlurilor de
|
| | | | | | ||
||
| valoare
|
| | | | | | ||
||___|____________________________________________|_______________|_|_|_|_|_|_||
|| 29| Venituri din operaiuni de
| adeverin
| | | | | | ||
||
| vnzare-cumprare de valut la termen, pe | eliberat de | | | | | | ||
||
| baz de contract, precum i orice alte
| Adm.
| | | | | | ||
||
| operaiuni similare
| financiar
| | | | | | ||
||___|____________________________________________|
|_|_|_|_|_|_||
|| 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
|_|_|_|_|_|_||
| cont/decizie | | | | | | ||
||___|____________________________________________|
|_|_|_|_|_|_||
|
| | | | | | ||
||___|____________________________________________|
|_|_|_|_|_|_||
|| 40| Pensia I.O.V.R.
|
| | | | | | ||
||___|____________________________________________|_______________|_|_|_|_|_|_||
| ____________________________________________________________________________ |
|| INDEMNIZAII
||
||____________________________________________________________________________||
|| 41| Indemnizaia pt. persoanele care i-au
| mandat potal/| | | | | | ||
||
| pierdut total sau parial capacitatea de
| extras de
| | | | | | ||
||
| munc ca urmare a participrii la revoluie| cont/decizie | | | | | | ||
||
| i pt. urmaii acestora
|
| | | | | | ||
||___|____________________________________________|
|_|_|_|_|_|_||
|| 42| Indemnizaia de nsoitor pentru pensionari|
| | | | | | ||
||
| gr. I invaliditate/nevztori handicap grav|
| | | | | | ||
||___|____________________________________________|_______________|_|_|_|_|_|_||
|| 43| Indemnizaia pentru incapacitatea temporar| adeverin
| | | | | | ||
||
| de munc
| 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
| | | | | | ||
||
|
| angajator
| | | | | | ||
||___|____________________________________________|_______________|_|_|_|_|_|_||
|| 46| Indemnizaia pentru creterea copilului
| mandat potal/| | | | | | ||
||
| pn la vrsta de 1, 2 sau 3 ani
| extras de
| | | | | | ||
||___|____________________________________________| cont/decizie |_|_|_|_|_|_||
|| 47| Stimulent lunar/de inserie
|
| | | | | | ||
||___|____________________________________________|
|_|_|_|_|_|_||
|| 48| Indemnizaia i ajutoare pentru creterea |
| | | | | | ||
||
| copilului cu handicap
|
| | | | | | ||
||___|____________________________________________|_______________|_|_|_|_|_|_||
| ____________________________________________________________________________ |
|| INDEMNIZAII CU CARACTER PERMANENT
||
||____________________________________________________________________________||
|| 49| Indemnizaia lunar acordat magistrailor | mandat potal/| | | | | | ||
||
| nlturai din justiie din considerente
| extras de
| | | | | | ||
||
| 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 care | mandat potal/| | | | | | ||
||
| au efectuat stagiul militar n cadrul
| extras de
| | | | | | ||
||
| Direciei Generale a Serviciului Muncii n | cont/decizie | | | | | | ||
||
| 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 valorificarea
| adeverin
| | | | | | ||
||
| florilor, legumelor i zarzavaturilor, n | eliberat de | | | | | | ||
||
| sere i solarii special destinate acestor | Administraia | | | | | | ||
||
| scopuri i/sau n sistem irigat
| financiar
| | | | | | ||
||___|____________________________________________|
|_|_|_|_|_|_||
|
| | | | | | ||
||
| arbutilor, plantelor decorative i
|
| | | | | | ||
||
| ciupercilor
|
| | | | | | ||
||___|____________________________________________|_______________|_|_|_|_|_|_||
|| 60| Venituri din exploatarea pepinierelor
| adeverin
| | | | | | ||
||
| viticole i pomicole i altele asemenea
| eliberat de | | | | | | ||
||___|____________________________________________| Administraia |_|_|_|_|_|_||
|| 61| Venituri din valorificarea produselor
| financiar
| | | | | | ||
||
| 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 veniturile| adeverin
| | | | | | ||
||
| din concursuri
| eliberat de | | | | | | ||
||___|____________________________________________| Administraia |_|_|_|_|_|_||
|| 63| Veniturile din jocuri de noroc ce cuprind | financiar
| | | | | | ||
||
| 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 cu titlu de | Administraia | | | | | | ||
||
| motenire
| financiar
| | | | | | ||
||___|____________________________________________|_______________|_|_|_|_|_|_||
| ____________________________________________________________________________ |
|| VENITURI DIN ALTE SURSE
||
||____________________________________________________________________________||
|| 65| Prime de asigurri suportate de o persoan | adeverin
| | | | | | ||
||
| fizic independent sau de orice alt
| eliberat de | | | | | | ||
||
| entitate, n cadrul unei activiti pentru | Administraia | | | | | | ||
||
| o persoan fizic n legtur cu care
| financiar
| | | | | | ||
||
| 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 - Cu excepia burselor de studiu i a burselor sociale precum i a
||
|| sprijinului financiar prevzut de H.G. nr. 1488/2004
||
||____________________________________________________________________________||
|| 74| Burse pentru elevi
| adeverin
| | | | | | ||
||___|____________________________________________| instituie
|_|_|_|_|_|_||
|| 75| Burse pentru studeni
| nvmnt
| | | | | | ||
||___|____________________________________________|_______________|_|_|_|_|_|_||
| ____________________________________________________________________________ |
|| AJUTOARE
||
||____________________________________________________________________________||
|| 76| Ajutorul bnesc lunar pentru persoanele
| mandat potal/| | | | | | ||
||
| care au devenit incapabile de munc n
| extras de
| | | | | | ||
||
| perioada efecturii unei pedepse privative | cont/decizie | | | | | | ||
||
| de libertate
|
| | | | | | ||
||___|____________________________________________|_______________|_|_|_|_|_|_||
| ____________________________________________________________________________ |
|| ALTE SURSE DE VENIT
||
||____________________________________________________________________________||
|| 77| Depozite bancare
| adeverin
| | | | | | ||
||___|____________________________________________| eliberat de |_|_|_|_|_|_||
|| 78| Rent viager agricol
| instituiile | | | | | | ||
||___|____________________________________________| competente
|_|_|_|_|_|_||
|| 79| Alte venituri (inclusiv din arend)
|
| | | | | | ||
||___|____________________________________________|
|_|_|_|_|_|_||
|| 80| Sume primite din proiecte cu finanare
|
| | | | | | ||
||
| internaional nerambursabil
|
| | | | | | ||
||___|____________________________________________|_______________|_|_|_|_|_|_||
| ____________________________________________________________________________ |
|| FAMILIA/PERSOANA SINGUR BENEFICIAZ DE UNELE DREPTURI SPECIALE CONFORM
||
|| CONTRACTULUI COLECTIV SAU INDIVIDUAL DE MUNC? (se vor meniona natura lor ||
|| i valoarea)
||
||____________________________________________________________________________||
|| 81|
|
| | | | | | ||
||___|____________________________________________|_______________|_|_|_|_|_|_||
|| 82|
|
| | | | | | ||
||___|____________________________________________|_______________|_|_|_|_|_|_||
|| 83|
|
| | | | | | ||
||___|____________________________________________|_______________|_|_|_|_|_|_||
| ____________________________________________________________________________ |
|| VENIT LUNAR TOTAL AL FAMILIEI
| | | | | | ||
||________________________________________________________________|_|_|_|_|_|_||
| ____________________________________________________________________________ |
|| VENIT NET LUNAR PE MEMBRU DE FAMILIE
| | | | | | ||
||________________________________________________________________|_|_|_|_|_|_||
|______________________________________________________________________________|
*) Se vor anexa pentru fiecare membru de familie

**) Pentru aceeai categorie de venituri se va nscrie suma total a acestora.
______________________________________________________________________________
| Familia/persoana singur ndreptit deine n proprietate/folosin?
|
|
|
| Bunuri imobile
|
| _
|
| |_| Cldiri sau spaii locative, altele dect locuina de domiciliu i
|
|
anexele gospodreti
|
| _
|
| |_| Terenuri de mprejmuire a locuinei i curtea aferent i alte terenuri |
|
intravilane care depesc 1.000 mp n zona urban i 2.000 mp n zona
|
|
rural
|
|
|
| Bunuri mobile, aflate n stare de funcionare
|
| _
|
| |_| Autoturism i/sau motociclet cu o vechime mai mic de 10 ani
|
| _
|
| |_| Dou sau mai multe autoturisme i/sau motociclete cu o vechime mai mare |
|
de 10 ani
|
| _
|
| |_| Autovehicule: autoutilitare, autocamioane de orice fel cu sau fr
|
|
remorci, rulote, autobuze, microbuze
|
| _
|
| |_| alupe, brci cu motor, scutere de ap, iahturi
|
| _
|
| |_| Utilaje agricole: tractor, combin autopropulsat
|
| _
|
| |_| Utilaje de prelucrare agricol: pres de ulei, moar de cereale
|
| _
|
| |_| Utilaje de prelucrat lemnul: gater sau alte utilaje acionate hidraulic, |
|
mecanic sau electric
|
|
|
| Terenuri, animale i psri din gospodrie
|
| ____________________________________________________________________________ |
|| 1 | Gru comun (ha)
|
||
||____|___________________________________________________________________|___||
|| 2 | Gru dur (ha)
|
||
||____|___________________________________________________________________|___||
|| 3 | Secar (ha)
|
||
||____|___________________________________________________________________|___||
|| 4 | Orz (ha)
|
||
||____|___________________________________________________________________|___||
|| 5 | Orzoaic (ha)
|
||
||____|___________________________________________________________________|___||
|| 6 | Ovz (ha)
|
||
||____|___________________________________________________________________|___||
|| 7 | Amestecuri de cereale de var (ha)

|
||
||____|___________________________________________________________________|___||
|| 8 | Porumb boabe (ha)
|
||
||____|___________________________________________________________________|___||
|| 9 | Orez (ha)
|
||
||____|___________________________________________________________________|___||
|| 10 | Alte cereale (ha)
|
||
||____|___________________________________________________________________|___||
|| 11 | Mazre, fasole de cmp i lupin dulce (ha)
|
||
||____|___________________________________________________________________|___||
|| 12 | Linte, nut i mazariche (ha)
|
||
||____|___________________________________________________________________|___||
|| 13 | Alte culturi proteice (ha)
|
||
||____|___________________________________________________________________|___||
|| 14 | Cartofi (ha)
|
||
||____|___________________________________________________________________|___||
|| 15 | Sfecl de zahr - fr seminceri (ha)
|
||
||____|___________________________________________________________________|___||
|| 16 | Rapi (ha)
|
||
||____|___________________________________________________________________|___||
|| 17 | Floarea soarelui (ha)
|
||
||____|___________________________________________________________________|___||
|| 18 | Soia (ha)
|
||
||____|___________________________________________________________________|___||
|| 19 | In pentru ulei (ha)
|
||
||____|___________________________________________________________________|___||
|| 20 | Altele (ricin, mac, mutar, s.a) (ha)
|
||
||____|___________________________________________________________________|___||
|| 21 | Hamei (fr seminceri) (ha)
|
||
||____|___________________________________________________________________|___||
|| 22 | Tutun (ha)
|
||
||____|___________________________________________________________________|___||
|| 23 | Plante medicinale, condimentare, aromatice (ha)
|
||
||____|___________________________________________________________________|___||
|| 24 | In pentru fibr (ha)
|
||
||____|___________________________________________________________________|___||
|| 25 | Cnepa (ha)
|
||
||____|___________________________________________________________________|___||
|| 26 | Alte culturi industriale (inclusiv in, cnepa pt. fibr) (ha)
|
||
||____|___________________________________________________________________|___||
|| 27 | Legume proaspete, pepeni, cpuni n cmp (ha)
|
||
||____|___________________________________________________________________|___||
|| 28 | Legume proaspete, pepeni, cpuni n grdin (ha)
|
||
||____|___________________________________________________________________|___||
|| 29 | Legume proaspete, pepeni, cpuni n sistem protejat (ha)
|
||
||____|___________________________________________________________________|___||
|| 30 | Ciuperci (100 m2)
|
||
||____|___________________________________________________________________|___||
|| 31 | Flori, plante ornamentale cult. n aer liber (ha)
|
||
||____|___________________________________________________________________|___||
|| 32 | Flori, plante ornamentale cult. n sist. protejat
|
||
||____|___________________________________________________________________|___||
|| 33 | Semine de iarb (graminee i legumin. furaj) (ha)
|
||
||____|___________________________________________________________________|___||
|| 34 | Alte semine (pt hortic, cult arabile fr cereale, cartofi,
|
||
||
| oleaginoase) (ha)
|
||
||____|___________________________________________________________________|___||
|| 35 | Culturi furajere rdcinoase (sfecl furajer, napi, morcovi
|
||
||
| furajeri) (ha)
|
||
||____|___________________________________________________________________|___||
|| 36 | Porumb furajer pentru siloz (ha)
|
||
||____|___________________________________________________________________|___||
|| 37 | Alte cereale pentru siloz (ha)
|
||
||____|___________________________________________________________________|___||
|| 38 | Alte plante furajere (ha)
|
||
||____|___________________________________________________________________|___||
|| 39 | Terenuri productive i necultivate (ha)
|
||
||____|___________________________________________________________________|___||
|| 40 | Alte culturi arabile neincluse (ha)
|
||
||____|___________________________________________________________________|___||
|| 41 | Pajiti i puni permanente (ha)
|
||
||____|___________________________________________________________________|___||
|| 42 | Puni srace, de obicei nefertilizate i necultivate (ha)
|
||
||____|___________________________________________________________________|___||
|| 43 | Livezi de mr, pr (ha)
|
||
||____|___________________________________________________________________|___||
|| 44 | Livezi de prun, piersic, cais, cire (ha)
|
||
||____|___________________________________________________________________|___||
|| 45 | Livezi de nuc, alun, migdal, castan (ha)
|
||
||____|___________________________________________________________________|___||
|| 46 | Livezi de coacz, smochin, zmeur (ha)
|
||
||____|___________________________________________________________________|___||
|| 47 | Struguri pentru mas (ha)
|
||
||____|___________________________________________________________________|___||
|| 48 | Struguri pentru vin de calitate (ha)
|
||
||____|___________________________________________________________________|___||
|| 49 | Struguri pentru vin de mas (ha)
|
||
||____|___________________________________________________________________|___||
|| 50 | Pepiniere fr silvicultur (ha)
|
||
||____|___________________________________________________________________|___||
|| 51 | Alte culturi permanente (rchit, salcie) (ha)
|
||
||____|___________________________________________________________________|___||
|| 52 | Cabaline (buc.)
|
||
||____|___________________________________________________________________|___||
|| 53 | Viei pt. ngrat
|
||
||____|___________________________________________________________________|___||
|| 54 | Viei sub un an (buc.)
|
||
||____|___________________________________________________________________|___||
|| 55 | Turai de la 1 la 2 ani (buc.)
|
||
||____|___________________________________________________________________|___||
|| 56 | Viele de la 1 la 2 ani (buc.)
|
||
||____|___________________________________________________________________|___||
|| 57 | Turai de 2 ani i mai mult (buc.)
|
||
||____|___________________________________________________________________|___||
|| 58 | Juninci de reproducie (buc.)
|
||
||____|___________________________________________________________________|___||
|| 59 | Viele pt ngrat (buc.)
|
||
||____|___________________________________________________________________|___||
|| 60 | Vaci de lapte (buc.)
|
||
||____|___________________________________________________________________|___||
|| 61 | Vaci de lapte la reform (buc.)
|
||
||____|___________________________________________________________________|___||
|| 62 | Alte vaci (buc.)
|
||
||____|___________________________________________________________________|___||
|| 63 | Stupi (buc.)
|
||
||____|___________________________________________________________________|___||
|| 64 | Iepuri, femele pt. prsil (buc.)
|
||
||____|___________________________________________________________________|___||
|| 65 | Caprine, femele pt. prsil (buc.)
|
||
||____|___________________________________________________________________|___||
|| 66 | Alte caprine (buc.)
|
||
||____|___________________________________________________________________|___||
|| 67 | Oi mame (buc.)
|
||
||____|___________________________________________________________________|___||
|| 68 | Alte ovine (buc.)
|
||
||____|___________________________________________________________________|___||
|| 69 | Purcei (buc.)
|
||
||____|___________________________________________________________________|___||
|| 70 | Scroafe pt reproducie (buc.)
|
||
||____|___________________________________________________________________|___||
|| 71 | Porci pt ngrat (buc.)
|
||
||____|___________________________________________________________________|___||
|| 72 | Alte porcine (buc.)
|
||
||____|___________________________________________________________________|___||
|| 73 | Pui de carne (buc.)
|
||
||____|___________________________________________________________________|___||
|| 74 | Gini outoare (buc.)
|
||
||____|___________________________________________________________________|___||
|| 75 | Alte psri (buc.)
|
||
||____|___________________________________________________________________|___||
|______________________________________________________________________________|
______________________________________________________________________________
| CAP. 6
|
| Modalitatea de plat al ajutoarelor (cu excepia ajutoarelor pentru
|
| nclzirea locuinei cu energie termic, gaze naturale i energie electric) |
| _
|
| |_| Mandat potal
|
| _
|
| |_| n cont bancar
Nume titular cont ................................. |
|
Numr cont bancar ................................. |
|
Deschis la banca .................................. |
|______________________________________________________________________________|
______________________________________________________________________________
| CAP. 7
|
| Declar pe proprie rspundere i sub sanciunile Codului penal c datele i
|
| informaiile prezentate sunt complete i corespund realitii i m oblig s |
| aduc la cunotina autoritilor, n scris i n termenul prevzut de lege, |
| orice modificare a situaiei mai sus prezentate care poate conduce la
|
| ncetarea sau suspendarea drepturilor.
|
|
|
| Data ....................
|
| Numele solicitantului ...................................................... |
| Semntura ................................
|
|______________________________________________________________________________|
______________________________________________________________________________
| Se ataeaz urmtoarele documente:
|
| 1. ......................................................................... |
| 2. ......................................................................... |
| 3. ......................................................................... |
| 4. ......................................................................... |
| 5. ......................................................................... |
| 6. ......................................................................... |
| 7. ......................................................................... |
| 8. ......................................................................... |
| 9. ......................................................................... |
| 10. ........................................................................ |
| 11. ........................................................................ |
| 12. ........................................................................ |
| 13. ........................................................................ |
| 14. ........................................................................ |
| 15. ........................................................................ |
| 16. ........................................................................ |
| 17. ........................................................................ |
| 18. ........................................................................ |
| 19. ........................................................................ |
| 20. ........................................................................ |
| 21. ........................................................................ |
| 22. ........................................................................ |
| 23. ........................................................................ |
| 24. ........................................................................ |
| 25. ........................................................................ |
| 26. ........................................................................ |
| 27. ........................................................................ |
| 28. ........................................................................ |
| 29. ........................................................................ |
| 30. ........................................................................ |
|______________________________________________________________________________|
ANEXA 2*)
______________________________________________________________________________
| UNITATEA ADMINISTRATIV TERITORIAL ........................................ |
|______________________________________________________________________________|
____________________
| CERTIFICARE PRIMAR |
|
____
|
|
/
\
|
|
( L.S. )
|
|
\____/
|
|____________________|
ANCHET SOCIAL
efectuat astzi .../.../....
urmare a cererii nr. ........... din data de .../.../....
a solicitantului:
______________________________________________________________________________
| A. Domnul/Doamna
|
| _______________
|
|| Numele
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
||
|
|| Prenumele
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
||_______________
|
| ______________________
|
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
||______________________
|
| ____________________________________________________________________________ |
||
_
_
|
|| Cetenia?
|_| UE
|
|
||
_
_
> i anume (ara) .................... |
||
|_| Romn
|_| Non-UE _|
|
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
||
|
|
|| (copie ataat)
|
|| Eliberat de |_|_|_|_|_|_|_|_|_|_|_|
La data de |__|__|__|__|__|__|__|__| |
||
(z z) (l l) (a a a a) |
||
|
|
||
sau apatrizi:
UE, SEE sau
|
||
Confed. Elveian: |
|| BI - buletin de P - paaport PST - permis de edere
CIN - certificat
|
||
identitate
temporar
nregistrare |
|| CI - carte de
DI - document de
CR - carte de
|
||
identitate
identitate
reziden
|
|| CIP - carte de
|
||
identitate
pe termen lung
|
||
provizorie
|
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
|
||
|
|| Strada |_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
||
|
|| Nr. |_|_|_| Bl. |_|_|_| Sc. |_|_| Et. |_|_| Apart. |_|_| Sector |_|_| |
||
|
|| Localitatea |_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
||
|
|| Jude |_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
|
||
|
|| Telefon |_|_|_|_|_|_|_|_|_|_|_|_|_|
Mobil |_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
|| Reedina (loc de edere obinuit) este n afara Romniei?
|
||
_
_
|
|| |_| Nu
|_| Da, n localitatea ................. ara ................ |
||____________________________________________________________________________ |
|______________________________________________________________________________|
_
_
_
|_| n nume propriu |_| n calitate de reprezentant |_| n numele persoanei
al familiei mele
ndreptite
Care s-a adresat primarului pentru acordarea:
_
_
|_| Ajutorului
|_| Alocaiei pt.
social
susinerea familiei
_
|_| Ajutorului
pentru nclzire
Pentru
CAP. 2
Date despre persoana ndreptit
(n cazul n care solicitantul este persoana ndreptit sau reprezentantul familiei, datele se
vor repeta de la cap. 1).
______________________________________________________________________________
| _______________
|
|| Numele
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
||
|
|| Prenumele
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
||_______________
|
| ______________________
|
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
||______________________
|
| ____________________________________________________________________________ |
||
_
_
|
|| Cetenia?
|_| UE
|
|
||
_
_
> i anume (ara) ..................... |
||
|_| Romn
|_| Non-UE _|
|
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
||
|
|
|| (copie ataat)
|
|| Eliberat de |_|_|_|_|_|_|_|_|_|_|_|
La data de |__|__|__|__|__|__|__|__| |
||
(z z) (l l) (a a a a) |
||
|
|
||
sau apatrizi:
UE, SEE sau
|
||
Confed. Elveian:
|| CN - Certificat
CIN - certificat
||
de natere
temporar
nregistrare
|| BI - buletin de
DI - document de
CR - carte de
||
identitate
identitate
reziden
|| CI - carte de
||
identitate
pe termen lung
|| CIP - carte de
||
identitate
||
provizorie
|| P - paaport
||____________________________________________________________________________
| ____________________________________________________________________________
||
|| Strada |_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
||
|| Nr. |_|_|_| Bl. |_|_|_| Sc. |_|_| Et. |_|_| Apart. |_|_| Sector |_|_|
||
|| Localitatea |_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
||
|| Jude |_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
||
|| Telefon |_|_|_|_|_|_|_|_|_|_|_|_|_|
Mobil |_|_|_|_|_|_|_|_|_|_|_|_|_|_|
||____________________________________________________________________________
||
_
_
_
|| Starea civil?
|_| cstorit() |_| necstorit() |_| uniune
||
consensual
||
_
_
_
||
|_| vduv()
|_| divorat()
|_| desprit()
||
n fapt
||____________________________________________________________________________
| ____________________________________________________________________________
||
_
||
_
|| _
|| |_| Da <
||
||____________________________________________________________________________
| ____________________________________________________________________________
||
_
_
_
_
|_| superioare
||____________________________________________________________________________
| ____________________________________________________________________________
||
_
_
_
_
|| Situaia
|_| salariat
|_| student
|| profesional?
_
_
_
_
||
||
agricol
ocazional
||
||
Altele ..................................................
||____________________________________________________________________________
| ____________________________________________________________________________
||
_
||
_
|| _
|| |_| Da <
||
||____________________________________________________________________________
| ____________________________________________________________________________
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|

