I.C.C.

DECLARATIE

Subsemnatul (a)___________________________________________ domiciliat (a)

in _________________str.______________________________________nr._________,
bl._________sc.____et.____, ap.______, sector_____, CNP_______________________,
Beneficiar (a) de indemnizatie pentru cresterea copilului/stimulent
conf.OUG.nr.111/2010, cunoscand prevederile art.292 din codul penal cu privire la falsul
in declaratii, declar pe propria raspundere urmatoarele:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

Mobil:
Fix:

In conditiile prevederilor Legii nr.677/2001, prin prezenta imi exprim in

mod expres si neechivoc consimtamantul ca D.G.A.S.P.C.sector 3 sa prelucreze datele cu
caracter personal furnizate numai in scopul solicitarii formulate.

DATA SEMNATURRA

Nota
________________________________________________________________________
________________________________________________________________________