Mu s: 04 - LTL

(Ban hnh theo Thng t s 200/2014/TT-BTC

Ngy 22/12/2014 ca B Ti chnh)

n v:........................
B phn: ....................

Cng ho x hi ch ngha Vit Nam

c lp - T do - Hnh phc
=======&=======

GIY I NG
S: .........................
Cp cho:.........................................................................................................................................
Chc v:.........................................................................................................................................
c c i cng tc ti:.................................................................................................................
Theo cng lnh (hoc giy gii thiu) s........ ngy........ thng........ nm........
T ngy...... thng...... nm...... n ngy...... thng...... nm........
Ngy...... thng...... nm......
Ngi duyt
(K, h tn, ng du)
Tin ng trc
Lng........................................
Cng tc ph..............................
Cng..........................................
Ni i
Ni n

Ngy

Phng
tin
s dng
3

di
chng
ng
4

S ngy
cng
tc
5

L do
lu tr
6

Chng nhn
ca c quan
(K tn, ng du)
7

Ni i...
Ni n...
Ni i...
Ni n...

- V ngi.........................................v

x...................... = .............................

- V cc ......................................... v

x...................... = .............................

- Ph ph ly v bng in thoi....... v

x...................... = .............................

- Phng ngh......................................v

x...................... = .............................

1- Ph cp i ng: cng.............................

2- Ph cp lu tr:..........................................
Tng cng ngy cng tc:...............................
Ngy ... thng ... nm ...
Duyt
S tin c thanh ton l:..........................
Ngi i cng tc
(K, h tn)

Ph trch b phn
(K, h tn)

K ton trng
(K, h tn)