|_|_|_|_| lei
|
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
|
|| _
_
|
|| |_| Nu
|
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
|| Dac beneficiaz sau a beneficiat de unele drepturi de asisten social?
|
|
|| _
|
|| |_| Nu
|
|| _
_ _
_
|
|| |_| Da, din alte ri | |_| Ajutor Social
| Drepturi|
|| _
|
_
>n curs |
|| |_| Da, din Romnia <
|_| Alocaia pentru Susinerea Familiei _|
|
||
|
_
|
||
|_ |_| Ajutorul pentru nclzirea Locuinei
|
||
(pentru sezonul rece anterior)
|
||
_____________________________/\______________________
|
||
|
|
|
|| _________________________________________________________________________ |
|| | | Energie termic | | Gaze naturale | | Energie
| | Lemne, crbuni | |
|| | |
| |
| | electric
| |
| |
|| |_|_________________|_|_______________|_|______________|_|________________| |
||____________________________________________________________________________ |
|______________________________________________________________________________|
CAP. 3
Date despre familia persoanei ndreptite format din ... persoane majore (inclusive persoana
ndreptit) i ... copii:
a) Date despre partenerul/partenera persoanei ndreptite:
______________________________________________________________________________
| ________________________
|
||
Numele
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
||
|
||
Prenumele
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
||________________________
|
| ________________________
|
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
||________________________
|
| ____________________________________________________________________________ |
||
_
_
|
|| Cetenia?
|_| UE
|
|
||
_
_
> i anume (ara) ..................... |
||
|_| Romn
|_| Non-UE _|
|
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
||
|
|
|| (copie ataat)
|
|| Eliberat de |_|_|_|_|_|_|_|_|_|_|_|
La data de |__|__|__|__|__|__|__|__| |
||
(z z) (l l) (a a a a) |
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
||
_
|
|
||
_
|
|| _
|
|| |_| Da <
|
||
|
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
||
_
_
_
_
|
|_| superioare |
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
||
_
_
_
_
|
|| Situaia
|_| salariat
|_| student |
|| profesional?
_
_
_
_
|
||
|
||
agricol
ocazional
|
||
|
||
Altele .................................................. |
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
||
_
|
|
||
_
|
|| _
|
|| |_| Da <
|
||
|
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
|
|_|_|_|_| lei
|
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
|
|| _
_
|
|| |_| Nu
|
||____________________________________________________________________________ |
|______________________________________________________________________________|
b) Date despre copiii persoanei ndreptite:
______________________________________________________________________________
| ________________________
|
||
Numele
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
|| 1.
|
||
Prenumele
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
||________________________
|
| ________________________
|
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
||________________________
|
| ______________________________
|
|
|| (copie ataat)
|
||_______________________________|_|_|_|_| Seria |_|_|_| Nr. |_|_|_|_|_|_|_|
|
| ____________________________________________________________________________ |
_
_
_
|
|| cu persoana
|_| copil
|_| copil
|| ndreptit?
natural
adoptat
familial
|
||
_
_
_
|
||
|_| copil n
|
||
tutel
curatel
spre adopie
|
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
||
_
_
_
_
|
|_| elev
| | coala nr. ..... |
||
cls. I - VIII | |
|
||
_
_
><
|
||
| | Loc. ........... |
||
cls. IX - XII _| |_
|
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
|
|| _
_
|
|| |_| Nu
|
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
|
|
|| _
_
_
|
|| |_| Nu
|_| Da, din alte ri
|_| Da, din Romnia
|
||____________________________________________________________________________ |
|______________________________________________________________________________|

sau apatrizi:
CN - certificat
de natere
BI - buletin de
identitate
CI - carte de
identitate
CIP - carte de
identitate
provizorie
P - paaport

temporar
DI - document de
identitate
pe termen lung
Pentru cetenii
UE, SEE sau
Confed. Elveian:
CIN - certificat
nregistrare
CR - carte de
reziden
______________________________________________________________________________
| ________________________
|
||
Numele
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
|| 2.
|
||
Prenumele
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
||________________________
|
| ________________________
|
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
||________________________
|
| ______________________________
|
|
|| (copie ataat)
|
||_______________________________|_|_|_|_| Seria |_|_|_| Nr. |_|_|_|_|_|_|_|
|
| ____________________________________________________________________________ |
_
_
_
|
|| cu persoana
|_| copil
|_| copil
|| ndreptit?
natural
adoptat
familial
|
||
_
_
_
|
||
|_| copil n
|
||
tutel
curatel
spre adopie
|
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
||
_
_
_
_
|
|_| elev
| | coala nr. ..... |
||
cls. I - VIII | |
|
||
_
_
><
|
||
| | Loc. ........... |
||
cls. IX - XII _| |_
|
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
|
|| _
_
|
|| |_| Nu
|
||____________________________________________________________________________ |
| ____________________________________________________________________________ |

|
|
|| _
_
_
|
|| |_| Nu
|_| Da, din alte ri
|_| Da, din Romnia
|
||____________________________________________________________________________ |
|______________________________________________________________________________|
______________________________________________________________________________
| ________________________
|
||
Numele
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
|| 3.
|
||
Prenumele
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
||________________________
|
| ________________________
|
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
||________________________
|
| ______________________________
|
|
|| (copie ataat)
|
||_______________________________|_|_|_|_| Seria |_|_|_| Nr. |_|_|_|_|_|_|_|
|
| ____________________________________________________________________________ |
_
_
_
|
|| cu persoana
|_| copil
|_| copil
|| ndreptit?
natural
adoptat
familial
|
||
_
_
_
|
||
|_| copil n
|
||
tutel
curatel
spre adopie
|
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
||
_
_
_
_
|
|_| elev
| | coala nr. ..... |
||
cls. I - VIII | |
|
||
_
_
><
|
||
| | Loc. ........... |
||
cls. IX - XII _| |_
|
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
|
|| _
_
|
|| |_| Nu
|
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
|
|
|| _
_
_
|
|| |_| Nu
|_| Da, din alte ri
|_| Da, din Romnia
|
||____________________________________________________________________________ |
|______________________________________________________________________________|
______________________________________________________________________________
| ________________________
|
||
Numele
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
|| 4.
|
||
Prenumele
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
||________________________
|
| ________________________
|
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
||________________________
|
| ______________________________
|
|
|| (copie ataat)
|
||_______________________________|_|_|_|_| Seria |_|_|_| Nr. |_|_|_|_|_|_|_|
|
| ____________________________________________________________________________ |
_
_
_
|
|| cu persoana
|_| copil
|_| copil
|| ndreptit?
natural
adoptat
familial
|
||
_
_
_
|
||
|_| copil n
|
||
tutel
curatel
spre adopie
|
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
||
_
_
_
_
|
|_| elev
| | coala nr. ..... |
||
cls. I - VIII | |
|
||
_
_
><
|
||
| | Loc. ........... |
||
cls. IX - XII _| |_
|
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
|
|| _
_
|
|| |_| Nu
|
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
|
|
|| _
_
_
|
|| |_| Nu
|_| Da, din alte ri
|_| Da, din Romnia
|
||____________________________________________________________________________ |
|______________________________________________________________________________|

sau apatrizi:
CN - certificat
de natere
BI - buletin de
identitate
CI - carte de
identitate
CIP - carte de
identitate
provizorie
P - paaport

temporar
DI - document de
identitate
pe termen lung
Pentru cetenii
UE, SEE sau
Confed. Elveian:
CIN - certificat
nregistrare
CR - carte de
reziden
c) Date despre celelalte persoane majore din familia persoanei ndreptite:

