CNG HO X HI CH NGHA VIT NAM

c lp - T do - Hnh phc

Mu s: 01/K-TNCN
(Ban hnh km theoThng t s
84/2008/TT-BTC ngy
30/9/2008 ca B Ti chnh)

T KHAI NG K THU THU NHP C NHN

M s thu
(C quan thu ghi nu cp mi hoc c nhn ghi nu c cp m s)
[01]. H v tn ngi ng k thu:

[02]. Ngy thng nm sinh:

ngy

Nam

thng

nm

[03]. Gii tnh:

[04]. Quc
tch:....................................

[05]. S chng minh nhn dn:

[05.1]. Ngy cp
ngy thng
nm
[05.2]. Ni cp:....................................................................................................
[06]. S h chiu:
[06.1]. Ngy cp:
ngy

thng

nm

[06.2]. Ni cp: ....................................................................................................

[07]. a ch ng k theo h khu:
[07.1]. S nh/ng ph, thn, xm:..................................................................
[07.2]. X, phng:...............................................................................................
[07.3]. Qun, huyn:..............................................................................................
[07.4]. Tnh, thnh ph:................................. [07.5]. Quc gia: ..........................
[08]. a ch c tr:
[08.1]. S nh/ng ph, thn, xm:..................................................................
[08.2]. X, phng:................................................................................................
[08.3]. Qun, huyn:..............................................................................................
[08.4]. Tnh, thnh ph:.........................................................................................
[09]. in thoi lin h:........................................................[10].Email:..........................
[11]. C quan thu qun l: .............................................................................................
Ti cam oan nhng ni dung k khai l ng v chu trch nhim trc php lut
v nhng ni dung khai./.
, ngy thng nm
NGI NG K THU
(K v ghi r h tn)