CNG HA X HI CH NGHA VIT NAM

c lp - T do - Hnh phc
---------------

Mu
BH km theo Thng t s
12/2013/TT-BCA ngy
01/3/2013 ca B Cng an

GIY KHAI NG K SANG TN, DI CHUYN XE

A. PHN K KHAI, CAM KT CA NGI ANG S DNG XE
1- H tn ngi ang s dng xe:............................................................................
2- a ch: .................................................................................................................
..................................................................................................................................
3- S CMND: cp ngy /.. /.. ti .............
4- C chic xe vi c im sau:
Xe: Bin s: ..
Nhn hiu:.. S loi:
Loi xe:.Mu sn:
S my: S khung:..
S ch: ngi: .ng ....... nm:.. ; dung tch. cm3
5- Tn ngi ng tn trong giy ng k xe: .........................................................
6- a ch: .................................................................................................................
7- Trnh by ngun gc xe: (1) ................................................................................
..................................................................................................................................
..................................................................................................................................
..................................................................................................................................
..................................................................................................................................
8- Km theo:.............................................................................................................
.................................................................................................................................

9- ngh c quan ng k: (2)...............................................................................

ng k sang tn

ng k sang tn, di chuyn

10- Ti xin cam kt v hon ton chu trch nhim trc php lut v xe lm th tc sang
tn di chuyn. Nu c tranh chp, khiu kin ti s c trch nhim gii quyt theo quy
nh ca php lut.

XC NHN CA CNG AN X,
PHNG, TH TRN
(V a ch thng tr ca ch xe)

ngy.. thng.. nm ..
NGI ANG S DNG XE
(K, ghi r h tn, ng du nu l c quan)

B. PHN KIM TRA, XC MINH CA C QUAN NG K XE

BIN S C:BIN S MI:

DN BN C S MY S KHUNG (NG K TM THI KHNG PHI DN)

Ni dn bn c s my

Ni dn bn c s khung

Kt qu kim tra, xc minh:...............................................................................................

.......................................................................................................................................
CN B LM TH TC
(K, ghi r h tn)

(3)
(K, ghi r h tn)

(4)
(K, ghi r h tn, ng du)

____________
(1) Trnh by ngun gc xe (xe do mua, cho, tng, tha k.)
(2) B ghi Cc CSGTB-S, tnh, Tp ghi Phng CSGT.; huyn, qun, th x, TP
thuc tnh ghi Cng an huyn
(3) B ghi Trng phng; Tnh, Tp ghi i trng; huyn, qun, th x, TP thuc
tnh ghi i trng.

(4) B ghi Cc trng; Tnh, Tp ghi Trng phng: huyn, qun, th x, TP thuc
tnh ghi Trng CA huyn, qun, th x, TP.