CNG HA X HI CH NGHA VIT NAM

c lp - T do - Hnh phc

Mu HK01 ban hnh

theo TT s 36/2014/TT-BCA
ngy 09/9/2014

BN KHAI NHN KHU

(Dng cho ngi t 14 tui tr ln)
1. H v tn (1):................................................................................................................................
2. H v tn gi khc (nu c): .....................................................................................................
3. Ngy, thng, nm sinh:............./........./............ 4. Gii tnh:........................................
5. Ni sinh:.....................................................................................................................................
6. Nguyn qun:.............................................................................................................................
7. Dn tc:.........8. Tn gio:..........9. Quc tch:....................................
10. CMND s:. 11. H chiu s:....................................................................
12. Ni thng tr:.........................................................................................................................
........................................................................................................................................................
13. a ch ch hin nay:.............................................................................................................
........................................................................................................................................................
14. Trnh hc vn (2):..........15. Trnh chuyn mn (3):.........................................
16. Bit ting dn tc:..............17. Trnh ngoi ng:...............................................
18. Ngh nghip, ni lm vic:.......................................................................................................
........................................................................................................................................................
19. Tm tt v bn thn (T 14 tui tr ln n nay u, lm g):
T thng, nm
Ch
Ngh nghip, ni lm vic
n thng, nm (Ghi r s nh, ng ph; thn, xm, lng, p,
bn, bun, phum, sc; x/ phng/th trn; qun/
huyn; tnh/ thnh ph. Nu nc ngoi th ghi
r tn nc)

20. Tin n (Ti danh, hnh pht, theo bn n s, ngy, thng, nm ca Ta n):
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
21. Tm tt v gia nh (B, m; v/chng; con; anh, ch, em rut)
TT

H v tn

Ngy,
thng, Gii tnh Quan h
nm sinh

Ngh
nghip

(4)

:
a ch ch hin nay

Ti cam oan nhng li khai trn y l ng s tht v chu trch nhim trc php lut v
cam oan ca mnh./.
., ngy..thng..nm
NGI KHAI HOC NGI VIT H
(K, ghi r h tn)

(1) Vit ch in hoa du;

(2) Ghi r trnh hc vn cao nht (Tin s, Thc s, i hc, Cao ng, Trung cp, tt nghip ph thng
trung hc, tt nghip ph thng c s...; nu khng bit ch th ghi r "khng bit ch");
(3) Ghi r chuyn ngnh c o to hoc trnh tay ngh, bc th, chuyn mn k thut khc c ghi
trong vn bng, chng ch.
(4) Ghi c cha, m, con nui; ngi nui dng; ngi gim h theo quy nh ca php lut (nu c).

CNG HA X HI CH NGHA VIT NAM

c lp - T do - Hnh phc

Mu HK02 ban hnh

theo TT s 36/2014/TT-BCA
ngy 09/9/2014

PHIU BO THAY I H KHU, NHN KHU

Knh gi: ..
I. Thng tin v ngi vit phiu bo
1. H v tn (1): ..................................... 2. Gii tnh:..................
3. CMND s:..............4. H chiu s:................................................
5. Ni thng tr:.......................................................................................................................
6. a ch ch hin nay: .........................................................................................................
......................................................................S in thoi lin h:............................
II. Thng tin v ngi c thay i h khu, nhn khu
1. H v tn (1):................................... 2. Gii tnh:.....................
3. Ngy, thng, nm sinh:/.../................ 4. Dn tc:..5. Quc tch:......................
6. CMND s:. 7. H chiu s:.............................................................
8. Ni sinh:.................................................................................................................................
9. Nguyn qun:.........................................................................................................................
10. Ngh nghip, ni lm vic:..................................................................................................
11. Ni thng tr:.....................................................................................................................
12. a ch ch hin nay: .......................................................................................................
.................. S in thoi lin h:.............................
13. H v tn ch h:.....................14. Quan h vi ch h:....................
15. Ni dung thay i h khu, nhn khu

(2)

:............................................................................

....................................................................................................................................................
16. Nhng ngi cng thay i:
TT

H v tn

Ngy, thng, Gii

nm sinh
tnh

Ni sinh

Ngh Dn Quc
nghip tc tch

Quan h
CMND s
vi ngi
(hoc H
c thay
chiu s)
i

, ngy.thng.nm
KIN CA CH H (3)
(Ghi r ni dung v k, ghi r h tn)

, ngy.thng.nm
NGI VIT PHIU BO
(K, ghi r h tn)

XC NHN CA CNG AN (4):................................................................................................

....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................

, ngythngnm
TRNG CNG AN:..
(K, ghi r h tn v ng du)

____________
(1) Vit ch in hoa du
(2) Ghi tm tt ni dung thay i h khu, nhn khu. V d: ng k thng tr, tm tr; thay i ni ng k
thng tr, tm tr; tch s h khu; iu chnh nhng thay i trong s h khu ...
(3) Ghi r kin ca ch h l ng cho ng k thng tr, ng k tm tr hoc ng cho tch s h
khu; ch h k v ghi r h tn, ngy, thng, nm.
(4) p dng i vi trng hp: Xc nhn vic cng dn trc y ng k thng tr v trng hp cp
li s h khu do b mt.
Ghi ch: Trng hp ngi vit phiu bo cng l ngi c thay i h khu, nhn khu th cng dn ch cn
k khai nhng ni dung quy nh ti mc II