CNG HA X HI CH NGHA VIT NAM

c lp - T do - Hnh phc
T KHAI NG K KHAI SINH
Knh gi: (1)...................................................................................
H v tn ngi khai: ..................................................................................................
Ni thng tr/tm tr: (2)...............................................................................................
S CMND/Giy t hp l thay th: (3)............................................................................
Quan h vi ngi c khai sinh: ................................................................................

Mu TP/HT-2012-TKKS.1

ngh(1)...........................................................................................ng k khai
sinh cho ngi c tn di y:
H v tn:.............................................................................. Gii tnh:.......................
Ngy, thng, nm sinh: ............................................(Bng ch:.....................................
.......................................................................................................................................)
Ni sinh: (4)..
Dn tc: ......................................................... Quc tch: ..
H v tn cha:
Dn tc:

. Quc

tch: ........................Nm sinh ................................

Ni thng tr/tm tr: (2)

H v tn m: .
Dn tc: ........................ ......Quc tch: ....................... .Nm sinh .
Ni thng tr/tm tr: (2)
Ti cam oan li khai trn y l ng s tht v chu trch nhim trc php lut v
cam oan ca mnh.
Lm ti: ., ngy ........... thng ......... nm ..............
Ngi i khai sinh(5)
(K, ghi r h tn)
..........................................

Ngi cha

Ngi m

(K, ghi r h tn)

(K, ghi r h tn)

..

Ch thch:
(1)
Ghi r tn c quan ng k khai sinh.
(2)
Ghi theo a ch ng k thng tr v gch cm t tm tr; nu khng c ni
ng k thng tr th gch hai t thng tr v ghi theo a ch ng k tm tr.
(3)
Nu ghi theo s CMND, th gch cm t Giy t hp l thay th; nu ghi theo s
Giy t hp l thay th th ghi r tn giy t, s ca giy t v gch cm t CMND.
(4)
Trng hp tr em sinh ti bnh vin th ghi tn bnh vin v a danh hnh chnh
ni tr em sinh ra (v d: bnh vin Ph sn H Ni). Trng hp tr em sinh ti c s y t,
th ghi tn c s y t v a danh hnh chnh ni tr em sinh ra (v d: trm y t x nh
Bng, huyn T Sn, tnh Bc Ninh).
Trng hp tr em sinh ra ngoi bnh vin v c s y t, th ghi a danh ca 03 cp
hnh chnh (cp x, cp huyn, cp tnh), ni tr em sinh ra (v d: x nh Bng, huyn T
Sn, tnh Bc Ninh).
(5)
Ch cn thit trong trng hp ngi i khai sinh khng phi l cha, m.