______________________________________________________________________________
| ________________________
|
||
Numele
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
|| 1.
|
||
Prenumele
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
||________________________
|
| ________________________
|
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
||________________________
|
| ____________________________________________________________________________ |
||
_
_
|
|| Cetenia?
|_| UE
|
|
||
_
_
> i anume (ara) .................... |
||
|_| Romn
|_| Non-UE _|
|
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
||
|
|
|| (copie ataat)
|
|| Eliberat de |_|_|_|_|_|_|_|_|_|_|_|
La data de |__|__|__|__|__|__|__|__| |
||
(z z) (l l) (a a a a) |
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
|| Dac a locuit n afara rii n ultimii 2 ani?
|
||
_
|
||
_
_
| n perioada anilor ....... ara ................ |
|| |_| Nu
|_| Da <
|
||
|_ n perioada anilor ....... ara ................ |
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
||
_
_
_
_
|
|_| superioare |
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
||
_
_
_
_
|
|| Situaia
|_| salariat
|_| student |
|| profesional?
_
_
_
_
|
||
|
||
agricol
ocazional
|
||
|
||
Altele .................................................. |
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
|| Dac a lucrat n
_
|
|| afara rii n
_
_
| n perioada anilor .... ara ...... |
|| ultimii 2 ani?
|_| Nu |_| Da <
|
||
|_ n perioada anilor .... ara ...... |
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
|
|_|_|_|_| lei
|
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
|
|| _
_
|
|| |_| Nu
|
||____________________________________________________________________________ |
|______________________________________________________________________________|
______________________________________________________________________________
| ________________________
|
||
Numele
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
|| 2.
|
||
Prenumele
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
||________________________
|
| ________________________
|
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
||________________________
|
| ____________________________________________________________________________ |
||
_
_
|
|| Cetenia?
|_| UE
|
|
||
_
_
> i anume (ara) .................... |
||
|_| Romn
|_| Non-UE _|
|
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
||
|
|
|| (copie ataat)
|
|| Eliberat de |_|_|_|_|_|_|_|_|_|_|_|
La data de |__|__|__|__|__|__|__|__| |
||
(z z) (l l) (a a a a) |
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
|
||
_
|
||
_
_
|| |_| Nu
|_| Da <
|
||
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
||
_
_
_
_
|
|_| superioare |
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
||
_
_
_
_
|
|| Situaia
|_| salariat
|_| student |
|| profesional?
_
_
_
_
|
||
|
||
agricol
ocazional
|
||
|
||
Altele .................................................. |
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
|| Dac a lucrat n
_
|
|| afara rii n
_
_
|| ultimii 2 ani?
|_| Nu |_| Da <
|
||
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
|
|_|_|_|_| lei
|
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
|
|| _
_
|
|| |_| Nu
|
||____________________________________________________________________________ |
|______________________________________________________________________________|
______________________________________________________________________________
| ________________________
|
||
Numele
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
|| 3.
|
||
Prenumele
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
||________________________
|
| ________________________
|
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
||________________________
|
| ____________________________________________________________________________ |
||
_
_
|
|| Cetenia?
|_| UE
|
|
||
_
_
> i anume (ara) .................... |
||
|_| Romn
|_| Non-UE _|
|
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
||
|
|
|| (copie ataat)
|
|| Eliberat de |_|_|_|_|_|_|_|_|_|_|_|
La data de |__|__|__|__|__|__|__|__| |
||
(z z) (l l) (a a a a) |
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
|
||
_
|
||
_
_
|| |_| Nu
|_| Da <
|
||
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
||
_
_
_
_
|
|_| superioare |
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
||
_
_
_
_
|
|| Situaia
|_| salariat
|_| student |
|| profesional?
_
_
_
_
|
||
|
||
agricol
ocazional
|
||
|
||
Altele .................................................. |
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
|| Dac a lucrat n
_
|
|| afara rii n
_
_
|| ultimii 2 ani?
|_| Nu |_| Da <
|
||
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
|
|_|_|_|_| lei
|
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
|
|| _
_
|
|| |_| Nu
|
||____________________________________________________________________________ |
|______________________________________________________________________________|
______________________________________________________________________________
| ________________________
|
||
Numele
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
|| 4.
|
||
Prenumele
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
||________________________
|
| ________________________
|
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
||________________________
|
| ____________________________________________________________________________ |
||
_
_
|
|| Cetenia?
|_| UE
|
|
||
_
_
> i anume (ara) .................... |
||
|_| Romn
|_| Non-UE _|
|
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
||
|
|
|| (copie ataat)
|
|| Eliberat de |_|_|_|_|_|_|_|_|_|_|_|
La data de |__|__|__|__|__|__|__|__| |
||
(z z) (l l) (a a a a) |
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
|
||
_
|
||
_
_
|| |_| Nu
|_| Da <
|
||
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
||
_
_
_
_
|
|_| superioare |
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
||
_
_
_
_
|
|| Situaia
|_| salariat
|_| student |
|| profesional?
_
_
_
_
|
||
|
||
agricol
ocazional
|
||
|
||
Altele .................................................. |
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
|| Dac a lucrat n
_
|
|| afara rii n
_
_
|| ultimii 2 ani?
|_| Nu |_| Da <
|
||
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
|
|_|_|_|_| lei
|
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
|
|| _
_
|
|| |_| Nu
|
||____________________________________________________________________________ |
|______________________________________________________________________________|
CAP. 4
Date privind locuina familiei/persoanei singure ndreptit
______________________________________________________________________________
| ____________________________________________________________________________ |
|| Familia/persoana singur ndreptit locuiete:
|
|| _
_
|
|| |_| singur
|_| mpreun cu alt persoan singur sau familie |
||____________________________________________________________________________ |
| ____________________________________________ ______________________________ |
|| Model locuin:
|| _____________________
|
|
||| | Cas cu curte
|\
| _
|
|||_|___________________| |
|
|| _____________________ |
|
|
||| | Cas fr curte
| |
| _
|
|||_|___________________| |
_____________ ||_| n nchiriere public/privat|
|| _____________________ |
/| | 1 camer | |
|
|
|||_|___________________| | | _____________ | Altele ...................... |
|| _____________________ | | | | 2 camere | |______________________________ |
||| | Locuin social | | | |_|___________|
|
|||_|___________________| | | _____________
______________________________ |
|
||| | Locuin de
| >< |_|___________| | locuinei
|
||| | serviciu
| | | _____________ |
|
|||_|___________________| | | | | 4 camere | | _
|
|| _____________________ | | |_|___________| ||_| Cumprare
|
||| | Locuin de
| | | _____________ |
|
||| | necesitate
| | | | | > 4 camere| | _
|
|||_|___________________| |
\|_|___________| ||_| Motenire
|
|| _____________________ |
|
|
|
|
||| | nu are locuin
| |
| Altele ...................... |
|||_|___________________|/
|
|
||____________________________________________ |______________________________ |
| ____________________________________________________________________________ |
|| Tipul locuinei
|
||
________________________________________________________________________ |
|| _ | TIP A | construcia cu structura de rezisten din beton armat, metal, ||
||| ||
| lemn, piatr, crmid ars sau din orice alte materiale
||
|||_||
| 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
||
||
|_______|________________________________________________________________||
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
|| Dac are ncheiat poli de asigurare a locuinei?
|
|| _
_
|
|| |_| Nu
|_| Da, la societatea ....................................... |
||
|
|| Nr. poli .............. Valabil de la ........... La ................... |
||
|
|| Dac polia acoper riscurile obligatorii (cutremur, alunecri de teren,
|
|| inundaii)
|
|| _
_
|
|| |_| Nu
|_| Da
|
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
|| Familia/persoana singur ndreptit se nclzete cu:
|
|| _
|
|||_| ENERGIE TERMIC
||
|
||
Codul titularului de contract |_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
|| _
|
|||_| GAZE NATURALE
||
|
||
Codul client |_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
|| _
|
|||_| COMBUSTIBILI SOLIZI I LICHIZI (lemne, crbuni, combustibili petrolieri) |
|| _
|
|||_| ENERGIE ELECTRIC Denumire furnizor |_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
||
|
||
Codul client |_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
||____________________________________________________________________________ |
|______________________________________________________________________________|
CAP. 5
Date privind toate veniturile i bunurile familiei/persoanei singure ndreptite n luna
....................
______________________________________________________________________________
| ____________________________________________________________________________ |
||Cod|
Categoria de venituri
| Acte
|Venitul
||
||
|
| doveditoare*) |realizat**)||
||
|
|
|lei
||
||___|____________________________________________|_______________|___________||
| ____________________________________________________________________________ |
|| VENITURI DIN ACTIVITI INDEPENDENTE
||
||____________________________________________________________________________||
|| 1| Venituri din profesii libere veniturile
| adeverin
| | | | | | ||
||
| obinute din exercitarea profesiilor
| eliberat de | | | | | | ||
||
| medicale, de avocat, notar, auditor
||
| financiar, consultant fiscal, expert
| financiar
| | | | | | ||
||
| 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 de
| adeverina
| | | | | | ||
||
| 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 asociat
| adeverin
| | | | | | ||
||
| sau persoan autorizat s desfoare o
| eliberat de | | | | | | ||
||
| activitate independent
| Adm.
| | | | | | ||
||
|
| financiar
| | | | | | ||
||___|____________________________________________|_______________|_|_|_|_|_|_||
|| 9| Indemnizaia de omaj i/sau venit lunar de| mandat potal/| | | | | | ||
||
| completare
| extras de
| | | | | | ||
||
|
| cont/decizie | | | | | | ||
||___|____________________________________________|_______________|_|_|_|_|_|_||
|| 10| Indemnizaiile din activiti desfurate | adeverin
| | | | | | ||
||
| ca urmare a unei funcii de demnitate
| eliberat de | | | | | | ||
||
| public, stabilite potrivit legii
| Adm.
| | | | | | ||
||___|____________________________________________| 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
|
| | | | | | ||
||___|____________________________________________|
|_|_|_|_|_|_||
|
| | | | | | ||
||
| adunarea general a acionarilor, n
|
| | | | | | ||
||
| consiliul de administraie, membrii
|
| | | | | | ||
||
| directoratului i ai consiliului de
|
| | | | | | ||
||
| supraveghere, precum i n comisia de
|
| | | | | | ||
||
| cenzori
|
| | | | | | ||
||___|____________________________________________|
|_|_|_|_|_|_||
|
| | | | | | ||
||
| 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 i | adeverin
| | | | | | ||
||
| suma din profitul net cuvenite
| eliberat de | | | | | | ||
||
| administratorilor societilor comerciale | Adm.
| | | | | | ||
||
| potrivit actului constitutiv sau stabilite | financiar
| | | | | | ||
||
| 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
|
| | | | | | ||
||
| salarial ori asimilate salariilor n
|
| | | | | | ||
||
| vederea impunerii
|
| | | | | | ||
||___|____________________________________________|_______________|_|_|_|_|_|_||
| ____________________________________________________________________________ |
|| VENITURI DIN CEDAREA FOLOSINEI BUNURILOR
||
||____________________________________________________________________________||
|| 25| Veniturile, n bani i/sau n natur,
| adeverin
| | | | | | ||
||
| provenind din cedarea folosinei bunurilor | eliberat de | | | | | | ||
||
| mobile i imobile, obinute de ctre
| Adm.
| | | | | | ||
||
| proprietar, uzufructuar sau alt deintor | financiar
| | | | | | ||
||
| legal, altele dect veniturile din
|
| | | | | | ||
||
| activiti independente
|
| | | | | | ||
||___|____________________________________________|_______________|_|_|_|_|_|_||
| ____________________________________________________________________________ |
|| VENITURI DIN INVESTIII
||
||____________________________________________________________________________||
|| 26| Dividende
| adeverin
| | | | | | ||
||___|____________________________________________| eliberat de |_|_|_|_|_|_||
|| 27| Venituri impozabile din dobnzi
| Adm.
| | | | | | ||
||___|____________________________________________| financiar
|_|_|_|_|_|_||
|| 28| Ctiguri din transferul titlurilor de
|
| | | | | | ||
||
| valoare
|
| | | | | | ||
||___|____________________________________________|_______________|_|_|_|_|_|_||
|| 29| Venituri din operaiuni de
| adeverin
| | | | | | ||
||
| vnzare-cumprare de valut la termen, pe | eliberat de | | | | | | ||
||
| baz de contract, precum i orice alte
| Adm.
| | | | | | ||
||
| operaiuni similare
| financiar
| | | | | | ||
||___|____________________________________________|
|_|_|_|_|_|_||
|| 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
|
| | | | | | ||
||___|____________________________________________|
|_|_|_|_|_|_||
|
| | | | | | ||
||___|____________________________________________|
|_|_|_|_|_|_||
|
| | | | | | ||
||___|____________________________________________|_______________|_|_|_|_|_|_||
|| PENSII AGRICULTORI
||
||____________________________________________________________________________||
|| 36| Pensie agricultor
| mandat potal/| | | | | | ||
||
|
| extras de
| | | | | | ||
||
|
| cont/decizie | | | | | | ||
||___|____________________________________________|_______________|_|_|_|_|_|_||
|| PENSII MILITARE
||
||____________________________________________________________________________||
|| 37| Pensie de serviciu
| mandat potal/| | | | | | ||
||___|____________________________________________| extras de
|_|_|_|_|_|_||
| cont/decizie | | | | | | ||
||___|____________________________________________|
|_|_|_|_|_|_||
|
| | | | | | ||
||___|____________________________________________|
|_|_|_|_|_|_||
|| 40| Pensia I.O.V.R.
|
| | | | | | ||
||___|____________________________________________|_______________|_|_|_|_|_|_||
| ____________________________________________________________________________ |
|| INDEMNIZAII
||
||____________________________________________________________________________||
|| 41| Indemnizaia pt. persoanele care i-au
| mandat potal/| | | | | | ||
||
| pierdut total sau parial capacitatea de
| extras de
| | | | | | ||
||
| munc ca urmare a participrii la revoluie| cont/decizie | | | | | | ||
||
| i pt. urmaii acestora
|
| | | | | | ||
||___|____________________________________________|
|_|_|_|_|_|_||
|| 42| Indemnizaia de nsoitor pentru pensionari|
| | | | | | ||
||
| gr. I invaliditate/nevztori handicap grav|
| | | | | | ||
||___|____________________________________________|_______________|_|_|_|_|_|_||
|| 43| Indemnizaia pentru incapacitatea temporar| adeverin

| | | | | | ||
||
| de munc
| 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
| | | | | | ||
||
|
| angajator
| | | | | | ||
||___|____________________________________________|_______________|_|_|_|_|_|_||
|| 46| Indemnizaia pentru creterea copilului
| mandat potal/| | | | | | ||
||
| pn la vrsta de 1, 2 sau 3 ani
| extras de
| | | | | | ||
||___|____________________________________________| cont/decizie |_|_|_|_|_|_||
|| 47| Stimulent lunar/de inserie
|
| | | | | | ||
||___|____________________________________________|
|_|_|_|_|_|_||
|| 48| Indemnizaia i ajutoare pentru creterea |
| | | | | | ||
||
| copilului cu handicap
|
| | | | | | ||
||___|____________________________________________|_______________|_|_|_|_|_|_||
| ____________________________________________________________________________ |
|| INDEMNIZAII CU CARACTER PERMANENT
||
||____________________________________________________________________________||
|| 49| Indemnizaia lunar acordat magistrailor | mandat potal/| | | | | | ||
||
| nlturai din justiie din considerente
| extras de
| | | | | | ||
||
| 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 care | mandat potal/| | | | | | ||
||
| au efectuat stagiul militar n cadrul
| extras de
| | | | | | ||
||
| Direciei Generale a Serviciului Muncii n | cont/decizie | | | | | | ||
||
| 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
||
||____________________________________________________________________________||
| adeverin
| | | | | | ||
||
| florilor, legumelor i zarzavaturilor, n | eliberat de | | | | | | ||
||
| sere i solarii special destinate acestor | Administraia | | | | | | ||
||
| scopuri i/sau n sistem irigat
| financiar
| | | | | | ||
||___|____________________________________________|
|_|_|_|_|_|_||
|
| | | | | | ||
||
| arbutilor, plantelor decorative i
|
| | | | | | ||
||
| ciupercilor
|
| | | | | | ||
||___|____________________________________________|_______________|_|_|_|_|_|_||
|| 60| Venituri din exploatarea pepinierelor
| adeverin
| | | | | | ||
||
| viticole i pomicole i altele asemenea
| eliberat de | | | | | | ||
||___|____________________________________________| Administraia |_|_|_|_|_|_||
|| 61| Venituri din valorificarea produselor
| financiar
| | | | | | ||
||
| 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 veniturile| adeverin
| | | | | | ||
||
| din concursuri
| eliberat de | | | | | | ||
||___|____________________________________________| Administraia |_|_|_|_|_|_||
|| 63| Veniturile din jocuri de noroc ce cuprind | financiar
| | | | | | ||
||
| 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 de
||
| motenire
| financiar
| | | | | | ||
||___|____________________________________________|_______________|_|_|_|_|_|_||
| ____________________________________________________________________________ |
|| VENITURI DIN ALTE SURSE
||
||____________________________________________________________________________||
|| 65| Prime de asigurri suportate de o persoan | adeverin
| | | | | | ||
||
| fizic independent sau de orice alt
| eliberat de | | | | | | ||
||
| entitate, n cadrul unei activiti pentru | Administraia | | | | | | ||
||
| o persoan fizic n legtur cu care
| financiar
| | | | | | ||
||
| 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 - Cu excepia burselor de studiu i a burselor sociale precum i a
||
|| sprijinului financiar prevzut de H.G. nr. 1488/2004
||
||____________________________________________________________________________||
|| 74| Burse pentru elevi
| adeverin
| | | | | | ||
||___|____________________________________________| instituie
|_|_|_|_|_|_||
|| 75| Burse pentru studeni
| nvmnt
| | | | | | ||
||___|____________________________________________|_______________|_|_|_|_|_|_||
| ____________________________________________________________________________ |
|| AJUTOARE
||
||____________________________________________________________________________||
|| 76| Ajutorul bnesc lunar pentru persoanele
| mandat potal/| | | | | | ||
||
| care au devenit incapabile de munc n
| extras de
| | | | | | ||
||
| perioada efecturii unei pedepse privative | cont/decizie | | | | | | ||
||
| de libertate
|
| | | | | | ||
||___|____________________________________________|_______________|_|_|_|_|_|_||
| ____________________________________________________________________________ |
|| ALTE SURSE DE VENIT
||
||____________________________________________________________________________||
|| 77| Depozite bancare
| adeverin
| | | | | | ||
||___|____________________________________________| eliberat de |_|_|_|_|_|_||
|| 78| Rent viager agricol
| instituiile | | | | | | ||
||___|____________________________________________| competente
|_|_|_|_|_|_||
|| 79| Alte venituri (inclusiv din arend)
|
| | | | | | ||
||___|____________________________________________|
|_|_|_|_|_|_||
|| 80| Sume primite din proiecte cu finanare
|
| | | | | | ||
||
| internaional nerambursabil
|
| | | | | | ||
||___|____________________________________________|_______________|_|_|_|_|_|_||
| ____________________________________________________________________________ |
|| FAMILIA/PERSOANA SINGUR BENEFICIAZ DE UNELE DREPTURI SPECIALE CONFORM
||
|| CONTRACTULUI COLECTIV SAU INDIVIDUAL DE MUNC? (se vor meniona natura lor ||
|| i valoarea)
||
||____________________________________________________________________________||
|| 81|
|
| | | | | | ||
||___|____________________________________________|_______________|_|_|_|_|_|_||
|| 82|
|
| | | | | | ||
||___|____________________________________________|_______________|_|_|_|_|_|_||
|| 83|
|
| | | | | | ||
||___|____________________________________________|_______________|_|_|_|_|_|_||
| ____________________________________________________________________________ |
|| VENIT LUNAR TOTAL AL FAMILIEI
| | | | | | ||
||________________________________________________________________|_|_|_|_|_|_||
| ____________________________________________________________________________ |
|| VENIT NET LUNAR PE MEMBRU DE FAMILIE
| | | | | | ||
||________________________________________________________________|_|_|_|_|_|_||
|______________________________________________________________________________|
*) Se vor anexa pentru fiecare membru de familie

