Mu s 17-CBH

CNG HA X HI CH NGHA VIT NAM

c lp - T do - Hnh phc
--------------GIY NGH TRUY LNH
S TIN CHA NHN CH BO HIM X HI HNG THNG
Knh gi: Bo him x hi Huyn Lc Nam
H v tn: ..
S chng minh nhn dn Ngy cp: ... Ni cp:
Ni c tr: ..
S in thoi lin h: ...
Hng ch BHXH: Tht Nghip s tin hng thng: ..
S s hng BHXH:..
ang lnh ti: BHXH Huyn Lc Nam
L do:
ngh c quan Bo him x hi gii quyt cho ti c lnh trc tip s tin ch BHXH t thng .
nm . n thng nm ... ti c quan Bo him x hi huyn Lc Nam
S tin: ..
S tin bng ch: .
Xt duyt ca c quan BHXH
- Tng s thng c truy lnh:..
thng

Lc nam, ngy thng nm 2014

Ngi ngh
(K, ghi r h tn)

T thng nm . n thng ..
nm
- Tng s tin c truy lnh: ..
ng
Bng ch:
.
.., ngy thng nm
Gim c BHXH
(K tn, ng du)

Ghi ch:
- Gim c BHXH tnh: Xt duyt i vi trng hng mi, t tnh khc chuyn n c nhng thng cha
nhn lng hu, tr cp BHXH.
- Gim c BHXH huyn: Xt duyt i vi trng hp truy lnh lng hu, tr cp BHXH hng thng ca
ngi ht hn hng khng cn tn trong danh sch chi tr thng ny nhng cn s tin ca cc thng
trc cha nhn: nhn lng hu, tr cp BHXH sau k chi tr.