ANEXA nr.

1
FORMULAR DE CERERE
[Articolul 1014 alineatul (2) din Codul de procedur civil]

1. Instana judectoreasc
La aceast rubric trebuie s indicai judectoria creia i adresai cererea.
2. Identificarea prilor
2.1. Reclamantul
2.1.1. Nu avei obligaia de a fi reprezentat de un avocat.
2.2. Prtul
Prtului i se va comunica, n copie, formularul de cerere i, dac este cazul, nscrisurile
depuse de reclamant. Prtului i se ofer posibilitatea de a-i prezenta punctul de vedere.
2.2.1. Prtul nu are obligaia de a fi reprezentat de un avocat.
3. Informaii privind cererea introductiv
Domeniul de aplicare a procedurii cu privire la cererile de valoare redus: Reinei faptul c
procedura cu privire la cererile de valoare redus are un domeniu de aplicare limitat. Cererile cu o
valoare mai mare de 10.000 RON sau cele care sunt menionate la articolul 1011 alin. (2) i (3) din
Codul de procedur civil (cererile n materiile fiscal, vamal sau administrativ; cererile n angajarea
rspunderii statului pentru acte sau omisiuni n cadrul exercitrii autoritii publice; cererile referitoare
la starea civil sau capacitatea persoanelor fizice, drepturile patrimoniale nscute din raporturile de
familie, motenire, insolven, concordatul preventiv, procedurile privind lichidarea societilor
insolvabile i a altor persoane juridice sau alte proceduri asemntoare, asigurri sociale, dreptul
muncii, nchirierea unor bunuri imobile, cu excepia aciunilor privind creanele avnd ca obiect plata
unei sume de bani, arbitraj i atingeri aduse dreptului la via privat sau drepturilor care privesc
personalitatea) nu pot fi soluionate potrivit acestei proceduri. n cazul n care cererea nu poate fi
soluionat potrivit acestei proceduri, instana judectoreasc l informeaz pe reclamant n acest
sens, iar dac reclamantul nu i retrage cererea, aceasta va fi judecat potrivit dreptului comun. n
cazul n care nu dorii continuarea procedurii n aceste condiii, trebuie s v retragei cererea.
3.1. n cazul cererilor evaluabile n bani, indicai doar valoarea obligaiei principale, fr a
preciza i accesoriile preteniei principale, precum dobnzile, penalitile, fructele, cheltuielile sau
altele asemenea.
3.2. n cazul n care cererea nu este evaluabil n bani, v rugm s indicai valoarea
estimativ a acesteia.
3.3.1. n cazul n care dorii s reclamai dobnzi contractuale, de exemplu, n cazul unui
credit, v rugm s precizai rata dobnzii i data de la care se aplic.

3.3.2. n cazul n care obinei ctig de cauz, instana judectoreasc poate aproba
acordarea de dobnzi legale; v rugm s precizai dac solicitai acest lucru i, dac este cazul, data
de la care ar trebui s curg dobnda.
3.4. n cazul n care solicitai restituirea cheltuielilor de judecat (de exemplu, onorariul
avocatului etc.), precizai acest lucru la rubrica 3.4.
4. Detalii privind cererea
4.2. Descriei probele de care nelegei s v folosii n susinerea cererii dvs.
4.2.1. Avei obligaia de a depune, odat cu prezentul formular de cerere, i copii de pe
nscrisurile de care nelegei s v folosii n susinerea cererii.
4.2.2. Instana va putea ncuviina i alte probe n afara nscrisurilor depuse de pri. Nu vor fi
ns ncuviinate acele probe a cror administrare necesit cheltuieli disproporionate fa de valoarea
cererii de chemare n judecat sau a cererii reconvenionale.
4.3. Dezbaterea oral
Procedura cu privire la cererile de valoare redus este o procedur scris. Cu toate acestea,
n prezentul formular de cerere sau ntr-o etap ulterioar, putei solicita organizarea unor dezbateri
orale. De asemenea, i instana poate dispune nfiarea prilor, dac apreciaz acest fapt ca fiind
necesar.
Instana judectoreasc poate s refuze solicitarea de organizare a unor dezbateri orale n
cazul n care consider c, innd seama de mprejurrile cauzei, nu sunt necesare dezbateri orale.
5. Data i semntura
Verificai dac v-ai scris numele lizibil i dac ai semnat i datat cererea n ncheiere.
File suplimentare: n cazul n care spaiul nu este suficient, putei aduga file noi.

