CERERE DE DESPGUBIRE

Ctre,

FONDUL DE PROTECIE A VICTIMELOR STRZII

Subsemnata/Subsemnatul______________________,avnd C.N.P._______________, identificat/identificat cu

_______ seria ____ nr. _________ eliberat de ______________ , cu domiciliul n localitatea _______________
(BI/CI/Paaport )

, str. ________________ , nr. _____ , bl. ____ , ap. ___ , jud. ________ , tel. ___________, solicit prin
prezenta acordarea despgubirilor care mi se cuvin, conform prevederilor legale n vigoare, ca urmare a
prejudiciului suferit n accidentul de circulaie produs n data de _________ n localitatea _________________ ,
str.______________ , nr. _____ , jud. _____________.
Din actul ntocmit de organele competente,(Proces-verbal, Anexa nr.2, etc,) ____________________________
(se subliniaz doc. care corespunde cazului respectiv sau se completeaz numele acestuia )

seria ______ , nr. ___________, din data de ____________ , rezult c vinovat de producerea accidentului este:
1) Doamna/Domnul ___________________, identificat/identificat cu ______ seria ______ , nr._____
(BI/CI/Paaport )

, cu domiciliul n localitatea _______________ , str. ________________ , nr. _____ , bl. ____ , ap. ___
, jud. ________ , care a condus autovehiculul marca ___________ , cu numrul de nmatriculare
______________ proprietate personal sau proprietatea
a)(persoan juridic) _____________________________________________ cu sediul social n localitatea
_______________ , str. ________________ , nr. _____ , bl. ____ , ap. ___ , jud. ________,
b)Doamnei/Domnului __________________________ , cu domiciliul n localitatea
_______________ , str. ________________, nr. _____ , bl. ____ , ap. ___ , jud. ________ ,
2) o persoan rmas necunoscut.
Accidentul s-a produs n urmtoarele condiii (scurt descriere a circumstanelor producerii accidentului);
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Schia producerii accidentului:

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n urma accidentului de circulaie am suferit urmtoarele prejudicii:
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Subsemnata/Subsemnatul___________________________,avnd C.N.P._____________________________,
identificat/identificat cu ______ seria ____ nr. _________ eliberat de Pol. ______________ , cu domiciliul n
(BI/CI/Paaport )

localitatea _______________ , str. ________________ , nr. _____ , bl. ____ , ap. ___ , jud. ________ , declar
pe proprie rspundere prin semnarea prezentei Cereri de despgubire, cunoscnd sanciunile prevzute de
art. 292 Cod penal privind Falsul n declaraii c bunurile distruse total sau parial n accidentul din data de
___________ , pentru care solicit despgubiri, nu erau asigurate la data producerii accidentului prin nici un
contract de asigurare de bunuri. Declar, de asemenea, c sunt de acord ca Fondul de protecie a victimelor
strzii s solicite date de la orice persoane fizice sau juridice i dau ncuviinare acestor persoane s furnizeze
informaiile solicitate, n legtur cu existena unor astfel de contracte de asigurare.
Anexez prezentei cereri urmtoarele documente:
- Proces-verbal, Anexa nr.2, etc_____________, seria ___ , nr. ______ , din data de ____________________
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Doresc

ca

plata

despgubirilor

ce

mi

se

cuvin

se

fac

in

contul

deschis la ____________________________
titular__________________________

Data

Nume, Prenume _________________________

Semntura