**) Pentru aceeai categorie de venituri se va nscrie suma total a acestora.
______________________________________________________________________________
| Familia/persoana singur ndreptit deine n proprietate/folosin?
|
|
|
| Bunuri imobile
|
| _
|
| |_| Cldiri sau spaii locative, altele dect locuina de domiciliu i
|
|
anexele gospodreti
|
| _
|
| |_| Terenuri de mprejmuire a locuinei i curtea aferent i alte terenuri |
|
intravilane care depesc 1.000 mp n zona urban i 2.000 mp n zona
|
|
rural
|
|
|
| Bunuri mobile, aflate n stare de funcionare
|
| _
|
| |_| Autoturism i/sau motociclet cu o vechime mai mic de 10 ani
|
| _
|
| |_| Dou sau mai multe autoturisme i/sau motociclete cu o vechime mai mare |
|
de 10 ani
|
| _
|
| |_| Autovehicule: autoutilitare, autocamioane de orice fel cu sau fr
|
|
remorci, rulote, autobuze, microbuze
|
| _
|
| |_| alupe, brci cu motor, scutere de ap, iahturi
|
| _
|
| |_| Utilaje agricole: tractor, combin autopropulsat
|
| _
|
| |_| Utilaje de prelucrare agricol: pres de ulei, moar de cereale
|
| _
|
| |_| Utilaje de prelucrat lemnul: gater sau alte utilaje acionate hidraulic, |
|
mecanic sau electric
|
|
|
| Terenuri, animale i psri din gospodrie
|
| ____________________________________________________________________________ |
|| 1 | Gru comun (ha)
|
||
||____|___________________________________________________________________|___||
|| 2 | Gru dur (ha)
|
||
||____|___________________________________________________________________|___||
|| 3 | Secar (ha)
|
||
||____|___________________________________________________________________|___||
|| 4 | Orz (ha)
|
||
||____|___________________________________________________________________|___||
|| 5 | Orzoaic (ha)
|
||
||____|___________________________________________________________________|___||
|| 6 | Ovz (ha)
|
||
||____|___________________________________________________________________|___||
|| 7 | Amestecuri de cereale de var (ha)
|
||
||____|___________________________________________________________________|___||
|| 8 | Porumb boabe (ha)
|
||
||____|___________________________________________________________________|___||
|| 9 | Orez (ha)
|
||
||____|___________________________________________________________________|___||
|| 10 | Alte cereale (ha)
|
||
||____|___________________________________________________________________|___||
|| 11 | Mazre, fasole de cmp i lupin dulce (ha)
|
||
||____|___________________________________________________________________|___||
|| 12 | Linte, nut i mazariche (ha)
|
||
||____|___________________________________________________________________|___||
|| 13 | Alte culturi proteice (ha)

|
||
||____|___________________________________________________________________|___||
|| 14 | Cartofi (ha)
|
||
||____|___________________________________________________________________|___||
|| 15 | Sfecl de zahr - fr seminceri (ha)
|
||
||____|___________________________________________________________________|___||
|| 16 | Rapi (ha)
|
||
||____|___________________________________________________________________|___||
|| 17 | Floarea soarelui (ha)
|
||
||____|___________________________________________________________________|___||
|| 18 | Soia (ha)
|
||
||____|___________________________________________________________________|___||
|| 19 | In pentru ulei (ha)
|
||
||____|___________________________________________________________________|___||
|| 20 | Altele (ricin, mac, mutar, s.a) (ha)
|
||
||____|___________________________________________________________________|___||
|| 21 | Hamei (fr seminceri) (ha)
|
||
||____|___________________________________________________________________|___||
|| 22 | Tutun (ha)
|
||
||____|___________________________________________________________________|___||
|| 23 | Plante medicinale, condimentare, aromatice (ha)
|
||
||____|___________________________________________________________________|___||
|| 24 | In pentru fibr (ha)
|
||
||____|___________________________________________________________________|___||
|| 25 | Cnepa (ha)
|
||
||____|___________________________________________________________________|___||
|| 26 | Alte culturi industriale (inclusiv in, cnepa pt. fibr) (ha)
|
||
||____|___________________________________________________________________|___||
|| 27 | Legume proaspete, pepeni, cpuni n cmp (ha)
|
||
||____|___________________________________________________________________|___||
|| 28 | Legume proaspete, pepeni, cpuni n grdin (ha)
|
||
||____|___________________________________________________________________|___||
|| 29 | Legume proaspete, pepeni, cpuni n sistem protejat (ha)
|
||
||____|___________________________________________________________________|___||
|| 30 | Ciuperci (100 m2)
|
||
||____|___________________________________________________________________|___||
|| 31 | Flori, plante ornamentale cult. n aer liber (ha)
|
||
||____|___________________________________________________________________|___||
|| 32 | Flori, plante ornamentale cult. n sist. protejat
|
||
||____|___________________________________________________________________|___||
|| 33 | Semine de iarb (graminee i legumin. furaj) (ha)
|
||
||____|___________________________________________________________________|___||
|| 34 | Alte semine (pt hortic, cult arabile fr cereale, cartofi,
|
||
||
| oleaginoase) (ha)
|
||
||____|___________________________________________________________________|___||
|| 35 | Culturi furajere rdcinoase (sfecl furajer, napi, morcovi
|
||
||
| furajeri) (ha)
|
||
||____|___________________________________________________________________|___||
|| 36 | Porumb furajer pentru siloz (ha)
|
||
||____|___________________________________________________________________|___||
|| 37 | Alte cereale pentru siloz (ha)
|
||
||____|___________________________________________________________________|___||
|| 38 | Alte plante furajere (ha)
|
||
||____|___________________________________________________________________|___||
|| 39 | Terenuri productive i necultivate (ha)
|
||
||____|___________________________________________________________________|___||
|| 40 | Alte culturi arabile neincluse (ha)
|
||
||____|___________________________________________________________________|___||
|| 41 | Pajiti i puni permanente (ha)
|
||
||____|___________________________________________________________________|___||
|| 42 | Puni srace, de obicei nefertilizate i necultivate (ha)
|
||
||____|___________________________________________________________________|___||
|| 43 | Livezi de mr, pr (ha)
|
||
||____|___________________________________________________________________|___||
|| 44 | Livezi de prun, piersic, cais, cire (ha)
|
||
||____|___________________________________________________________________|___||
|| 45 | Livezi de nuc, alun, migdal, castan (ha)
|
||
||____|___________________________________________________________________|___||
|| 46 | Livezi de coacz, smochin, zmeur (ha)
|
||
||____|___________________________________________________________________|___||
|| 47 | Struguri pentru mas (ha)
|
||
||____|___________________________________________________________________|___||
|| 48 | Struguri pentru vin de calitate (ha)
|
||
||____|___________________________________________________________________|___||
|| 49 | Struguri pentru vin de mas (ha)
|
||
||____|___________________________________________________________________|___||
|| 50 | Pepiniere fr silvicultur (ha)
|
||
||____|___________________________________________________________________|___||
|| 51 | Alte culturi permanente (rchit, salcie) (ha)
|
||
||____|___________________________________________________________________|___||
|| 52 | Cabaline (buc.)
|
||
||____|___________________________________________________________________|___||
|| 53 | Viei pt. ngrat
|
||
||____|___________________________________________________________________|___||
|| 54 | Viei sub un an (buc.)
|
||
||____|___________________________________________________________________|___||
|| 55 | Turai de la 1 la 2 ani (buc.)
|
||
||____|___________________________________________________________________|___||
|| 56 | Viele de la 1 la 2 ani (buc.)
|
||
||____|___________________________________________________________________|___||
|| 57 | Turai de 2 ani i mai mult (buc.)
|
||
||____|___________________________________________________________________|___||
|| 58 | Juninci de reproducie (buc.)
|
||
||____|___________________________________________________________________|___||
|| 59 | Viele pt ngrat (buc.)
|
||
||____|___________________________________________________________________|___||
|| 60 | Vaci de lapte (buc.)
|
||
||____|___________________________________________________________________|___||
|| 61 | Vaci de lapte la reform (buc.)
|
||
||____|___________________________________________________________________|___||
|| 62 | Alte vaci (buc.)
|
||
||____|___________________________________________________________________|___||
|| 63 | Stupi (buc.)
|
||
||____|___________________________________________________________________|___||
|| 64 | Iepuri, femele pt. prsil (buc.)
|
||
||____|___________________________________________________________________|___||
|| 65 | Caprine, femele pt. prsil (buc.)
|
||
||____|___________________________________________________________________|___||
|| 66 | Alte caprine (buc.)
|
||
||____|___________________________________________________________________|___||
|| 67 | Oi mame (buc.)
|
||
||____|___________________________________________________________________|___||
|| 68 | Alte ovine (buc.)
|
||
||____|___________________________________________________________________|___||
|| 69 | Purcei (buc.)
|
||
||____|___________________________________________________________________|___||
|| 70 | Scroafe pt reproducie (buc.)
|
||
||____|___________________________________________________________________|___||
|| 71 | Porci pt ngrat (buc.)
|
||
||____|___________________________________________________________________|___||
|| 72 | Alte porcine (buc.)
|
||
||____|___________________________________________________________________|___||
|| 73 | Pui de carne (buc.)
|
||
||____|___________________________________________________________________|___||
|| 74 | Gini outoare (buc.)
|
||
||____|___________________________________________________________________|___||
|| 75 | Alte psri (buc.)

|
||
||____|___________________________________________________________________|___||
|______________________________________________________________________________|
______________________________________________________________________________
| CAP. 6
|
| Starea de sntate a persoanei singure/membrilor familiei sau persoanei
|
| ndreptite
|
|
|
|
|
|
|
|
|
|
|
|
|
|______________________________________________________________________________|
______________________________________________________________________________
| CAP. 7
|
| Nevoi speciale ale persoanei singure/membrilor familiei sau persoanei
|
| ndreptite
|
|
|
|
|
|
|
|
|
|
|
|
|
|______________________________________________________________________________|
______________________________________________________________________________
| CAP. 8
|
| Alte aspecte
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|______________________________________________________________________________|
______________________________________________________________________________
| CAP. 9
|
| Concluzii
|
|
_
|
| Se propune
|_| acordarea
_________________________________________ |
|
_
|
|
|_| neacordarea
_________________________________________ |
|
|
| MOTIVAIA:
|
|
|
|
|
| AM LUAT LA CUNOTIN
|
| SOLICITANT ___________________
NTOCMIT _________________
|
|
|
| SEMNTURA ____________________
SEMNTURA ________________
|
|______________________________________________________________________________|
______________________________________________________________________________
| Se ataeaz urmtoarele documente:
|
| 1. ......................................................................... |
| 2. ......................................................................... |
| 3. ......................................................................... |
| 4. ......................................................................... |
| 5. ......................................................................... |
| 6. ......................................................................... |
| 7. ......................................................................... |
| 8. ......................................................................... |
| 9. ......................................................................... |
| 10. ........................................................................ |
| 11. ........................................................................ |
| 12. ........................................................................ |
| 13. ........................................................................ |
| 14. ........................................................................ |
| 15. ........................................................................ |
| 16. ........................................................................ |
| 17. ........................................................................ |
| 18. ........................................................................ |
| 19. ........................................................................ |
| 20. ........................................................................ |
| 21. ........................................................................ |
| 22. ........................................................................ |
| 23. ........................................................................ |
| 24. ........................................................................ |
| 25. ........................................................................ |
| 26. ........................................................................ |
| 27. ........................................................................ |
| 28. ........................................................................ |
| 29. ........................................................................ |
| 30. ........................................................................ |
|______________________________________________________________________________|
ANEXA 3
LISTA BUNURILOR
ce conduc la excluderea acordrii ajutorului social
______________________________________________________________________________
| Bunuri imobile
|
|______________________________________________________________________________|
| 1 | Cldiri sau alte spaii locative n afara locuinei de domiciliu i a
|
|
| anexelor gospodreti
|
|___|__________________________________________________________________________|
| 2 | Terenuri de mprejmuire a locuinei i curtea aferent i alte terenuri |
|
| intravilane care depesc 1.000 mp n zona urban i 2.000 mp n zona
|
|
| rural
|
|___|__________________________________________________________________________|
______________________________________________________________________________
| Bunuri mobile*)
|
|______________________________________________________________________________|
| 1 | Autoturism/Autoturisme i/sau motociclet/motociclete cu o vechime mai
|
|
| mic de 10 ani, cu excepia celor adaptate pentru persoanele cu handicap |
|
| ori destinate transportului acestora sau persoanelor dependente, precum |
|
| i pentru uzul persoanelor aflate n zone greu accesibile
|
|___|__________________________________________________________________________|
| 2 | Mai mult de un autoturism/motociclet cu o vechime mai mare de 10 ani
|
|___|__________________________________________________________________________|
| 3 | Autovehicule: autoutilitare, autocamioane de orice fel cu sau fr
|
|
| remorci, rulote, autobuze, microbuze
|
|___|__________________________________________________________________________|
| 4 | alupe, brci cu motor, scutere de ap, iahturi, cu excepia brcilor
|
|
| necesare pentru uzul persoanelor care locuiesc n Rezervaia Biosferei
|
|
| "Delta Dunrii"
|
|___|__________________________________________________________________________|
| 5 | Utilaje agricole: tractor, combin autopropulsat
|
|___|__________________________________________________________________________|
| 6 | Utilaje de prelucrare agricol: pres de ulei, moar de cereale
|
|___|__________________________________________________________________________|
| 7 | Utilaje de prelucrat lemnul: gater sau alte utilaje de prelucrat lemnul |
|
| acionate hidraulic, mecanic sau electric
|
|___|__________________________________________________________________________|
|
*) Aflate n stare de funcionare
|
|______________________________________________________________________________|
______________________________________________________________________________
| Depozite bancare
|
|______________________________________________________________________________|
| 1 | Depozite bancare cu valoare de peste 3.000 lei
|
|___|__________________________________________________________________________|
______________________________________________________________________________
| Terenuri/animale i/sau psri
|
|______________________________________________________________________________|
| 1 | Suprafee de teren, animale i psri a cror valoare net de producie |
|
| anual depete suma de 1.000 euro pentru persoana singur, respectiv
|
|
| suma de 2.500 euro pentru familie
|
|___|__________________________________________________________________________|
NOT:
Deinerea unuia dintre bunurile menionate conduce la excluderea acordrii ajutorului social.
ANEXA 4
BORDEROU
documente stabilire pli drepturi noi
- model ______________________________________
| Unitatea administrativ-teritorial
|
|______________________________________|
| Judeul
|
|
|________________|_____________________|
| Adresa
|
|
|________________|_____________________|
| CUI
|
|
|________________|_____________________|
| Cod potal
|
|______________________________________|
| Oficiu potal
|
|______________________________________|
Nr. ................
Data ...............
_____________________________________
| Delegat unitate
|
| administrativ-teritorial
|
|_____________________________________|
| Nume
|
|
|_____________|_______________________|
| Prenume
|
|
|_____________|_______________________|
| CNP
|
|
|_____________|_______________________|
nsuit primar
____
/
\
( LS )
\____/
Semnificaia coloanelor din tabelul de mai jos este urmtoarea:
A - Nume
B - Prenume
C - CNP
D - Strada
E - Nr.
F - Bloc
G - Scara
H
I
J
K
L
M
N
O
P
Etaj
Apart.
Sector
Localitatea
Oficiu potal
Cod potal
dispoziie
fi calcul
cerere
_________________________________________________________________________________________
_______________
|Nr. |Titular |
Adresa
|Nr.
|Tip
|Risc
|Nr.
|Nr.
|Cuantum| Documente |
|crt.|
|
|membri/|locuin|seismic|nre|dispo|lunar | transmise |
|
|
|
|familie|*)
|**)
|gistrare|ziie
|ajutor | ***)
|
|
|________|_____________________________|
|
|
|cerere |
|
|___________|
|
| A| B| C| D| E| F| G| H| I| J| K| L| M|
|
|
|
|
|
| N | O | P |
|____|__|__|__|__|__|__|__|__|__|__|__|__|__|_______|________|_______|________|______|___
____|___|___|___|
|
| | | | | | | | | | | | | |
|
|
|
|
|
|
|
|
|
|____|__|__|__|__|__|__|__|__|__|__|__|__|__|_______|________|_______|________|______|___
____|___|___|___|
|
| | | | | | | | | | | | | |
|
|
|
|
|
|
|
|
|
|____|__|__|__|__|__|__|__|__|__|__|__|__|__|_______|________|_______|________|______|___
____|___|___|___|
|
| | | | | | | | | | | | | |
|
|
|
|
|
|
|
|
|
|____|__|__|__|__|__|__|__|__|__|__|__|__|__|_______|________|_______|________|______|___
____|___|___|___|
|
| | | | | | | | | | | | | |
|
|
|
|
|
|
|
|
|
|____|__|__|__|__|__|__|__|__|__|__|__|__|__|_______|________|_______|________|______|___
____|___|___|___|
|
| | | | | | | | | | | | | |
|
|
|
|
|
|
|
|
|
|____|__|__|__|__|__|__|__|__|__|__|__|__|__|_______|________|_______|________|______|___
____|___|___|___|
|
| | | | | | | | | | | | | |
|
|
|
|
|
|
|
|
|
|____|__|__|__|__|__|__|__|__|__|__|__|__|__|_______|________|_______|________|______|___
____|___|___|___|
|
| | | | | | | | | | | | | |
|
|
|
|
|
|
|
|
|
|____|__|__|__|__|__|__|__|__|__|__|__|__|__|_______|________|_______|________|______|___
____|___|___|___|
|
| | | | | | | | | | | | | |
|
|
|
|
|
|
|
|
|
|____|__|__|__|__|__|__|__|__|__|__|__|__|__|_______|________|_______|________|______|___
____|___|___|___|
|
| | | | | | | | | | | | | |
|
|
|
|
|
|
|
|
|
|____|__|__|__|__|__|__|__|__|__|__|__|__|__|_______|________|_______|________|______|___
____|___|___|___|
|
| | | | | | | | | | | | | |
|
|
|
|
|
|
|
|
|
|____|__|__|__|__|__|__|__|__|__|__|__|__|__|_______|________|_______|________|______|___
____|___|___|___|
|
| | | | | | | | | | | | | |
|
|
|
|
|
|
|
|
|
|____|__|__|__|__|__|__|__|__|__|__|__|__|__|_______|________|_______|________|______|___
____|___|___|___|
|
| | | | | | | | | | | | | |
|
|
|
|
|
|
|
|
|
|____|__|__|__|__|__|__|__|__|__|__|__|__|__|_______|________|_______|________|______|___
____|___|___|___|
|
| | | | | | | | | | | | | |
|
|
|
|
|
|
|
|
|
|____|__|__|__|__|__|__|__|__|__|__|__|__|__|_______|________|_______|________|______|___
____|___|___|___|
|
| | | | | | | | | | | | | |
|
|
|
|
|
|
|
|
|
|____|__|__|__|__|__|__|__|__|__|__|__|__|__|_______|________|_______|________|______|___
____|___|___|___|
|
|
|
|____________________________________________________________________|___________________
________________|
*) Se va trece tipul locuinei, respectiv "A" sau "B", conform clasificrii din Legea nr.
260/2008.
**) Se completeaz n cazul locuinelor ncadrate n clasa I de risc seismic.
***) Se bifeaz pe coloan documentul corespunztor ataat borderoului.
Figura 1Lex: Borderou documente stabilire pli drepturi noi
ANEXA 5
- model -
_____________________________________________
|
SITUAIE
CENTRALIZATOARE
|
_______________________________________________________
|_____________________________________________|
| NREGISTRARE IEIRE UNITATE ADMINISTRATIV-TERITORIAL | | Pli VMG aferente lunii |
|
|_______________________________________________________|
|__________________________|__________________|
| Nr.
|
|
|______________|________________________________________|
_____________________________________________
| Data
|
|
| |
APROBAT.
Primar,
|
|______________|________________|_______________________|
|_____________________________________________|
|
Nume
|
Prenume
|
|________________________|____________________|
|
|
|________________________|____________________|
| Semntur i tampila
|
|________________________|____________________|
| Unitatea administrativ-|
|
|
|________________________|____________________|
|
_______________________________________________________
|________________________|____________________|
| DELEGAT UNITATE ADMINISTRATIV-TERITORIAL
|
|
|_______________________________________________________|
|________________________|____________________|
| Nume
|
|
|_______________________________________________________|
|________________________|____________________|
| Prenume
|
|
|_______________________________________________________|
|________________________|____________________|
| CNP
|
|
|
|_______________|_______________________________________|
|________________________|____________________|
| teritorial
| Judeul
| Adresa
| CUI
| Cod potal
| Oficiu potal