Dosar nr. (*):

nregistrat la Judectoria _________________ la: _____(ziua)/_____________(luna)/______(anul)(*)
(*) A se completa de ctre instana judectoreasc.
1. Crei judectorii i adresai cererea?
1.1. Denumirea i adresa judectoriei: __________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
2. Identificarea prilor
2.1. Informaii privind reclamantul
2.1.1. Numele i prenumele sau, pentru persoanele juridice, denumirea:________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
2.1.2. Domiciliul sau reedina ori, pentru persoanele juridice, sediul: __________________________

_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
2.1.3. Codul numeric personal sau, dup caz, codul unic de nregistrare ori codul de identificare
fiscal, numrul de nmatriculare n registrul comerului sau de nscriere n registrul persoanelor
juridice i contul bancar (1):___________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
2.1.4. Numrul de telefon (2): __________________________________________________________
2.1.5. Adresa de pot electronic (3): __________________________________________________
2.1.6. Numrul de fax (4): _____________________________________________________________
2.1.7. Numele, prenumele i calitatea reprezentantului reclamantului, iar, n cazul reprezentrii prin
avocat, numele i prenumele acestuia i sediul profesional (dac este cazul):____________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
2.1.8. Alte informaii (5): ______________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
2.2. Informaii privind prtul
2.2.1. Numele i prenumele sau, pentru persoanele juridice, denumirea:________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

Dac avei sau vi s-au atribuit aceste elemente de identificare potrivit legii.
Dac este cazul/Dac avei.
3
Dac este cazul/Dac avei.
4
Dac este cazul/Dac avei.
5
Dac este cazul.
2

2.2.2. Domiciliul sau reedina ori, pentru persoanele juridice, sediul: __________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
2.2.3. Codul numeric personal sau, dup caz, codul unic de nregistrare ori codul de identificare
fiscal, numrul de nmatriculare n registrul comerului sau de nscriere n registrul persoanelor
juridice
i
contul
bancar(6):____________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
2.2.4. Numrul de telefon (7): __________________________________________________________
2.2.5. Adresa de pot electronic (8): __________________________________________________
2.2.6. Numrul de fax (9): _____________________________________________________________
2.2.7. Numele, prenumele i calitatea reprezentantului prtului, iar, n cazul reprezentrii prin avocat,
numele i prenumele acestuia i sediul profesional (dac este cazul i dac v este cunoscut):
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
2.2.8. Alte informaii (10): _____________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
3. Informaii privind cererea introductiv
3.1. Cerere evaluabil n bani
3.1.1. Valoarea obligaiei principale (fr accesoriile preteniei principale):
_________________________________________________________________________________
3.2. Cerere neevaluabil n bani
3.2.1. Obiectul cererii: ____________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

Dac prul posed ori i s-au atribuit aceste elemente de identificare potrivit legii i acestea v sunt
cunoscute.
7
Dac este cazul/Dac v sunt cunoscute.
8
Dac este cazul/Dac v sunt cunoscute.
9
Dac este cazul/Dac v sunt cunoscute.
10
Dac este cazul.

_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
3.2.2. Valoarea estimativ a cererii: _________________________________________________
3.3. Solicitai plata unor dobnzi?
Da
Nu

n caz afirmativ, dobnda este:

Contractual?

completai punctul 4.4.1, dac este cazul

Legal?

completai punctul 4.4.2, dac este cazul

3.3.1. Dac este contractual

1) rata dobnzii este:

_________ %
cu _________%

mai mare dect rata dobnzii

de referin a Bncii Naionale a Romniei

alta: _______________________
2) dobnda ar trebui s curg de la: ______(ziua)/_______________(luna)/_______(anul)/
3.3.2. Dac este legal,
dobnda ar trebui s curg de la: ______(ziua)/_______________(luna)/_______(anul)/
3.4. Solicitai restituirea cheltuielilor de judecat?
3.4.1. Da

3.4.2. Nu

3.4.3. n caz afirmativ, precizai cheltuielile i indicai suma solicitat sau cheltuit pn n prezent:
__________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

_________________________________________________________________________________
_________________________________________________________________________________
4. Detalii privind cererea
4.1. Prezentai, pe scurt, motivele de fapt i de drept pe care se ntemeiaz cererea:
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
4.2. Indicai probele pe care dorii s le aducei n sprijinul cererii dvs. i specificai care capt de
cerere este susinut de fiecare dintre probe.

