Domnule Director,

Subsemnatul(a)_________________________________________________

CNP_______________________, cu domiciliul in localitatea __________________,

str. _________________________________________, nr._____, bloc__________,

sc._____, et._____, ap.______, Judetul Galati, pensionar(a) cu dosarul numarul (de

pe cuponul de pensie) ____________ va rog sa-mi aprobati_________________

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Data Semnatura

Domnului Director Executiv al Casei Judetene de Pensii Galati