A - Strada
B - Nr.
C - Bloc
D - Scara
E - Etaj
F - Apart.
G - Sector
H - Localitatea
I - Oficiu potal
J - Cod potal
K - Suma curent
L - Suma restant
_____________________________
|
Adresa
|
______________________________|_____________________________|____________________________
_______________
|Nr |Prestaie|CNP|Nume|Prenume| A| B| C| D| E| F| G| H| I| J| K| L|Total
|Luna |An
|Mod |IBAN|Banca|
|crt|
|
|
|
| | | | | | | | | | | | |sum
|drept|drept|de
|
|
|
|
|
|
|
|
| | | | | | | | | | | | |(suma
|
|
|plat|
|
|
|
|
|
|
|
| | | | | | | | | | | | |restant|
|
|M/C |
|
|
|
|
|
|
|
| | | | | | | | | | | | |+ total |
|
|
|
|
|
|
|
|
|
|
| | | | | | | | | | | | |sum)
|
|
|
|
|
|
|___|_________|___|____|_______|__|__|__|__|__|__|__|__|__|__|__|__|________|_____|_____|
_____|____|_____|
| 0 |
1
| 2 | 3 |
4 | 5| 6| 7| 8| 9|10|11|12|13|14|15|16|
17
| 18 | 19 |
20 | 21| 22 |
|___|_________|___|____|_______|__|__|__|__|__|__|__|__|__|__|__|__|________|_____|_____|
_____|____|_____|
|
|
|
|
|
| | | | | | | | | | | | |
|
|
|
|
|
|
|___|_________|___|____|_______|__|__|__|__|__|__|__|__|__|__|__|__|________|_____|_____|
_____|____|_____|
|
|
|
|
|
| | | | | | | | | | | | |
|
|
|
|
|
|
|___|_________|___|____|_______|__|__|__|__|__|__|__|__|__|__|__|__|________|_____|_____|
_____|____|_____|
|
|
|
|
|
| | | | | | | | | | | | |
|
|
|
|
|
|
|___|_________|___|____|_______|__|__|__|__|__|__|__|__|__|__|__|__|________|_____|_____|
_____|____|_____|
|
|
|
|
|
| | | | | | | | | | | | |
|
|
|
|
|
|
|___|_________|___|____|_______|__|__|__|__|__|__|__|__|__|__|__|__|________|_____|_____|
_____|____|_____|
|
|
|
|
|
| | | | | | | | | | | | |
|
|
|
|
|
|
|___|_________|___|____|_______|__|__|__|__|__|__|__|__|__|__|__|__|________|_____|_____|
_____|____|_____|
|
|
|
|
|
| | | | | | | | | | | | |
|
|
|
|
|
|
|___|_________|___|____|_______|__|__|__|__|__|__|__|__|__|__|__|__|________|_____|_____|
_____|____|_____|
|
|
|
|
|
| | | | | | | | | | | | |
|
|
|
|
|
|
|___|_________|___|____|_______|__|__|__|__|__|__|__|__|__|__|__|__|________|_____|_____|
_____|____|_____|
|
|
|
|
|
| | | | | | | | | | | | |
|
|
|
|
|
|
|___|_________|___|____|_______|__|__|__|__|__|__|__|__|__|__|__|__|________|_____|_____|
_____|____|_____|
|
|
|
|
|
| | | | | | | | | | | | |
|
|
|
|
|
|
|___|_________|___|____|_______|__|__|__|__|__|__|__|__|__|__|__|__|________|_____|_____|
_____|____|_____|
|
|
|
|
|
| | | | | | | | | | | | |
|
|
|
|
|
|
|___|_________|___|____|_______|__|__|__|__|__|__|__|__|__|__|__|__|________|_____|_____|
_____|____|_____|
|
|
|
|
|
| | | | | | | | | | | | |
|
|
|
|
|
|
|___|_________|___|____|_______|__|__|__|__|__|__|__|__|__|__|__|__|________|_____|_____|
_____|____|_____|
|
|
|
|
|
| | | | | | | | | | | | |
|
|
|
|
|
|
|___|_________|___|____|_______|__|__|__|__|__|__|__|__|__|__|__|__|________|_____|_____|
_____|____|_____|
|
|
|
|
|
| | | | | | | | | | | | |
|
|
|
|
|
|
|___|_________|___|____|_______|__|__|__|__|__|__|__|__|__|__|__|__|________|_____|_____|
_____|____|_____|
|
|
|
|
|
| | | | | | | | | | | | |
|
|
|
|
|
|
|___|_________|___|____|_______|__|__|__|__|__|__|__|__|__|__|__|__|________|_____|_____|
_____|____|_____|
|
|
|
|
|
| | | | | | | | | | | | |
|
|
|
|
|
|
|___|_________|___|____|_______|__|__|__|__|__|__|__|__|__|__|__|__|________|_____|_____|
_____|____|_____|
| TOTAL:
| | |
|
|
|
|
|
|
|____________________________________________________________|__|__|________|_____|_____|
_____|____|_____|
Figura 2Lex: Situaie centralizatoare privind titularii ajutorului social i sumele de plat
ANEXA 6
- model AGENIA PENTRU PLI I INSPECIE SOCIAL A JUDEULUI ................../
MUNICIPIULUI BUCURETI
DECIZIE
Nr. ..... din ............
privind aprobarea acordrii ajutorului social
Directorul executiv al Ageniei pentru Pli i Inspecie Social a Judeului
......................../Municipiului Bucureti ..................., numit prin decizia directorului general al
Ageniei Naionale pentru Pli i Inspecie Social nr. ...............,
avnd n vedere:
- art. 16 alin. (1) lit. l) din Ordonana de urgen a Guvernului nr. 113/2011 privind
organizarea i funcionarea Ageniei Naionale pentru Pli i Inspecie Social, aprobat cu
modificri i completri prin Legea nr. 198/2012;
- art. 13^1 alin. (2) din Legea nr. 416/2001 privind venitul minim garantat, cu modificrile i
completrile ulterioare;
- art. 26 alin. (1) din Normele metodologice de aplicare a prevederilor Legii nr. 416/2001
privind venitul minim garantat, aprobate prin Hotrrea Guvernului nr. 50/2011, cu modificrile
i completrile ulterioare;
- Regulamentul de organizare i funcionare al Ageniei pentru Pli i Inspecie Social a
Judeului ......................../Municipiului Bucureti,
- dispoziia primarului nr. .............. din ...........................
i n temeiul competenelor conferite de lege,
decide:
ART. 1
Se aprob plata ajutorului social n cuantum de ................ lei pentru doamna/domnul
........................................, n calitate de titular.
ART. 2
(1) Drepturile prevzute la art. 1 se acord ncepnd cu data de ..........

