Mu s 09A-HSB

CNG HA X HI CH NGHA VIT NAM

c lp - T do - Hnh phc
---------------------T KHAI CA THN NHN
I. H v tn ngi khai (1): Nguyn Th Chc ; sinh nm 1937 quan h vi ngi cht: v
Ni c tr: An L- Cng Sn - Lc Nam- Bc Giang
S CMND 121115903 do Cng An tnh Bc Giang Cp ngy 06 thng 12 nm 1990
II. H, tn ngi cht: Thn Vn phng .s s BHXH/s h s 56941; cht ngy 06 thng 12 nm 2014
Ni hng lng hu/tr cp BHXH hoc n v cng tc (i vi ngi ang lm vic), ni c tr (i vi ngi
bo lu thi gian ng BHXH), ni ng BHXH (i vi ngi ang ng BHXH t nguyn, t ng tip BHXH)
trc khi cht: An L- Cng Sn - Lc Nam- Bc Giang
III. Danh sch thn nhn ca ngi cht (k khai tt c thn nhn theo th t con, v hoc chng, cha , m ,
cha v hoc cha chng, m v hoc m chng; ngi khc m ngi tham gia BHXH c trch nhim nui dng
khi cn sng. Trng hp thn nhn cht th ghi " cht thng nm " vo ct a ch ni c tr v khng
phi k khai ct ngy thng nm sinh v 3 ct ngoi cng bn phi) (2):
S
TT

H v tn

Mi quan Ngy,
h vi thng, nm
ngi cht
sinh

a ch ni c tr
(ghi a ch t cp x tr ln)

Mc thu Ngun
Ngh
nhp hng thu nhp
nghip (5)
thng (3)
(4)

1 Thn Vn Dng

Con

1965

Cng Sn - Lc Nam- Bc Giang

2.000.000Lm rung

2 Thn Th Hi

Con

1958

Phng V Ninh- TP Bc Ninh

2.500.000Hu tr

3 Thn Th Tuyn

Con

1973

Cng Sn - Lc Nam- Bc Giang

2.000.000Lm rung

4 Nguyn Th ChcV

1937

Cng Sn - Lc Nam- Bc Giang

5 Thn Vn Cc

1901

cht

6 Trn Th Li

1901

Cht

7 Nguyn Vn Phc B v

1902

Cht

8 Phm Th Giang

1902

Cht

M v

600.000 Lm rung

Sau khi nghin cu quy nh ca chnh sch, ti ngh c quan BHXH gii quyt tr cp tut hng thng i vi
cc thn nhn theo th t u tin di y (nu khng c thn nhn iu kin hng tr cp tut hng thng th
gch cho phn ny):
S
TT

a ch ni c tr ca ngi hng
H v tn

(ghi c th s nh, ph, t, thn, x/phng/th trn,

qun/huyn, tnh/thnh ph)

1 Nguyn Th Chc An L- Cng Sn - Lc Nam- Bc Giang

S chng minh
nhn dn (nu
c)

Ghi ch (6)

121115903

2
Trng hp thn nhn cha 15 tui hoc b mt, hn ch nng lc hnh vi dn s th khai b sung:
S H tn thn nhn
H v tn ngi
TT c hng tr cp ng nhn tr cp

Mi quan h ca ngi nhn tr cp

vi ngi c hng tr cp

S chng minh nhn dn

IV. Cam kt ca ngi khai: Trng hp c hng tr cp mai tng, tr cp cht do TNL, BNN hoc tr cp
tut mt ln, ti xin thay mt cho tt c thn nhn ng tn nhn tin tr cp.

Ti xin cam oan nhng ni dung k khai trn y l y , ng s tht v chu trch nhim trc php lut v
ni dung k khai cng nh trong trng hp xy ra tranh chp v tin tr cp gia cc thn nhn. ngh c quan
BHXH xem xt, gii quyt ch t tut cho gia nh ti theo quy nh. /.
. . . . . . , ngy . . . . .thng . . . .nm . . ..
Xc nhn ca UBND cp x ni ngi khai c tr
(k, ng du)

. . . . . . , ngy . . . . .thng . . . .nm . . ..

Ngi khai
(k, ghi r h tn)

. . . . . . , ngy . . . . .thng . . . .nm . . ..

Xc nhn ca UBND cp x ni thn nhn hng tut
thng c tr (7)
(k, ng du)

. . . . . . , ngy . . . . .thng . . . .nm . . ..

Xc nhn ca UBND cp x ni thn nhn hng tut
thng c tr (7)
(k, ng du)

HNG DN LP T KHAI THEO MU S 09A-HSB

- (1) Ngi khai l thn nhn ca ngi cht theo quy nh, i din cho cc thn nhn lnh tr cp mai tng, tr
cp tut mt ln, tr cp khu vc mt ln (nu c) v tr cp cht do TNL, BNN (nu c); trng hp thn nhn
cha 15 tui hoc b mt, hn ch nng lc hnh vi dn s th ngi khai l ngi i din hp php ca thn
nhn theo quy nh ca php lut dn s v ng tn nhn tr cp tut thng;
- (2) Trng hp ngi cht ang hng tr cp cn b x hng thng, tr cp cng nhn cao su, tr cp theo
Q91, tr cp theo Q613 th thn nhn khng phi k khai Mc III;
-(3) Ch k khai i vi thn nhn l cha , m , v hoc chng; cha, m ca v hoc chng m nam t 60
tui tr ln, n t 55 tui tr ln; ngi c nui dng m nam t 60 tui tr ln, n t 55 tui tr ln
v thn nhn c nguyn vng gim nh y khoa;
-(4) Ghi r tin lng, tin cng hoc lng hu hoc loi tr cp hoc ngun thu nhp thc t hin c;
-(5) Ghi ngh nghip hin ti; nu ang i hc th ghi hc sinh, sinh vin;
-(6) Trng hp thn nhn c nguyn vng gim nh mc suy gim kh nng lao ng lm cn c hng tr
cp tut thng th ghi: ngh GYK;
-(7) Trng hp ngi khai ng thi l ngi hng tr cp tut thng hoc l ngi ng tn nhn tr cp tut
thng th khng cn phn xc nhn ny; trng hp nhiu thn nhn c tr cng n v hnh chnh cp x th ch
cn xc nhn mt ln; i vi thn nhn hng tr cp tut thng tnh khc th c th ly xc nhn sau khi nhn
c T khai ny do Bo him x hi huyn ni thn nhn c tr chuyn n.
Nu T khai t 03 trang tr ln th gia cc t phi ng du gip lai ca chnh quyn a phng ni thc hin
xc nhn u tin.