Nr.............................../....................................

Decl. 5.
DECLARATIE,
Subsenmatul (a) ______________________________________, posesor
al ____, seria _____, nr. __________, eliberat (a) la data de __________, de politia
_________, domiciliat (a) in localitatea ________________________, str.
_______________________, bl. ____, sc. ____, ap. ___, judetul ___________,
cunoscand prevederile art. 292 cod penal, privind declaratii false, declar pe propria
raspundere ca membrii familiei monoparentale
Nume............................................................../CNP....................................................
Nume............................................................../CNP....................................................
Nume............................................................../CNP....................................................
Nume............................................................../CNP....................................................
al carui unic intretinator sunt, locuiesc impreuna cu subsemnatul.

DATA,

F85.5,Ed.1,Rev.1

SEMNATURA,