(2) Plata drepturilor prevzute la art. 1 se efectueaz n perioada ................ a fiecrei luni prin
mandat potal/cont personal/cont de card.
Decizia poate fi contestat n termen de 30 de zile de la comunicare, la Agenia pentru Pli i
Inspecie Social a Judeului ............./Municipiului Bucureti.
n cazul n care suntei nemulumit de soluionarea contestaiei, decizia poate fi atacat la
Tribunalul ....................., n termen de 30 de zile de la comunicarea soluiei contestaiei, potrivit
prevederilor Legii contenciosului administrativ nr. 554/2004, cu modificrile i completrile
ulterioare.
Director executiv,
...........................
ANEXA 7*)
______________________________________________________________________________
| UNITATEA ADMINISTRATIV TERITORIAL ......................................... |
|______________________________________________________________________________|
______________________
|
AVIZAT PRIMAR
|
- model |
____
|
|
/
\
|
|
( L.S. )
|
|
\____/
|
|______________________|
SITUAIE LUNAR
privind persoanele din familiile beneficiare de ajutor social precum i activitile
realizate de acetia, conform planului de aciuni
n luna ............. anul ............
______________________________________________________________________________
|Nr. | Titular ajutor | Persoana apt de | Numr ore | Numr ore| Activiti|
|crt.| social
| munc din familia | aferente | efectuate| prestate |
|
|
| beneficiar de
| ajutorului|
|
|
|
|
| ajutor social
|
|
|
|
|
|__________________|___________________|
|
|
|
|
|Nume| Prenume| CNP| Nume| Prenume| CNP|
|
|
|
|____|____|________|____|_____|________|____|___________|__________|___________|
|
|
|
|
|
|
|
|
|
|
|
|____|____|________|____|_____|________|____|___________|__________|___________|
|
|
|
|
|
|
|
|
|
|
|
|____|____|________|____|_____|________|____|___________|__________|___________|
|
|
|
|
|
|
|
|
|
|
|
|____|____|________|____|_____|________|____|___________|__________|___________|
|
|
|
|
|
|
|
|
|
|
|
|____|____|________|____|_____|________|____|___________|__________|___________|
|
|
|
|
|
|
|
|
|
|
|
|____|____|________|____|_____|________|____|___________|__________|___________|
|
|
|
|
|
|
|
|
|
|
|
|____|____|________|____|_____|________|____|___________|__________|___________|
|
|
|
|
|
|
|
|
|
|
|
|____|____|________|____|_____|________|____|___________|__________|___________|
|
|
|
|
|
|
|
|
|
|
|
|____|____|________|____|_____|________|____|___________|__________|___________|
|
|
|
|
|
|
|
|
|
|
|
|____|____|________|____|_____|________|____|___________|__________|___________|
|
|
|
|
|
|
|
|
|
|
|
|____|____|________|____|_____|________|____|___________|__________|___________|
|
|
|
|
|
|
|
|
|
|
|
|____|____|________|____|_____|________|____|___________|__________|___________|
|
|
|
|
|
|
|
|
|
|
|
|____|____|________|____|_____|________|____|___________|__________|___________|
|
|
|
|
|
|
|
|
|
|
|
|____|____|________|____|_____|________|____|___________|__________|___________|
|
|
|
|
|
|
|
|
|
|
|
|____|____|________|____|_____|________|____|___________|__________|___________|
|
|
|
|
|
|
|
|
|
|
|
|____|____|________|____|_____|________|____|___________|__________|___________|
|
|
|
|
|
|
|
|
|
|
|
|____|____|________|____|_____|________|____|___________|__________|___________|
|
|
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|
|____|____|________|____|_____|________|____|___________|__________|___________|
ntocmit: Nume ........................
Semntura ...................
ANEXA 8*)
______________________________________________________________________________
| CASA NAIONAL DE PENSII PUBLICE
|
| CASA DE PENSII A ........................................................... |
|______________________________________________________________________________|
Nr.
/
CERTIFICAT MEDICAL DE CONSTATARE A CAPACITII DE MUNC
______________________________________________________________________________
|
|
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Subsemnatul |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__| |
|
medic expert al cabinetului de expertiz medical i recuperare a capacitii|
|
de munc din localitatea |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__||
|
judeul |__|__|__|__|__|__|__|__|__|__| examinnd astzi |__|__|__|__|__|__| |
(z z) (l l) (a a) |
|
pe dna/dl |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__||
|
n vrst de |__|__|__| ani, cu ocupaia |__|__|__|__|__|__|__|__|__|__|__| |
|
cu domiciliul n localitatea |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__| |
|
strada |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__||
|
nr. |__|__|__| bl. |__|__|__|__| sc. |__|__|__| apart. |__|__|__| sector |_||
|
jude |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__| |
|
|
| am constatat c sufer de:
|
|
|
| Diagnostic clinic: _________________________________________________________ |
|
|
| ____________________________________________________________________________ |
|
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| ____________________________________________________________________________ |
|
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| Diagnostic funcional: _____________________________________________________ |
|
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| ____________________________________________________________________________ |
|
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| ____________________________________________________________________________ |
|
_ _
|
|
_
| |_| redus
|
|
| Capacitatea de munc <
_
|
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|_ |_| pierdut
|
| Concluzie: <
|
|
|
_____
|
|
|_ Este ncadrabil n gradul |_____| de invaliditate
|
|
|
| Termen de valabilitate _____________________________________________________ |
|
|
| Prezentul certificat s-a eliberat pentru a beneficia de prevederile
|
| Legii nr. 416/2001 privind venitul minim garantat.
|
|______________________________________________________________________________|
MEDIC EXPERT AL ASIGURRILOR SOCIALE
____________________________________
(semntur, paraf, tampil)
ANEXA 9
- model TABEL NOMINAL
cu persoanele aflate n cutarea unui loc de munc nregistrate n evidena ..... (se
completeaz numele ageniei pentru ocuparea forei de munc judeene sau a
municipiului Bucureti .............), pentru care s-au eliberat adeverine n condiiile Legii
nr. 416/2001 privind venitul minim garantat, cu modificrile i completrile ulterioare
anul ........... luna ..............
___________________________________________________________________________________
|Nr. |Numele,
|CNP|Domiciliul/|Adeverina,|A refuzat/Nu|Data
|A refuzat/Nu |
|crt.|prenumele,|
|Reedina |nr. i data|a refuzat un|ncadrrii |a refuzat
|
|
|iniiala |
|
|
|loc de munc|n munc (se|participarea |
|
|tatlui
|
|
|
|oferit (se |completeaz,|la programe |
|
|
|
|
|
|completeaz |dup caz)
|de formare
|
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|
|DA/NU)
|
|profesional,|
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|cursuri etc. |
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|(se
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|completeaz |
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|DA/NU)
|
|____|__________|___|___________|___________|____________|____________|_____________|
|
|
1
| 2 |
3
|
4
|
5
|
6
|
7
|
|____|__________|___|___________|___________|____________|____________|_____________|
| 1 |
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|____|__________|___|___________|___________|____________|____________|_____________|
| 2 |
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|____|__________|___|___________|___________|____________|____________|_____________|
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|____|__________|___|___________|___________|____________|____________|_____________|
Director executiv,
........................
ANEXA 10
- model Unitatea administrativ-teritorial ......................
Judeul .................................................
Adresa ..................................................
CUI .....................................................
Cod potal ..............................................
Oficiu potal ...........................................
LISTA
persoanelor apte de munc din familiile beneficiare de ajutor social
______________________________________________________________________________
|Nr. |
Nume
|
Prenume
|
CNP
| Localitatea de domiciliu|
|crt.|
|
|
| (municipiu/ora/comun) |
|____|______________|__________________|_____________|_________________________|
| 1. |
|
|
|
|
|____|______________|__________________|_____________|_________________________|
| 2. |
|
|
|
|
|____|______________|__________________|_____________|_________________________|
| ...|
|
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|____|______________|__________________|_____________|_________________________|
|
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|____|______________|__________________|_____________|_________________________|
Aprobat primar
____
/
\
( LS )
\____/
ANEXA 11
cu persoanele din familiile beneficiare de ajutor social care s-au ncadrat n munc, au
refuzat un loc de munc oferit sau un curs de calificare/recalificare/formare profesional
anul ........... luna ..............
_________________________________________________________________________________________
______________
|Nr. |Numele,
|CNP|Domiciliul/|Adeverin |Locul de munc |Data
|Program de
|Contract de
|
|crt.|prenumele,|
|Reedina |nr. i
|oferit ncadrat/|ncadrrii |formare
|munc n
|
|
|iniiala |
|
|dat - se
|nencadrat refuz|n munc |profesional,|strintate
|
|
|tatlui
|
|
|completeaz,|loc de munc - |se
|curs/refuz
|(perioada
|
|
|
|
|
|dup caz
|se completeaz, |completeaz,|curs - se
|valabilitate |
|
|
|
|
|
|dup caz
|dup caz
|completeaz,
|contract) - se|
|
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|
|dup caz
|completeaz, |
|
|
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|
|dup caz
|
|____|__________|___|___________|____________|________________|____________|_____________
|______________|
| 1 |
|
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|____|__________|___|___________|____________|________________|____________|_____________
|______________|
| 2 |
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|____|__________|___|___________|____________|________________|____________|_____________
|______________|
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|____|__________|___|___________|____________|________________|____________|_____________
|______________|
NOT:
Tabelul este ntocmit pe baza listei persoanelor apte de munc din familiile beneficiare de
ajutor social transmise de ctre primrii conform art. 15 alin. (3) din Legea nr. 416/2001 privind
venitul minim garantat, cu modificrile i completrile ulterioare (col. 1 - 3), i a informaiilor
existente n baza de date a ageniei pentru ocuparea forei de munc la data ntocmirii tabelului.
Director executiv
Numele i prenumele .............................
Semntura .............................................
____
\
( LS )
\____/
/
ANEXA 12
cu persoanele apte de munc din familiile beneficiare de ajutor social, care au ncheiat un
contract de munc
anul ...... luna ............
_________________________________________________________________________________________
___________
|Nr. |CNP
|Stare
|Nume i |Localitate|Denumire |CUI
|Nr. i|Dat
nceput|Tip
|Norm |
|crt.|salariat|conform
|prenume |de
|angajator|angajator|data |activitate
|C.I.M.|C.I.M.|
|
|
|registrului |salariat|domiciliu |
|
|C.I.M.|
|
|
|
|
|
|salariailor|
|salariat |
|
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|*)
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|____|________|____________|________|__________|_________|_________|______|____________|_
_____|______|
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|____|________|____________|________|__________|_________|_________|______|____________|_
_____|______|
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|____|________|____________|________|__________|_________|_________|______|____________|_
_____|______|
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|____|________|____________|________|__________|_________|_________|______|____________|_
_____|______|
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|____|________|____________|________|__________|_________|_________|______|____________|_
_____|______|
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|____|________|____________|________|__________|_________|_________|______|____________|_
_____|______|
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|____|________|____________|________|__________|_________|_________|______|____________|_
_____|______|
|
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|____|________|____________|________|__________|_________|_________|______|____________|_
_____|______|
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|____|________|____________|________|__________|_________|_________|______|____________|_
_____|______|
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|____|________|____________|________|__________|_________|_________|______|____________|_
_____|______|
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|____|________|____________|________|__________|_________|_________|______|____________|_
_____|______|
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|____|________|____________|________|__________|_________|_________|______|____________|_
_____|______|
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|____|________|____________|________|__________|_________|_________|______|____________|_
_____|______|
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|____|________|____________|________|__________|_________|_________|______|____________|_
_____|______|
*) Stare conform Registrului salariailor (REVISAL) la data verificrii n baza de date.
ANEXA 13*)
(Anexa nr. 16a la normele metodologice)
______________________________________________________________________________
| UNITATEA ADMINISTRATIV TERITORIAL ........................................ |
|______________________________________________________________________________|
____________________
| CERTIFICARE PRIMAR |
|
______
|
ANCHETA SOCIAL
|
/
\
|
pentru acordarea unui ajutor de urgen
|
( L.S. )
|
|
\______/
|
|____________________|
______________________________________________________________________________
| Efectuat la data de |__|__|__|__|__|__| pentru acordarea _________________ |
|
(z z) (l l) (a a)
|
|
|
| Urmare a cererii
|_|_|_|_|_|_|_| la data de |__|__|__|__|__|__| a
|
| nregistrat sub nr.
(z z) (l l) (a a)
|
| _
_
|
| |_| Dlui
|_| Dnei
|
|
|
| A1. DATE PERSONALE ALE SOLICITANTULUI/TITULARULUI
|
|
|
| Nume |_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
|
|
|
| Prenume |_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
|
|
|
| CNP |_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
|
|
|
| Act identitate*) |_|_|_|_| Seria |_|_| Nr. |_|_|_|_|_|_|
|
|
|
| eliberat de |_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| la data de |__|__|__|__|__|__| |
|
(z z) (l l) (a a) |
|
|
| *) Pentru cetenii romni:
*) Pentru cetenii strini sau apatrizi: |
| BI - buletin de
P - paaport
CR - carte de
|
|
identitate
temporar
reziden
|
| CI - carte de
PSTL - permis de edere CRP - carte de
|
|
identitate
pe termen lung
reziden
|
| CIP - carte de
DI - document de
permanent |
|
identitate
identitate
|
|
provizorie
|
|______________________________________________________________________________|
______________________________________________________________________________
| A2. DATE DE CONTACT ALE SOLICITANTULUI
|
|
|
| Strada |_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|
|
|
|
| Nr. |_|_|_|_| Bl. |_|_|_|_|_|_|_|_|_| Sc. |_|_|_| Apart. |_|_|_|_| Sector |_||
|
|
| Localitatea |_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
|
|
| Jude |_|_|_|_|_|_|_|_|_|_|_|_|_|_| Telefon |_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_||
|
|
| Mobil |_|_|_|_|_|_|_|_|_|_|_|_|_|_| Fax
|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_||
|
|
| E-mail |_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_|_| |
|______________________________________________________________________________|
______________________________________________________________________________
| A3. STAREA CIVIL A SOLICITANTULUI
|
| _
_
_
|
| |_| Cstorit()
|_| Necstorit()
|_| Vduv()
|
| _
_
_
|
| |_| Divorat()
|_| Desprit n fapt
|_| Uniune consensual
|
|
|
| Altele .................................................................... |
|______________________________________________________________________________|
______________________________________________________________________________
| A4. NUMRUL DE PERSOANE DIN FAMILIE
|
|
|
|
Numrul de persoane adulte
............
|
|
Numrul de persoane sub 18 ani ............
|
|______________________________________________________________________________|
______________________________________________________________________________
| B. DATE DESPRE LOCUIN
|
|
|
| ____________________________________________ ______________________________ |
|| Model locuin:
|| _____________________
|
|
||| | Cas cu curte
|\
| _
|
|||_|___________________| |
|
|| _____________________ |
|
|
||| | Cas fr curte
| |
| _
|
|||_|___________________| |
/ _____________ ||_| n nchiriere public/privat|
|| _____________________ | | | | 1 camer | |
|
|
|||_|___________________| | | _____________ | Altele ...................... |
|| _____________________ | | | | 2 camere | |______________________________ |
||| | Locuin social | | | |_|___________|
|
|||_|___________________| | | _____________
______________________________ |
|
||| | Locuin de
| >< |_|___________| | locuinei
|
||| | serviciu
| | | _____________ |
|
|||_|___________________| | | | | 4 camere | | _
|
|| _____________________ | | |_|___________| ||_| Cumprare
|
||| | Locuin de
| | | _____________ |
|
||| | necesitate
| | | | | > 4 camere| | _
|
|||_|___________________| | | |_|___________| ||_| Motenire
|
|| _____________________ |
\
|
|
|
|
||| | nu are locuin
| |
| Altele ...................... |
|||_|___________________|/
|
|
||____________________________________________ |______________________________ |
| ____________________________________________________________________________ |
||
___________________________________________________________ |
||
_ | TIP A | construcia cu structura de rezisten din beton ||
||
| ||
| armat, metal, lemn, piatr, crmid ars sau din ||
||
|_||
| orice alte materiale rezultate n urma unui
||
|| Tipul
|
| tratament termic i/sau chimic
||
|| locuinei
|_______|___________________________________________________||
||
___________________________________________________________ |
||
_ | TIP B | construcia cu perei exteriori din crmid
||
||
| ||
| nears sau din orice alte materiale nesupuse unui ||
||
|_||
| tratament termic i/sau chimic
||
||
|_______|___________________________________________________||
||____________________________________________________________________________ |
| ____________________________________________________________________________ |
||
_
|
|| Dac are ncheiat
|_| Nu
|
|| poli de asigurare
_
|
|| a locuinei?
|_| Da, la societatea ........................... |
||
|
||
Nr. poli ..... Din data de ................ |
||____________________________________________________________________________ |
|______________________________________________________________________________|
______________________________________________________________________________
| K. MOTIVUL SOLICITRII AJUTORULUI DE URGEN
|
|
|
|
|
|
|
|
|
|______________________________________________________________________________|
______________________________________________________________________________
| L. PREJUDICII CONSTATATE
|
|
|
|
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|
|
|
|
|
|
|
|
|______________________________________________________________________________|
______________________________________________________________________________
| M. CONCLUZII
|
|
_
_
|
| Se propune |_| acordarea
|_| neacordarea
ajutorului de urgen
|
|
|
|
|
| MOTIVAIA:
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|______________________________________________________________________________|
AM LUAT LA CUNOTIN
NTOCMIT _______________
SOLICITANT __________________
SEMNTURA ___________________
ANEXA 14
(Anexa nr. 1a la normele metodologice)
SEMNTURA ______________
- model ROMNIA
Judeul/Municipiul Bucureti ........................
(codul, denumirea)
Unitatea administrativ-teritorial ..............................
(codul, denumirea)
SITUAIA
privind beneficiarii i cuantumul ajutoarelor pentru energie termic
luna ........../an ..........
____________________________________________________________________________________
|Nr. |Titular|CNP|Adresa|Nr.
|Cod
|Venit | Valoare |Numr
|Compensare |
|crt.|
|
|
|membri |furnizor/|lunar/ | maxim
|dispoziie|
|
|
|
|
|
|n
|client
|membru | ajutor
|primar
|
|
|
|
|
|
|familie|
|familie|___________|
|___________|
|
|
|
|
|
|
|
|Buget|Buget|
|Buget|Buget|
|
|
|
|
|
|
|
|de
|local|
|de
|local|
|
|
|
|
|
|
|
|stat |
|
|stat |
|
|____|_______|___|______|_______|_________|_______|_____|_____|__________|_____|_____|
|
|
|
|
|
|
|
|
|
|
|
|
|
|____|_______|___|______|_______|_________|_______|_____|_____|__________|_____|_____|
|
|
|
|
|
|
|
|
|
|
|
|
|
|____|_______|___|______|_______|_________|_______|_____|_____|__________|_____|_____|
|
|
|
|
|
|
|
|
|
|
|
|
|
|____|_______|___|______|_______|_________|_______|_____|_____|__________|_____|_____|
|
|
|
|
|
|
|
|
|
|
|
|
|
|____|_______|___|______|_______|_________|_______|_____|_____|__________|_____|_____|
|
|
|
|
|
|
|
|
|
|
|
|
|
|____|_______|___|______|_______|_________|_______|_____|_____|__________|_____|_____|
|
|
|
|
|
|
|
|
|
|
|
|
|
|____|_______|___|______|_______|_________|_______|_____|_____|__________|_____|_____|
|
|
|
|
|
|
|
|
|
|
|
|
|
|____|_______|___|______|_______|_________|_______|_____|_____|__________|_____|_____|
|
|
|
|
|
|
|
|
|
|
|
|
|
|____|_______|___|______|_______|_________|_______|_____|_____|__________|_____|_____|
|
|
|
|
|
|
|
|
|
|
|
|
|
|____|_______|___|______|_______|_________|_______|_____|_____|__________|_____|_____|
|
|
|
|
|
|
|
|
|
|
|
|
|
|____|_______|___|______|_______|_________|_______|_____|_____|__________|_____|_____|
Primar,
................
NOT:
Se transmite n scris i n format electronic.
ANEXA 15
(Anexa nr. 1b la normele metodologice)
- model ROMNIA
(codul, denumirea)
(codul, denumirea)
SITUAIA
privind beneficiarii i cuantumul ajutoarelor pentru gaze naturale
luna ........../an ..........
______________________________________________________________________________
|Nr. |Titular| CNP |Adresa|Cod
|Nr.
|Venit |Numr
|Cuantumul lunar|
|crt.|
|
|
|furnizor/|membri |lunar/ |dispoziie|al ajutorului |
|
|
|
|
|client
|n
|membru |primar
|stabilit prin |
|
|
|
|
|
|familie|familie|
|dispoziia
|
|
|
|
|
|
|
|
|
|primarului
|
|
|
|
|
|
|
|
|
|_______________|
|
|
|
|
|
|
|
|
|Buget
|Buget |
|
|
|
|
|
|
|
|
|de stat |local |
|____|_______|_____|______|_________|_______|_______|__________|________|______|
|
|
|
|
|
|
|
|
|
|
|
|____|_______|_____|______|_________|_______|_______|__________|________|______|
|
|
|
|
|
|
|
|
|
|
|
|____|_______|_____|______|_________|_______|_______|__________|________|______|
|
|
|
|
|
|
|
|
|
|
|
|____|_______|_____|______|_________|_______|_______|__________|________|______|
|
|
|
|
|
|
|
|
|
|
|
|____|_______|_____|______|_________|_______|_______|__________|________|______|
|
|
|
|
|
|
|
|
|
|
|
|____|_______|_____|______|_________|_______|_______|__________|________|______|
|
|
|
|
|
|
|
|
|
|
|
|____|_______|_____|______|_________|_______|_______|__________|________|______|
|
|
|
|
|
|
|
|
|
|
|
|____|_______|_____|______|_________|_______|_______|__________|________|______|
|
|
|
|
|
|
|
|
|
|
|
|____|_______|_____|______|_________|_______|_______|__________|________|______|
|
TOTAL: |
|
|
|
|___________________________________________________|__________|________|______|
Primar,
................
NOT:
ANEXA 16
(Anexa nr. 1c la normele metodologice)
- model ROMNIA
(codul, denumirea)
(codul, denumirea)
SITUAIA
privind beneficiarii i cuantumul ajutoarelor pentru energie electric
luna ........../an ..........
______________________________________________________________________________
|Nr. |Titular| CNP |Adresa|Cod
|Nr.
|Venit |Numr
|Cuantumul lunar|
|crt.|
|
|
|furnizor/|membri |lunar/ |dispoziie|al ajutorului |
|
|
|
|
|client
|n
|membru |primar
|stabilit prin |
|
|
|
|
|
|familie|familie|
|dispoziia
|
|
|
|
|
|
|
|
|
|primarului
|
|
|
|
|
|
|
|
|
|_______________|
|
|
|
|
|
|
|
|
|Buget
|Buget |
|
|
|
|
|
|
|
|
|de stat |local |
|____|_______|_____|______|_________|_______|_______|__________|________|______|
|
|
|
|
|
|
|
|
|
|
|
|____|_______|_____|______|_________|_______|_______|__________|________|______|
|
|
|
|
|
|
|
|
|
|
|
|____|_______|_____|______|_________|_______|_______|__________|________|______|
|
|
|
|
|
|
|
|
|
|
|
|____|_______|_____|______|_________|_______|_______|__________|________|______|
|
|
|
|
|
|
|
|
|
|
|
|____|_______|_____|______|_________|_______|_______|__________|________|______|
|
|
|
|
|
|
|
|
|
|
|
|____|_______|_____|______|_________|_______|_______|__________|________|______|
|
|
|
|
|
|
|
|
|
|
|
|____|_______|_____|______|_________|_______|_______|__________|________|______|
|
|
|
|
|
|
|
|
|
|
|
|____|_______|_____|______|_________|_______|_______|__________|________|______|
|
|
|
|
|
|
|
|
|
|
|
|____|_______|_____|______|_________|_______|_______|__________|________|______|
|
|
|
|
|
|
|
|
|
|
|
|____|_______|_____|______|_________|_______|_______|__________|________|______|
|
TOTAL: |
|
|
|
|___________________________________________________|__________|________|______|
Primar,
................
NOT:
ANEXA 17
(Anexa nr. 1d la normele metodologice)
- model ROMNIA
(codul, denumirea)
(codul, denumirea)
SITUAIA
privind beneficiarii i cuantumul ajutoarelor pentru combustibili solizi sau lichizi
luna ........../an ..........
______________________________________________________________________________
|Nr. | Titular | CNP | Adresa
| Numr
| Nr.
| Venit |Cuantumul lunar|
|crt.|
|
|
| dispoziie| membri | lunar/ |al ajutorului |
|
|
|
|
| primar
| n
| membru |stabilit prin |
|
|
|
|
|
| familie| familie|dispoziia
|
|
|
|
|
|
|
|
|primarului
|
|
|
|
|
|
|
|
|_______________|
|
|
|
|
|
|
|
|Buget
|Buget |
|
|
|
|
|
|
|
|de stat |local |
|____|_________|_____|___________|___________|________|________|________|______|
|
|
|
|
|
|
|
|
|
|
|____|_________|_____|___________|___________|________|________|________|______|
|
|
|
|
|
|
|
|
|
|
|____|_________|_____|___________|___________|________|________|________|______|
|
|
|
|
|
|
|
|
|
|
|____|_________|_____|___________|___________|________|________|________|______|
|
|
|
|
|
|
|
|
|
|
|____|_________|_____|___________|___________|________|________|________|______|
|
|
|
|
|
|
|
|
|
|
|____|_________|_____|___________|___________|________|________|________|______|
|
|
|
|
|
|
|
|
|
|
|____|_________|_____|___________|___________|________|________|________|______|
|
|
|
|
|
|
|
|
|
|
|____|_________|_____|___________|___________|________|________|________|______|
|
|
|
|
|
|
|
|
|
|
|____|_________|_____|___________|___________|________|________|________|______|
|
|
|
|
|
|
|
|
|
|
|____|_________|_____|___________|___________|________|________|________|______|
|
TOTAL: |
|
|
|______________________________________________________________|________|______|
Primar,
................
NOT:
ANEXA 18
- model PROCES-VERBAL CONSTATATOR
ncheiat astzi, data ...................
ntre
1. Furnizorul de energie termic furnizat n sistem centralizat ..........................., reprezentat
prin dna/dl ........................., n calitate de .......................................,
i
2. Asociaia de proprietari/locatari ....................................., reprezentat prin dna/dl
........................................., n calitate de .................................., am procedat la determinarea
consumului general de energie termic aferent lunii ........................., nregistrat de aparatul de
msur instalat la nivelul branamentului imobilului din localitatea ..........................., str.
................ nr. ......, n cantitate de ............................. .
Reprezentat furnizor,
...........................
____
/
\
( LS )
\____/
Reprezentant asociaie proprietari/locatari,

