CNG HO X HI CH NGHA VIT NAM

c lp - T do - Hnh phc MU NG K NGI PH THUC GIM TR GIA CNH Chnh thc: [ ] B sung: [ ] Ln: [ ]
1. H v tn c nhn c thu nhp: NGUYN VN NGN

Mu s: 16/K-TNCN (Ban hnh km theo Thng t s 84/2008/TT-BTC ngy 30/9/2008 ca B Ti chnh)

2. M s thu:
3. Tn ca t chc, c nhn tr thu nhp: CTY C Phn Vin Thng ITC Mekong

4. M s thu:
Stt
1 2 3. 01

1
Ngy sinh
01/5/1954 2/6/1957 03/9/1993

Thi im tnh gim tr (thng/nm) Thi im kt thc gim tr (thng/nm)

H v tn
NGUYN THANH PHM MAI NGUYN CH THIN

M s thu

S CMND/ h chiu
123456789 123467987

Quan h vi TNT
Cha M Con

Tng cng:

Ti cam oan nhng ni dung k khai l ng v chu trch nhim trc php lut v nhng ni dung khai./.
Tp,Cn Th, ngy thng nm .
C NHN C THU NHP (K v ghi r h tn)

GHU CH MC S 02 ( M S THU ) : TRNG NHNG DNG CH MU S THAY TH THNG TIN C NHN : H TN NHN VIN , BA, M,con MI NHN S GI KM THEO BNG MU NG K NY : GIY CMND CA MNH + S H KHU ( KHNG CN CNG CHNG )

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