Declaratie,

Subsemnatul/a________________________________________________________________cetate
an_______________, nascut la data de ___________________, in localitatea
______________________________, de sex ___________________, casatorit/necasatorit,
domiciliat/a in __________________________, str. ___________________________________ nr.
_________, bloc ________, scara ________, etaj __________, apart. _____________, sector/judet
__________________, posesor/are a/al ___________, seria ________ nr.  ______________ eliberat
de _______________________ la data de ____________________, cod numeric personal
_________________________________, tel. ____________________________, Cont IBAN

___________________________________________________________________________,
Adresa de corespondenta (daca este alta decat adresa de
resedinta):________________________________________________________________________
________________________________________________________________________________
_

Cunoscand dispozitiile articolului 326 Cod penal cu privire la falsul in declaratii, declar
pe proprie raspundere urmatoarele:

- detin functia de baza la societatea ________________________________________________

- sunt asigurat la Casa de Asigurari de Sanatate _______________________________________

- am / nu am persoane in intretinere
Persoane aflate in intretinere

Nume,prenume ___________________________________________________________

Data nasterii______________________________________________________________

CNP ____________________________________________________________________
 Data:                   DECLARANT,
                                    (nume, prenume si semnatura)