..............................
____
/
\
( LS )
\____/
ANEXA 19
- model SITUAIA
cuprinznd consumurile defalcate de asociaia de proprietari/locatari pe beneficiarii
ajutorului pentru energie termic
Perioada de consum ..................
Denumirea titularului de contract .........................
Adresa titularului de contract ............................
Codul titularului de contract .............................
______________________________________________________________________________
|Nr. |Nr.|Nr.
|Beneficiar| CNP |Numr
| Valoare ajutor
|Consum
|
|crt.|ap.|camere|ajutor
|
|dispoziie| maxim stabilit
|defalcat pe|
|
|
|
|
|
|primar
| prin dispoziie
|apartamente|
|
|
|
|
|
|
| a primarului
| (Gcal)
|
|
|
|
|
|
|
|____________________|
|
|
|
|
|
|
|
|Buget |Buget|Total |
|
|
|
|
|
|
|
|de stat|local|ajutor|
|
|____|___|______|__________|_______|__________|_______|_____|______|___________|
| 0 | 1 | 2
|
3
|
4
|
5
|
6
| 7 |
8 |
9
|
|____|___|______|__________|_______|__________|_______|_____|______|___________|
| . |
|
|
|
|
|
|
|
|
|
| . |
|
|
|
|
|
|
|
|
|
| . |
|
|
|
|
|
|
|
|
|
|____|___|______|__________|_______|__________|_______|_____|______|___________|
| TOTAL:
|
|
|
|
|
|_____________________________________________|_______|_____|______|___________|
Valorile din coloana 9 reprezint consumul de energie termic pentru nclzire alocat prin
defalcarea consumului general stabilit n baza procesului-verbal pe beneficiarii ajutorului pentru
nclzirea locuinei.
Reprezentant titular de contract
Preluat de furnizor
Numele i prenumele .............

Data i semntura ...............
tampila (dup caz)
Numele i prenumele ..............

Funcia ..........................
Data i semntura ................
NOT:
Se ntocmete n dou exemplare, din care unul se pred furnizorului sub semntur de
primire.
ANEXA 20
- model BORDEROU CENTRALIZATOR
cuprinznd beneficiarii ajutorului pentru energie termic
i cuantumul acestuia pentru perioada ...................
Denumirea furnizorului ..............
_____________
/ CERTIFICARE \
(
PRIMAR
)
\_____________/
Adresa furnizorului .................

Anex la factura nr. ........./........
Denumirea titularului de contract .............. Adresa titularului de contract
........... Codul titularului de contract ..............
A - Consum repartizat de asociaia de proprietari/locatari
B - Preul energiei termice facturat populaiei
C - Cuantum efectiv ajutor nclzire buget de stat
D - Cuantum efectiv ajutor nclzire buget local
_________________________________________________________________________________________
_______________
|Nr. |Nr.|Nr.
|Beneficiar|CNP| Compensare| A | B | Valoare | Valoare
| C |
D |Suma de
|
|crt.|ap.|dispoziie|ajutor
|
|
(%)
|
|
| ajutor
| ajutor maxim
|
|
|plat pentru|
|
|
|primar
|
|
|___________|
|
| efectiv | stabilit
|
|
|beneficiarul|
|
|
|
|
|
|Buget|Buget|
|
|
| prin dispoziia |
|
|ajutorului |
|
|
|
|
|
|de
|local|
|
|
| primarului
|
|
|de nclzire|
|
|
|
|
|
|stat |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|_________________|
|
|____________|
|
|
|
|
|
|
|
|
|
|
|Total|Buget|Buget|
|
|Buget|Buget |
|
|
|
|
|
|
|
|
|
|
|
|de
|local|
|
|de
|local |
|
|
|
|
|
|
|
|
|
|
|
|stat |
|
|
|stat |
|
|____|___|__________|__________|___|_____|_____|___|___|__________|_____|_____|_____|___|
___|_____|______|
| 0 | 1 |
2
|
3
| 4 | 5 | 6 | 7 | 8 | 9=(5+6)x | 10 | 11 | 12 | 13|
14| 15 | 16 |
|
|
|
|
|
|
|
|
|
| 7x8
|
|
|
|
|
|
|
|
|____|___|__________|__________|___|_____|_____|___|___|__________|_____|_____|_____|___|
___|_____|______|
| . |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| . |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| . |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|____|___|__________|__________|___|_____|_____|___|___|__________|_____|_____|_____|___|
___|_____|______|
|
TOTAL: |
|
|
|
|
|
|
|
|
|
|
|______________________________________________|___|___|__________|_____|_____|_____|___|
___|_____|______|
NOT:
Valoarea efectiv a ajutorului pentru nclzirea locuinei nu poate depi valoarea maxim
stabilit prin dispoziie a primarului n condiiile Ordonanei de urgen a Guvernului nr.
70/2011.
Semntur i tampil furnizor,

...............................
-----------Situaia se ntocmete n 3 exemplare, n original, din care unul se transmite ageniei pentru
prestaii sociale judeene, respectiv a municipiului Bucureti, unul rmne la primar i cellalt
se remite furnizorului.
Col. 13 - 16 vor fi completate n funcie de autoritatea creia i se cere decontarea sumelor cu
titlu de ajutor pentru nclzirea locuinei.
Figura 3Lex: Borderou centralizator cuprinznd beneficiarii ajutorului pentru energie termic
ANEXA 21
- model PROCES-VERBAL
ncheiat astzi, data ...................
ntre
1. Furnizorul de gaze naturale ..........................................., reprezentat() prin dna/dl
...................................,
i
2. Asociaia de proprietari/locatari ....................................., reprezentat prin dna/dl
......................, am procedat la determinarea consumului general de gaze naturale aferent lunii
....................., pe baza citirii contorului.
Index citit:
Data citirii:
Reprezentat furnizor,
...........................
____
/
\
( LS )
\____/
Reprezentant asociaie proprietari/locatari,

..............................
____
/
\
( LS )
\____/
ANEXA 22
- model SITUAIA CENTRALIZATOARE
cuprinznd consumurile defalcate de asociaia de proprietari/locatari pe beneficiarii
ajutorului pentru gaze naturale

Denumire titular de contract (client) ............................
Adres titular de contract (client) ..............................
Cod titular de contract (client) .................................
______________________________________________________________________________
|Nr. | Beneficiar
| CNP | Numr
| Cuantum ajutor stabilit| Consum
|
|crt.| ajutor de
|
| dispoziie | prin dispoziie a
| defalcat pe |
|
| nclzire
|
| primar
| primarului
| apartamente |
|
|
|
|
|________________________| (NMC)
|
|
|
|
|
| Total | Buget | Buget |
|
|
|
|
|
|
| de stat| local |
|
|____|______________|_____|_____________|_______|________|_______|_____________|
| 0 |
1
| 2 |
3
|
4
|
5
|
6
|
7
|
|____|______________|_____|_____________|_______|________|_______|_____________|
| . |
|
|
|
|
|
|
|
| . |
|
|
|
|
|
|
|
| . |
|
|
|
|
|
|
|
|____|______________|_____|_____________|_______|________|_______|_____________|
| TOTAL:
|
|
|
|
|
|_______________________________________|_______|________|_______|_____________|
Valorile din coloana 7 reprezint consumul de gaze naturale pentru nclzire alocat
prin defalcarea consumului general de asociaia de proprietari/locatari pe beneficiarii
ajutorului pentru nclzirea locuinei.
Reprezentant titular de contract
(client)
Preluat de furnizor
Numele i prenumele .............

Data i semntura ...............
tampila (dup caz)
Numele i prenumele ..............

Funcia ..........................
Data i semntura ................
NOT:
Se ntocmete n dou exemplare, din care unul se pred furnizorului sub semntur de
primire.
ANEXA 23
- model _____________
/ CERTIFICARE \
(
PRIMAR
)
\_____________/
BORDEROU
cuprinznd beneficiarii ajutorului pentru nclzirea locuinei cu gaze naturale i
cuantumul efectiv al acestuia
Denumire furnizor ......................
Adres furnizor ........................
Anex la factura nr. .........../.......
Denumire titular de contract (client) .......... Adres titular de contract (client)
.................. Cod titular de contract (client) ................

A - Total
B - Buget de stat
C - Buget local
_________________________________________________________________________________________
_________
|Nr. |Beneficiar|CNP|Nr.
|Consum
|Preul
|Valoare|Cuantum
|Cuantumul
|Suma de
|
|crt.|ajutor
|
|dispoziie|repartizat |gazelor |consum |ajutor
|efectiv al
|plat
|
|
|
|
|primar
|de
|naturale |
|stabilit
|ajutorului
|pentru
|
|
|
|
|
|asociaia
|(lei/NMC)|
|prin
|pentru
|beneficiarul|
|
|
|
|
|de
|
|
|dispoziie |nclzire
|ajutorului |
|
|
|
|
|proprietari/|
|
|a
|
|de
nclzire|
|
|
|
|
|locatari
|
|
|primarului |
|
|
|
|
|
|
|
|
|
|___________|___________|____________|
|
|
|
|
|
|
|
| A | B | C | A | B | C |
B | C |
|____|__________|___|__________|____________|_________|_______|___|___|___|___|___|___|__
____|_____|
| 0 |
1
| 2 |
3
|
4
|
5
| 6=4x5 | 7 | 8 | 9 | 10| 11| 12|
13 | 14 |
|____|__________|___|__________|____________|_________|_______|___|___|___|___|___|___|__
____|_____|
| . |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| . |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| . |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|____|__________|___|__________|____________|_________|_______|___|___|___|___|___|___|__
____|_____|
| TOTAL:
|
|
|
|
|
|
|
|
|
|
|
|___________________________________________|_________|_______|___|___|___|___|___|___|__
____|_____|
NOT:
Valoarea efectiv a ajutorului pentru nclzirea locuinei nu poate depi cuantumul
ajutorului stabilit prin dispoziie a primarului n condiiile Ordonanei de urgen a Guvernului
nr. 70/2011 privind msurile de protecie social n perioada sezonului rece, aprobat prin
Legea nr. 92/2012, cu modificrile i completrile ulterioare.
...............................
prestaii sociale judeene, respectiv a municipiului Bucureti, unul rmne la primar i cellalt
se remite furnizorului.
Col. 13 i 14 se vor completa n funcie de autoritatea creia i se solicit decontarea sumelor

