Mu T khai cp giy xc nhn tnh trng hn nhn

(Mu TP/HT-2010 XNHN.1 ban hnh km theo Thng t 08.a/2010/TT-BTP

ngy 25/3/2010 ca B T php)
CNG HO X HI CH NGHA VIT NAM

c lp - T do - Hnh phc
T KHAI CP GIY XC NHN TNH TRNG HN NHN

Knh gi:..............................................................................................
H v tn ngi khai : ..............................................................................................................................
Dn tc:.......................................................................Quc tch:...................................................................
Ni thng tr/tm tr: ...............................................................................................................................
Quan h vi ngi c cp Giy xc nhn tnh trng hn nhn:.....................................
ngh cp Giy xc nhn tnh trng hn nhn cho ngi c tn di y:
H v tn: ...........................................................................................Gii tnh:...........................................
Ngy, thng, nm sinh:.................................................................................................................................
Ni sinh:................................................................................................................................................................
Dn tc:.....................................................................Quc tch:.....................................................................
S Giy CMND/H chiu/Giy t hp l thay th:....................................................................
Ni thng tr/tm tr (1):........................................................................................................................
Trong thi gian c tr ti............................................................................................
..............t ngy..........thng...........nm................., n ngy..........thng..........nm...................(2)
Tnh trng hn nhn (3)...............................................................................................................................
.....................................................................................................................................................................................
.....................................................................................................................................................................................

Mc ch ca vic yu cu cp Giy xc nhn tnh trng hn nhn (4):........................

.....................................................................................................................................................................................

Ti cam oan nhng ni dung khai trn y l ng s tht v chu trch nhim
trc php lut v li khai ca mnh.
Lm ti:..........................., ngy .........thng.........nm...........
Ngi khai
(K, ghi r h tn)
.