4.2.1. nscrisuri
precizai mai jos:
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

4.2.2. Alte probe

precizai mai jos:
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

4.3. Dorii s aib loc o dezbatere oral?

Da
Nu

n caz afirmativ, precizai motivele (11): _______________________________________________

_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
5. Data i semntura
Ataez prezentului formular un numr de file suplimentare. Fiecare fil este semnat.
Prin prezenta, solicit instanei judectoreti s pronune o hotrre mpotriva prtului n temeiul
cererii mele.
Declar c, dup tiina mea, informaiile furnizate mai sus sunt corecte i date cu bun-credin.

Data: ______(ziua)/_______________(luna)/_______ (anul)/

Numele i prenumele: ____________________________________________________________
Semntura:______________________________________

11

Facultativ.

ANEXA nr. 2

FORMULAR TIP PENTRU COMPLETAREA

I/SAU RECTIFICAREA FORMULARULUI DE CERERE (*)
[Articolul 1014 alineatul (4) din Codul de procedur civil]

(*) A se completa de ctre instan

Dosar nr.: ________________________________________________________________________
nregistrat la Judectoria _________________ la: _____(ziua)/________________(luna)/_____(anul)
1. Judectoria
1.1. Denumire i adres: _____________________________________________________________
2. Reclamant
2.1.
Numele
i
prenumele
sau,
pentru
persoanele
juridice,
denumirea:________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
2.2.
Domiciliul
sau
reedina
ori,
pentru
persoanele
juridice,
sediul:
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
2.3. Codul numeric personal sau, dup caz, codul unic de nregistrare ori codul de identificare

fiscal, numrul de nmatriculare n registrul comerului sau de nscriere n registrul persoanelor

juridice i contul bancar:______________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
2.4. Numrul de telefon: ___________________________________________________________
2.5. Adresa de pot electronic: ____________________________________________________
2.6. Numrul de fax: ______________________________________________________________
2.7. Numele, prenumele i calitatea reprezentantului reclamantului, iar, n cazul reprezentrii prin
avocat, numele i prenumele acestuia i sediul profesional:__________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
2.8. Alte informaii: _______________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
3. Prt
3.1. Numele i prenumele sau, pentru persoanele juridice, denumirea:_______________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
3.2. Domiciliul sau reedina ori, pentru persoanele juridice, sediul: __________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
3.3. Codul numeric personal sau, dup caz, codul unic de nregistrare ori codul de identificare
fiscal, numrul de nmatriculare n registrul comerului sau de nscriere n registrul persoanelor
juridice i contul bancar:______________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
3.4. Numrul de telefon: ___________________________________________________________
3.5. Adresa de pot electronic: ___________________________________________________
3.6. Numrul de fax: ______________________________________________________________

3.7. Numele, prenumele i calitatea reprezentantului prtului, iar, n cazul reprezentrii prin
avocat, numele i prenumele acestuia i sediul profesional: __________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
3.8 Alte informaii: ________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Instana a examinat formularul dvs. de cerere i consider c informaiile furnizate de dvs. nu sunt
suficient de clare/sunt inadecvate/formularul dvs. de cerere nu a fost completat corect:
v rugm s completai/s rectificai formularul de cerere/s furnizai informaii sau nscrisuri
suplimentare, astfel cum se indic mai jos, ct mai curnd posibil i cel mai trziu pn la data de
_______(ziua)/__________________(luna)/_______(anul)
Instana respinge aciunea, n conformitate cu dispoziiile art. 1014 alin. (5) din Codul de
procedur civil, n cazul n care nu completai i/sau nu rectificai formularul n termenul indicat mai
sus.
Urmtoarele seciuni ale formularului de cerere trebuie completate i/sau rectificate dup cum
urmeaz: _________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Trebuie s furnizai instanei urmtoarele informaii i/sau nscrisuri suplimentare:
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

10

_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
ntocmit la: ___________________________________________(denumirea instanei)
Data:
______(ziua)/_________________(luna)/_______(anul)
Semntura i tampila:

ANEXA nr. 3
FORMULAR DE RSPUNS
[Articolul 1015 alineatul (3) din Codul de procedur civil]

INFORMAII I INSTRUCIUNI PENTRU PRT:

1. mpotriva dvs. s-a depus o cerere n conformitate cu procedura cu privire la cererile de
valoare redus.
Putei s rspundei preteniilor reclamantului i fr a utiliza prezentul formular de rspuns,
prin orice alt mijloc adecvat. n cazul n care recurgei la alt mijloc pentru a rspunde preteniilor
reclamantului, prezentul formular de rspuns v poate ajuta la redactarea rspunsului dvs.
Putei rspunde acestei cereri prin completarea prii a II-a a prezentului formular de rspuns.
Rspunsul dvs. trebuie depus sau transmis instanei, n termen de 30 de zile de la
comunicarea prezentului formular de rspuns.
n cazul n care nu transmitei un rspuns n termen de 30 de zile, instana pronun o
hotrre.
Verificai dac v-ai scris numele i prenumele lizibil i dac ai semnat i datat formularul de
rspuns pe ultima sa pagin.
De asemenea, citii instruciunile cuprinse n formularul de cerere; acestea v pot ajuta la
redactarea rspunsului dvs.
Formularul de rspuns este disponibil i pe site-ul Ministerului Justiiei, la adresa de
internet:___________________________________________.
2. Probe
Avei obligaia de a depune, odat cu prezentul formular de rspuns, i copii de pe nscrisurile
cu care nelegei s v aprai.
Instana va putea ncuviina i alte probe n afara nscrisurilor depuse de pri. Nu vor fi ns
ncuviinate acele probe a cror administrare necesit cheltuieli disproporionate fa de valoarea
cererii de chemare n judecat sau a cererii reconvenionale.
3. Dezbaterea oral
Procedura cu privire la cererile de valoare redus este o procedur scris. Cu toate acestea,
n acest formular sau ntr-o etap ulterioar, putei solicita organizarea unor dezbateri orale. i
instana poate dispune nfiarea prilor, dac apreciaz acest fapt ca fiind necesar.

11

Instana judectoreasc poate s refuze solicitarea de organizare a unor dezbateri orale n

cazul n care consider c, innd seama de mprejurrile cauzei, nu sunt necesare dezbateri orale.
4. Cerere reconvenional: n cazul n care dorii s introducei o cerere reconvenional, v
rugm s completai i ataai un alt formular, formularul de cerere, cuprins n Anexa 1 la prezentul
ordin; acesta este disponibil i pe site-ul Ministerului Justiiei, la adresa de
Internet:____________________________ sau poate fi obinut de la instana judectoreasc care v-a
comunicat cererea.
5. Alte informaii. La rubrica "Alte informaii", putei rectifica sau completa datele dvs.
personale (de exemplu, date de contact, reprezentant etc.).
File suplimentare: n cazul n care spaiul nu este suficient, putei aduga file noi.

Partea I (a se completa de ctre instana judectoreasc)

Reclamant:
Prt:
Instana judectoreasc:
Cerere:
Numrul dosarului:

Partea II (a se completa de ctre prt)

1. Acceptai cererea?
Da
Nu
Parial

Dac ai rspuns "nu" sau "parial", motivai rspunsul: ___________________________________

_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

12

_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Cererea nu se ncadreaz n domeniul de aplicare
al procedurii cu privire la cererile de valoare redus

Specificai mai jos:

_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

Alte motive

Specificai mai jos:

_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
2. Probe. Indicai dovezile cu care nelegei s v aprai mpotriva fiecrui capt al cererii
reclamantului.

2.1. nscrisuri
precizai mai jos:
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

13

_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

2.2. Alte probe

precizai mai jos
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
3. Dorii s aib loc o dezbatere oral?
Da
Nu

n caz afirmativ, precizai motivele (12):

_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
4. Dorii s depunei o cerere reconvenional?
5.1. Da
5.2. Nu

5.3. n caz afirmativ, v rugm s completai i ataai un formular de cerere separat

5. Solicitai restituirea cheltuielilor de judecat?
4.1. Da
4.2. Nu

4.3. n caz afirmativ, precizai cheltuielile i indicai suma solicitat sau cheltuit pn n prezent:
12

Facultativ.

14

_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
6. Alte informaii (13)
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
7. Data i semntura
Ataez prezentului formular un numr de .file suplimentare. Fiecare fil este semnat.
Declar c, dup tiina mea, informaiile furnizate mai sus sunt corecte i date cu bun-credin.
Data: ______(ziua)/___________________(luna)/_______(anul)
Numele i prenumele: _______________________________________________________________
Semntura:___________________________________________

13

Facultativ.

15