Mu 015b/LPTB

CNG HA X HI CH NGHA VIT NAM

c lp T do Hnh phc
T KHAI L PH TRC B NH T

I- TN CH S HU, S DNG NH T:
1. a ch gi thng bo np tin LPT:
.................................................................................................................................
.......................................................................................................................
2. in thoi lin h (nu c):
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II. C IM NH T:
1. t:
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1.1 a ch tha t:
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1.2. V tr (mt tin ng ph hay ng, hm):
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1.3. Mc ch s dng t:
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1.4. Din tch (m2):
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1.5. Ngun gc t: (t c nh nc giao, cho thu; t nhn chuyn
nhng; nhn tha k, nhn tng cho):...................................................................
a)
Tn
t
chc,
c
nhn
chuyn
giao
QCD:
.................................................................................................................................
a
ch
ngi
giao
QSD:
.................................................................................................................................
b) Thi im lm giy t chuyn giao QSD ngy ......thng......nm
.................................................................................................................................
1.6.
Gi
tr
t
thc
t
chuyn
giao
(nu
c):
.................................................................................................................................
.......................................................................................................................

2. Nh:
2.1.
Cp
nh:...............................................Loi
nh:
.................................................................................................................................
2.2.
Din
tch
nh
(m2
sn
xy
dng):
.................................................................................................................................
2.3.
Ngun
gc
nh:
.................................................................................................................................
a)
T
xy
dng:
.................................................................................................................................
Nm hon cng (hoc nm bt u s dng nh):
.................................................................................................................................
b)
Mua,
tha
k,
cho,
tng:
.................................................................................................................................
Thi im lm giy t chuyn giao nh ngy ......thng ...... nm
.................................................................................................................................
2.4.
Gi
tr
nh
(ng):
.................................................................................................................................
3. Tng gi tr nh, t thc t chuyn nhng, nhn tha k, nhn tng
cho (ng):...............................................................................................................
.......................................................................................................................
4. Ti sn khng phi np l ph trc b (l do):
.................................................................................................................................
.......................................................................................................................
5.
Giy
t
c
lin
quan,
gm:
.................................................................................................................................
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Ti cam oan ni dung k khai y l ng s tht.
Ngy ...... thng ...... nm 200......
CH TI SN
K tn, ghi r h tn, ng du (nu l t chc)