cu titlu de ajutor pentru nclzire.
Figura 4Lex: Borderou cuprinznd beneficiarii ajutorului pentru nclzirea locuinei cu gaze
naturale
ANEXA 24
- model _____________
/ CERTIFICARE \
(
PRIMAR
)
\_____________/
BORDEROU
cuprinznd beneficiarii ajutorului pentru nclzirea locuinei cu energie electric i
cuantumul efectiv al acestuia
Denumire furnizor ......................
Adres furnizor ........................
Anex la factura nr. .........../.......
Denumire titular de contract (client) .......... Adres titular de contract (client)
.................. Cod titular de contract (client) ................
A - Total
B - Buget de stat
C - Buget local
_________________________________________________________________________________________
_________
|Nr. |Beneficiar|CNP|Nr.
|Consum
|Preul
|Valoare|Cuantum
|Cuantumul
|Suma de
|
|crt.|ajutor
|
|dispoziie|efectiv
|energiei |consum |ajutor
|efectiv al
|plat
|
|
|
|
|primar
|nregistrat |electrice|
|stabilit
|ajutorului
|pentru
|
|
|
|
|
|de
|(lei/kW/ |
|prin
|pentru
|beneficiarul|
|
|
|
|
|consumatorul|h)
|
|dispoziie |nclzire
|ajutorului |
|
|
|
|
|vulnerabil |
|
|a
|
|de
nclzire|
|
|
|
|
|individual |
|
|primarului |
|
|
|
|
|
|
|
|
|
|___________|___________|____________|
|
|
|
|
|
|
|
| A | B | C | A | B | C |
B | C |
|____|__________|___|__________|____________|_________|_______|___|___|___|___|___|___|__
____|_____|
| 0 |
1
| 2 |
3
|
4
|
5
| 6=4x5 | 7 | 8 | 9 | 10| 11| 12|
13 | 14 |
|____|__________|___|__________|____________|_________|_______|___|___|___|___|___|___|__
____|_____|
| . |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| . |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| . |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|____|__________|___|__________|____________|_________|_______|___|___|___|___|___|___|__
____|_____|
| TOTAL:
|
|
|
|
|
|
|
|
|
|
|
|___________________________________________|_________|_______|___|___|___|___|___|___|__
____|_____|
NOT:
Valoarea efectiv a ajutorului pentru nclzirea locuinei nu poate depi cuantumul
ajutorului stabilit prin dispoziie a primarului n condiiile Ordonanei de urgen a Guvernului
nr. 70/2011 privind msurile de protecie social n perioada sezonului rece, aprobat prin
Legea nr. 92/2012, cu modificrile i completrile ulterioare.
...............................
pli i inspecie social, respectiv a municipiului Bucureti, unul rmne la primar i cellalt se
remite furnizorului.
Col. 13 i 14 se vor completa n funcie de autoritatea creia i se solicit decontarea sumelor
cu titlu de ajutor pentru nclzire.
Figura 5Lex: Borderou cuprinznd beneficiarii ajutorului pentru nclzirea locuinei cu
energie electric
ANEXA 25*)
- model UNITATEA ADMINISTRATIV-TERITORIAL
RAPORT STATISTIC
A - 2 membri
B - 3 membri
C - 4 membri
D - 5 membri
E - > 5 membri
_________________________________________________________________
|
SISTEM
|
ENERGIE TERMIC
|
|_____________|___________________________________________________|
| Venit net
|
BUGET DE STAT
|
BUGET LOCAL
|
| mediu lunar |_________________________|_________________________|
| pe membru
|Pers.|
Familii cu
|Pers.|
Familii cu
|
| de familie |sing.|___________________|sing.|___________________|
|
(lei)
|
| A | B | C | D | E |
| A | B | C | D | E |
|_____________|_____|___|___|___|___|___|_____|___|___|___|___|___|
| pn la 155 |
0 | 0 | 0 | 0 | 0 | 0 |
0 | 0 | 0 | 0 | 0 | 0 |
| (ajutor
|
|
|
|
|
|
|
|
|
|
|
|
|
| social)
|
|
|
|
|
|
|
|
|
|
|
|
|
|_____________|_____|___|___|___|___|___|_____|___|___|___|___|___|
| pn la 155 |
0 | 0 | 0 | 0 | 0 | 0 |
0 | 0 | 0 | 0 | 0 | 0 |
|_____________|_____|___|___|___|___|___|_____|___|___|___|___|___|
| 155,1 - 210 |
0 | 0 | 0 | 0 | 0 | 0 |
0 | 0 | 0 | 0 | 0 | 0 |
|_____________|_____|___|___|___|___|___|_____|___|___|___|___|___|
| 210,1 - 260 |
0 | 0 | 0 | 0 | 0 | 0 |
0 | 0 | 0 | 0 | 0 | 0 |
|_____________|_____|___|___|___|___|___|_____|___|___|___|___|___|
| 260,1 - 310 |
0 | 0 | 0 | 0 | 0 | 0 |
0 | 0 | 0 | 0 | 0 | 0 |
|_____________|_____|___|___|___|___|___|_____|___|___|___|___|___|
| 310,1 - 355 |
0 | 0 | 0 | 0 | 0 | 0 |
0 | 0 | 0 | 0 | 0 | 0 |
|_____________|_____|___|___|___|___|___|_____|___|___|___|___|___|
| 355,1 - 425 |
0 | 0 | 0 | 0 | 0 | 0 |
0 | 0 | 0 | 0 | 0 | 0 |
|_____________|_____|___|___|___|___|___|_____|___|___|___|___|___|
| 425,1 - 480 |
0 | 0 | 0 | 0 | 0 | 0 |
0 | 0 | 0 | 0 | 0 | 0 |
|_____________|_____|___|___|___|___|___|_____|___|___|___|___|___|
| 480,1 - 540 |
0 | 0 | 0 | 0 | 0 | 0 |
0 | 0 | 0 | 0 | 0 | 0 |
|_____________|_____|___|___|___|___|___|_____|___|___|___|___|___|
| 540,1 - 615 |
0 | 0 | 0 | 0 | 0 | 0 |
0 | 0 | 0 | 0 | 0 | 0 |
|_____________|_____|___|___|___|___|___|_____|___|___|___|___|___|
| 615,1 - 786 |
0 | 0 | 0 | 0 | 0 | 0 |
0 | 0 | 0 | 0 | 0 | 0 |
|_____________|_____|___|___|___|___|___|_____|___|___|___|___|___|
| 786,1 - 1082|
0 |///////////////////|
0 |///////////////////|
|_____________|_____|___________________|_____|___________________|
| TOTAL
|
0 | 0 | 0 | 0 | 0 | 0 |
0 | 0 | 0 | 0 | 0 | 0 |
|_____________|_____|___|___|___|___|___|_____|___|___|___|___|___|
- continuare _________________________________________________________________________________________
__
|
SISTEM
|
GAZE NATURALE
|
ENERGIE ELECTRIC
|
LEMNE
|
|_____________|
|
|
|
| Venit net
|_________________________|_________________________|_________________________|
| mediu lunar |Pers.|
Familii cu
|Pers.|
Familii cu
|Pers.|
Familii cu
|
| pe membru
|sing.|___________________|sing.|___________________|sing.|___________________|
| de familie |
| A | B | C | D | E |
| A | B | C | D | E |
| A | B | C | D |
E |
|
(lei)
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|_____________|_____|___|___|___|___|___|_____|___|___|___|___|___|_____|___|___|___|___|
___|
| pn la 155 |
0 | 0 | 0 | 0 | 0 | 0 |
0 | 0 | 0 | 0 | 0 | 0 |
0 | 0 | 0 | 0 | 0 |
0 |
| (ajutor
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| social)
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|_____________|_____|___|___|___|___|___|_____|___|___|___|___|___|_____|___|___|___|___|
___|
| pn la 155 |
0 | 0 | 0 | 0 | 0 | 0 |
0 | 0 | 0 | 0 | 0 | 0 |
0 | 0 | 0 | 0 | 0 |
0 |
|_____________|_____|___|___|___|___|___|_____|___|___|___|___|___|_____|___|___|___|___|
___|
| 155,1 - 210 |
0 | 0 | 0 | 0 | 0 | 0 |
0 | 0 | 0 | 0 | 0 | 0 |
0 | 0 | 0 | 0 | 0 |
0 |
|_____________|_____|___|___|___|___|___|_____|___|___|___|___|___|_____|___|___|___|___|
___|
| 210,1 - 260 |
0 | 0 | 0 | 0 | 0 | 0 |
0 | 0 | 0 | 0 | 0 | 0 |
0 | 0 | 0 | 0 | 0 |
0 |
|_____________|_____|___|___|___|___|___|_____|___|___|___|___|___|_____|___|___|___|___|
___|
| 260,1 - 310 |
0 | 0 | 0 | 0 | 0 | 0 |
0 | 0 | 0 | 0 | 0 | 0 |
0 | 0 | 0 | 0 | 0 |
0 |
|_____________|_____|___|___|___|___|___|_____|___|___|___|___|___|_____|___|___|___|___|
___|
| 310,1 - 355 |
0 | 0 | 0 | 0 | 0 | 0 |
0 | 0 | 0 | 0 | 0 | 0 |
0 | 0 | 0 | 0 | 0 |
0 |
|_____________|_____|___|___|___|___|___|_____|___|___|___|___|___|_____|___|___|___|___|
___|
| 355,1 - 425 |
0 | 0 | 0 | 0 | 0 | 0 |
0 | 0 | 0 | 0 | 0 | 0 |
0 | 0 | 0 | 0 | 0 |
0 |
|_____________|_____|___|___|___|___|___|_____|___|___|___|___|___|_____|___|___|___|___|
___|
| 425,1 - 480 |
0 | 0 | 0 | 0 | 0 | 0 |
0 | 0 | 0 | 0 | 0 | 0 |
0 | 0 | 0 | 0 | 0 |
0 |
|_____________|_____|___|___|___|___|___|_____|___|___|___|___|___|_____|___|___|___|___|
___|
| 480,1 - 540 |
0 | 0 | 0 | 0 | 0 | 0 |
0 | 0 | 0 | 0 | 0 | 0 |
0 | 0 | 0 | 0 | 0 |
0 |
|_____________|_____|___|___|___|___|___|_____|___|___|___|___|___|_____|___|___|___|___|
___|
| 540,1 - 615 |
0 | 0 | 0 | 0 | 0 | 0 |
0 | 0 | 0 | 0 | 0 | 0 |
0 | 0 | 0 | 0 | 0 |
0 |
|_____________|_____|___|___|___|___|___|_____|___|___|___|___|___|_____|___|___|___|___|
___|
| 615,1 - 786
|/////////////////////////|/////////////////////////|/////////////////////////|
|_____________|/////////////////////////|/////////////////////////|//////////////////////
///|
| 786,1 1082|/////////////////////////|/////////////////////////|/////////////////////////|
|_____________|_________________________|_________________________|______________________
___|
| TOTAL
|
0 | 0 | 0 | 0 | 0 | 0 |
0 | 0 | 0 | 0 | 0 | 0 |
0 | 0 | 0 | 0 | 0 |
0 |
|_____________|_____|___|___|___|___|___|_____|___|___|___|___|___|_____|___|___|___|___|
___|
A - la 31 oct.
B - la 30 nov.
C - la 31 dec.
D - la 31 ian.
E - la 28 (29) febr.
F - la 31 mar.
_______________________________________________________________________
| ENERGIE TERMIC | GAZE NATURALE |ENERGIE ELECTRIC|
LEMNE
|
________|_________________|_________________|_________________|_________________|
|
| A| B| C| D| E| F| A| B| C| D| E| F| A| B| C| D| E| F| A| B| C| D| E| F|
|________|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
|Nr.
| 0| 0| 0| 0| 0| 0| 0| 0| 0| 0| 0| 0| 0| 0| 0| 0| 0| 0| 0| 0| 0| 0| 0| 0|
|total de| | | | | | | | | | | | | | | | | | | | | | | | |
|cereri | | | | | | | | | | | | | | | | | | | | | | | | |
|depuse | | | | | | | | | | | | | | | | | | | | | | | | |
|________|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
|Nr.
| 0| 0| 0| 0| 0| 0| 0| 0| 0| 0| 0| 0| 0| 0| 0| 0| 0| 0| 0| 0| 0| 0| 0| 0|
|total
| | | | | | | | | | | | | | | | | | | | | | | | |
|ajutoare| | | | | | | | | | | | | | | | | | | | | | | | |
|Buget
| | | | | | | | | | | | | | | | | | | | | | | | |
|Stat
| | | | | | | | | | | | | | | | | | | | | | | | |
|________|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
|Nr.
| 0| 0| 0| 0| 0| 0| 0| 0| 0| 0| 0| 0| 0| 0| 0| 0| 0| 0| 0| 0| 0| 0| 0| 0|
|total
| | | | | | | | | | | | | | | | | | | | | | | | |
|ajutoare| | | | | | | | | | | | | | | | | | | | | | | | |
|Buget
| | | | | | | | | | | | | | | | | | | | | | | | |
|Local
| | | | | | | | | | | | | | | | | | | | | | | | |
|________|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
Figura 6Lex: Raport statistic

ANEXA 26
- model Unitatea administrativ-teritorial .....................
Ajutoare pentru nclzirea locuinei cu combustibili solizi i lichizi pentru
beneficiarii de ajutor social n condiiile Legii nr. 416/2001 privind venitul minim
garantat
A - Nr. ajutoare aprobate n luna curent
B - Nr. ajutoare ncetate n luna curent
______________________________________________________________________________
| Tip familie
|Nr. ajutoare|noiembrie|decembrie|ianuarie|februarie|martie |
|
|aprobate la |_________|_________|________|_________|_______|
|
|nceputul
| A | B | A | B | A | B | A | B | A | B |
|
|sezonului
|
|
|
|
|
|
|
|
|
|
|
|
|rece
|
|
|
|
|
|
|
|
|
|
|
|__________________|____________|____|____|____|____|____|___|____|____|___|___|
| persoan singur |
|
|
|
|
|
|
|
|
|
|
|
|__________________|____________|____|____|____|____|____|___|____|____|___|___|
| familii cu 2
|
|
|
|
|
|
|
|
|
|
|
|
| membri
|
|
|
|
|
|
|
|
|
|
|
|
|__________________|____________|____|____|____|____|____|___|____|____|___|___|
| familii cu 3
|
|
|
|
|
|
|
|
|
|
|
|
| membri
|
|
|
|
|
|
|
|
|
|
|
|
|__________________|____________|____|____|____|____|____|___|____|____|___|___|
| familii cu 4
|
|
|
|
|
|
|
|
|
|
|
|
| membri
|
|
|
|
|
|
|
|
|
|
|
|
|__________________|____________|____|____|____|____|____|___|____|____|___|___|
| familii cu 5
|
|
|
|
|
|
|
|
|
|
|
|
| membri
|
|
|
|
|
|
|
|
|
|
|
|
|__________________|____________|____|____|____|____|____|___|____|____|___|___|
| familii cu > 5
|
|
|
|
|
|
|
|
|
|
|
|
| membri
|
|
|
|
|
|
|
|
|
|
|
|
|__________________|____________|____|____|____|____|____|___|____|____|___|___|
|
TOTAL:
|
|
|
|
|
|
|
|
|
|
|
|
|__________________|____________|____|____|____|____|____|___|____|____|___|___|
_____________________________________________________________________
| Pli |La nceputul |n luna |n luna |n luna |n luna |n luna|

|
|sezonului rece|noiembrie|decembrie|ianuarie|februarie|martie |
|
|______________|_________|_________|________|_________|_______|
|
|
|
|
|
|
|
|
|_______|______________|_________|_________|________|_________|_______|
Figura 7Lex: Ajutoare pentru nclzirea locuinei cu combustibili solizi i lichizi

ANEXA 27
Denumirea furnizorului .......................
Adresa furnizorului ..........................
SITUAIE
cu titularii de ajutor pentru nclzirea locuinei, n eviden, i pentru care se
solicit decontarea sumelor n luna .......................
______________________________________________________________________________
|Nr. | Numele i prenumele |
CNP
| Pli efectuate n luna |
|crt.|
|
| raportat*)
|
|
|
|
|
(lei)
|
|____|_____________________|_________________________|_________________________|
|
|
|
|
|
|____|_____________________|_________________________|_________________________|
|
|
|
|
|
|____|_____________________|_________________________|_________________________|
|
|
|
|
|
|____|_____________________|_________________________|_________________________|
|
|
|
|
|
|____|_____________________|_________________________|_________________________|
|
|
|
|
|
|____|_____________________|_________________________|_________________________|
|
|
|
|
|
|____|_____________________|_________________________|_________________________|
|
|
|
|
|
|____|_____________________|_________________________|_________________________|
|
|
|
|
|
|____|_____________________|_________________________|_________________________|
|
|
|
|
|
|____|_____________________|_________________________|_________________________|
|
|
|
|
|
|____|_____________________|_________________________|_________________________|
|
|
|
|
|
|____|_____________________|_________________________|_________________________|
|
|
|
|
|
|____|_____________________|_________________________|_________________________|
|
|
|
|
|
|____|_____________________|_________________________|_________________________|
|
|
|
|
|
|____|_____________________|_________________________|_________________________|
|
|
|
|
|
|____|_____________________|_________________________|_________________________|
|
|
|
|
|
|____|_____________________|_________________________|_________________________|
|
|
|
|
|
|____|_____________________|_________________________|_________________________|
|
|
|
|
|
|____|_____________________|_________________________|_________________________|
*) Reprezint suma total cu titlu de ajutor pentru nclzirea locuinei aferent titularului
nominalizat, care se solicit ageniei pentru pli i inspecie social judeene, respectiv a
municipiului Bucureti, n vederea decontrii n luna respectiv, indiferent dac aceasta

reprezint drepturi curente, restante ori alte sume rezultate din modificarea dreptului familiei
sau al persoanei singure, conform dispoziiei primarului sau facturilor emise de furnizori.
NOT:
Situaia se transmite n format electronic ntr-un limbaj informatic agreat cu ageniile pentru
pli i inspecie social judeene, respectiv a municipiului Bucureti.
---------------

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HOTRRE Nr.

778 din 9 octombrie 2013

10. La articolul 28, alineatul (7) se modific i va avea urmtorul cuprins:

sectorului municipiului Bucureti n a crei/crui raz teritorial se afl locuina de domiciliu

(2) n termen de 5 zile de la primire, primarii certific i transmit un exemplar ageniilor

hotrre, se va republica n Monitorul Oficial al Romniei, Partea I, dndu-se textelor o nou

Bucureti, 9 octombrie 2013.

CERERE - DECLARAIE PE PROPRIA RSPUNDERE

b) Date despre copiii persoanei ndreptite:

Pentru cetenii strini

PST - permis de edere

|| (se vor ataa acte doveditoare)

Pentru cetenii strini

PST - permis de edere

c) Date despre celelalte persoane majore din familia persoanei ndreptite:

|| Dac a locuit n afara rii n ultimii 2 ani? |_| Nu

|| VENITURI DIN ACTIVITI INDEPENDENTE

|| 56| Indemnizaia de merit acordat n temeiul |

*) Se vor anexa pentru fiecare membru de familie

|| 7 | Amestecuri de cereale de var (ha)

|| anterioar depunerii cererii?

Pentru cetenii strini

PST - permis de edere

|| Dac beneficiaz de unele drepturi de asisten social?

Pentru cetenii strini

PST - permis de edere

c) Date despre celelalte persoane majore din familia persoanei ndreptite:

|| 43| Indemnizaia pentru incapacitatea temporar| adeverin

|| 69| Venituri din alte surse sunt orice venituri|

*) Se vor anexa pentru fiecare membru de familie

|| 13 | Alte culturi proteice (ha)

|| 75 | Alte psri (buc.)

Semnificaia coloanelor din tabelul de mai jos este urmtoarea:

(1) Drepturile prevzute la art. 1 se acord ncepnd cu data de ..........

*) Stare conform Registrului salariailor (REVISAL) la data verificrii n baza de date.

Reprezentant asociaie proprietari/locatari,

Numele i prenumele .............

Numele i prenumele ..............

Adresa furnizorului .................

Semntur i tampil furnizor,

Reprezentant asociaie proprietari/locatari,

Perioada de consum ..................

Numele i prenumele .............

Numele i prenumele ..............

Semnificaia coloanelor din tabelul de mai jos este urmtoarea:

Col. 13 i 14 se vor completa n funcie de autoritatea creia i se solicit decontarea sumelor

Figura 6Lex: Raport statistic

| Pli |La nceputul |n luna |n luna |n luna |n luna |n luna|

Figura 7Lex: Ajutoare pentru nclzirea locuinei cu combustibili solizi i lichizi

municipiului Bucureti, n vederea decontrii n luna respectiv, indiferent dac aceasta

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