Sunteți pe pagina 1din 4

8

MONITORUL OFICIAL AL ROMNIEI, PARTEA I, Nr. 473/24.VI.2016


ANEXA Nr. 1*)
(Anexa nr. 1 la normele metodologice)

MINISTERUL MUNCII, FAMILIEI, PROTECIEI


SOCIALE I PERSOANELOR VRSTNICE

AGENIA NAIONAL PENTRU


PLI I INSPECIE SOCIAL

CERERE

CERTIFICARE

pentru

PRIMAR

fi
zi
ce

acordarea indemnizaiei de cretere a copilului / stimulentului de inserie /


indemnizaiei lunare / sprijinului lunar i alocaiei de stat pentru copii

/6

lo
r

Doamn / Domnule director al A.J.P.I.S.

pe

rs

oa

ne

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.
n cazul n care se solicit i alocaia de stat se va completa un singur formular.
A. Acest capitol al cererii se completeaz de ctre solicitant. Dac solicitantul este persoana ndreptit sau
reprezentantul familiei, datele se vor completa la Cap. C.

ii

Subsemnatul/a

ar

$'$7(3(5621$/($/(62/,&,7$178/8,

in

(z

3HQWUXFHWHQLLVWULQLVDXDSDWUL]L
367SHUPLVGHHGHUHWHPSRUDU
367/SHUPLVGHHGHUHSHWHUPHQOXQJ

z)

(l

iv

3HQWUXOFHWHQLLURPkQL
%,EXOHWLQGHLGHQWLWDWH
3SDDSRUW
&,FDUWHGHLGHQWLWDWH
&,3FDUWHGHLGHQWLWDWHSURYL]RULH

DUD 
$FWLGHQWLWDWH
6HULD
1U
ODGDWDGH

fo

5RPkQVDX

l)

(a

a)

',GRFXPHQWGHLGHQWLWDWH
&5FDUWHGHUH]LGHQ
&53FDUWHGHUH]LGHQSHUPDQHQW

us

&HWHQLH
&13
HOLEHUDWGH

rm

1XPH
3UHQXPH

ex

cl

$$'5(6$',1'2&80(178/'(,'(17,7$7($/62/,&,7$178/8,
%O

6F
-XGH

at

6WUDGD
1U
/RFDOLWDWHD

$SDUW

6HFWRU

in

$62/,&,7$178/$5(5((',1$ ORFXOGHHGHUHRELQXLW 1$)$5$5201,(,


'$vQORFDOLWDWHD

DUD

st

18

6WUDGD
1U
/RFDOLWDWHD

De

$$'5(6$'(5('(,16$8&25(6321'(1$62/,&,7$178/8,
%O

$'$7('(&217$&7
0RELO
(PDLO

6F
-XGH

$SDUW

6HFWRU

7HOHIRQ
)D[

%1&21)250,7$7(&835(9('(5,/(/(*$/(62/,&,7$178/32$7(),
3HUVRDQvQGUHSWLW
5HSUH]HQWDQWOHJDODOSHUVRDQHLvQGUHSWLWH
0DQGDWDUDOSHUVRDQHLvQGUHSWLWH

3HQWUX
*) Anexa nr. 1 este reprodus n facsimil.

MONITORUL OFICIAL AL ROMNIEI, PARTEA I, Nr. 473/24.VI.2016

C. Date privind persoana ndreptit


&'$7(3(5621$/($/(3(562$1(,1'5(37,7( 
1XPH
3UHQXPH
5RPkQVDX

DUD 
$FWLGHQWLWDWH
6HULD
1U
ODGDWDGH
(z

3HQWUXOFHWHQLLURPkQL
%,EXOHWLQGHLGHQWLWDWH
3SDDSRUW
&,FDUWHGHLGHQWLWDWH
&,3FDUWHGHLGHQWLWDWHSURYL]RULH

3HQWUXFHWHQLLVWULQLVDXDSDWUL]L
367SHUPLVGHHGHUHWHPSRUDU
367/SHUPLVGHHGHUHSHWHUPHQOXQJ

z)

(l

l)

(a

a)

',GRFXPHQWGHLGHQWLWDWH
&5FDUWHGHUH]LGHQ
&53FDUWHGHUH]LGHQSHUPDQHQW

fi
zi
ce

&HWHQLH
&13
HOLEHUDWGH

%O

6F
-XGH

$SDUW

6HFWRU

ne

6WUDGD
1U
/RFDOLWDWHD

lo
r

&$'5(6$',1'2&80(178/'(,'(17,7$7($/(3(562$1(,1'5(37,7( 

'$vQORFDOLWDWHD

rs

18

oa

&3(562$1$1'5(37,7$5(5((',1$1$)$5$5201,(, 
DUD

pe

&$'5(6$'(5('(,16$8&25(6321'(1$/(3(562$1(,1'5(37,7( 
6F
-XGH

ii

%O

&'$7('(&217$&7 

in

fo

)D[

6HFWRU

rm

7HOHIRQ

0RELO
(PDLO

$SDUW

ar

6WUDGD
1U
/RFDOLWDWHD

*HQHUDOH

0HGLL

6XSHULRDUH

us

)UVWXGLL

iv

&6,78$,$&2/$5 

'$

VHYRUDWDDDFWHOHGRYHGLWRDUHPDQGDWSRWDOH[WUDVGHFRQWGHFL]LHDGHYHULQHWF

ex

18

cl

&'$&(67(3(562$1&8',=$%,/,7$7( 

at

'6,78$,$352)(6,21$/$62/,&,7$178/8,3(562$1(,1'5(37,7(
6WXGHQW

/XFUWRUDJULFRO

,QGHSHQGHQW

RPHU

/XFUWRURFD]LRQDO

3HQVLRQDU

&DVQLF

$OWHOH

st

)UORFGHPXQF

in

(OHY
6DODULDW

6HYRUDWDDDGHYHULQHGXSFD]GHODXQLWDWHDFRODUDQJDMDWRURUJDQHFRPSHWHQWH

De

''$&/8&5($=1$)$5$5201,(,"
18
'$
''$&$/8&5$7/81,68&&(6,9(18/7,0(/(/81,$17(5,25'$7(,1$7(5,,
&23,/8/8, "
18

