Declaratie,

Subsemnatul/Subsemnata_______________________________________________________________
____ cetatean_______________, nascut la data de ___________________, in localitatea
______________________________, de sex ___________________, casatorit/necasatorit,
domiciliat in __________________________, str. ___________________________________ nr.
_________, bloc ________, scara ________, etaj __________, apart. _____________, sector/judet
__________________, posesor  al  ___________, seria ________ nr.  ______________ eliberat de 
_______________________ la  data  de ____________________, cod numeric personal
_________________________________,

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)