'$

vQ5RPkQLD

vQSHULRDGD

vQ8(VDX6(((OYHLD

vQSHULRDGD

VHDWDHD]DGHYHULQGHODDQJDMDWRU FXVSHFLILFDUHD&8,SHQWUX5RPkQLD




'1&(/(/81,68&&(6,9(/8&5$7($5($/,=$79(1,785,',1
9HQLWXULGLQVDODULLVL
DVLPLODWHVDODULLORU

9HQLWXULGLQDFWLYLWL
LQGHSHQGHQWH

9HQLWXULGLQDFWLYLWDWL
DJULFROHVLOYLFXOWXUDVL
SLVFLFXOWXUD

9HQLWXULUHDOL]DWHLQ
SHULRDGHOHDVLPLODWH

''$&$)267/81,68&&(6,9(',18/7,0(/(/81,17581$',13(5,2$'(/(
$6,0,/$7($17(5,25'$7(,1$7(5,,&23,/8/8, "
18

'$VHYDPHQLRQD&2'8/
SHULRDGHLDVLPLODWHFRQI
$QH[HL

vQSHULRDGD
vQSHULRDGD

6HFRPSOHWHD]GRDUvQVLWXDLDvQFDUHVROLFLWDQWXOQXHVWHSHUVRDQDvQGUHSWLW

st

in

at

ex

cl

us

iv

in

fo

rm

ar

ii

pe

rs

oa

ne

lo
r

fi
zi
ce

MONITORUL OFICIAL AL ROMNIEI, PARTEA I, Nr. 473/24.VI.2016

De

10

MONITORUL OFICIAL AL ROMNIEI, PARTEA I, Nr. 473/24.VI.2016

)02'$/,7$7($'(3/$7
0DQGDWSRWDO
1XPHWLWXODUFRQW

QFRQW
EDQFDU

1XPUFRQWEDQFDU
'HVFKLVODEDQFD

fi
zi
ce

$OWHOH

$EHQHILFLDWGHLQGHPQL]DLDGHPDWHUQLWDWHvQSHULRDGD
GHOD
SkQOD
]

lo
r

*3(562$1$1'5(37,7

$EHQHILFLDWGHVWLPXOHQWOXQDUGHLQVHULHvQSHULRDGD
GHOD
SkQOD
]

$EHQHILFLDWGHVSULMLQOXQDUvQSHULRDGD
GHOD
SkQOD
]

fo

ar

rm

$EHQHILFLDWGHLQGHPQL]DLDOXQDUvQSHULRDGD
GHOD
SkQOD

oa

rs

pe

ii

ne

$EHQHILFLDWGHLQGHPQL]DLDGHFUHWHUHDFRSLOXOXLvQSHULRDGD
GHOD
SkQOD

iv

in

1X D EHQHILFLDW GH LQGHPQL]DLD GH PDWHUQLWDWHLQGHPQL]DLD GH FUHWHUH D FRSLOXOXLVWLPXOHQW OXQDUGH


LQVHULHLQGHPQL]DLDOXQDUVSULMLQOXQDU

us

+3(562$1$1'5(37,7

1XHVWHDVLVWHQWSHUVRQDO

cl

(VWHDVLVWHQWSHUVRQDO

%HQHILFLD]GHLQGHPQL]DLDSUHY]XWOD
DUWGLQ/HJHDQU

ex

1XEHQHILFLD]GHLQGHPQL]DLDSUHY]XWODDUW
GLQ/HJHDQU

at



in

, 3HUVRDQD vQGUHSWLW VH RFXS GH FUHWHUHD L vQJULMLUHD FRSLOXOXL L ORFXLHWH vPSUHXQ FX DFHVWD

st

FRSLOXOQHILLQGvQFUHGLQDWVDXGDWvQSODVDPHQWXQHLDOWHSHUVRDQHRULXQXLRUJDQLVPSULYDWDXWRUL]DWVDX

De

VHUYLFLXSXEOLF



-&XQRVFkQGSUHYHGHULOH&RGXOXLSHQDOFXSULYLUHODIDOVXOvQGHFODUDLLUHVSHFWLYIDSWXOFGHFODUDUHD
QHFRUHVSXQ]WRDUH D DGHYUXOXL IFXW XQXL RUJDQ VDX XQHL LQVWLWXLL GH VWDW VH SHGHSVHWH FX vQFKLVRDUH
GHFODUSHSURSULHUVSXQGHUHFGDWHOHLLQIRUPDLLOHSUH]HQWDWHFRUHVSXQGUHDOLWLL

'DWD

BBBBBBBBBBBBBB




6HPQWXUDVROLFLWDQWXOXL

BBBBBBBBBBBBBBBBBBBBBBBB

11