Phiu giao nhn h s ny p dng k t ngy 14/10/2016

S H s: 305//SO CNG HA X HI CH NGHA VIT NAM

c lp - T do - Hnh phc

PHIU GIAO NHN H S

Loi h s: Cp li s BHXH do mt
(Thi hn gii quyt loi h s ny: 45 ngy lm vic)

1. Tn c nhn/n v: .............................................................. M n v:.........................................

2. in thoi: ............................................................................ Email: ..............................................
3. a ch nhn tr kt qu h s qua bu in (nu c): ...................................................................................
S
STT Loi giy t, biu mu lng
I. Cp li s BHXH do mt:
T khai cung cp v thay i thng tin ngi tham gia BHXH, BHYT (mu TK1-TS, 01 bn)
1. v chi tit nh km ca mc 13 (p dng cho trng hp c qu trnh tham gia BHXH, BHTN
tnh/thnh ph khc)
i vi ngi lao ng c qu trnh tham gia trc thng 7/1995, b sung:
2. - T khai cp s BHXH c duyt
- Nu mt t khai th np h s gc
II. Thu hi s do mt nay tm li c:
1. T khai cung cp v thay i thng tin ngi tham gia BHXH, BHYT (mu TK1-TS, 01 bn)
2. S BHXH cp ln u (s mu c hoc t ba s, cc trang t ri s BHXH)
Lu :
1. Th tc np h s:
- Ngi ang lm vic np h s cho c quan BHXH ni ang tham gia hoc np thng qua n v ni ang lm
vic.
- Ngi ngh vic, s BHXH cht sau sau cng trn a bn TP.HCM th np h s cho c quan BHXH ni cht
s sau cng. Trng hp ngi lao ng c cht s BHXH tnh/thnh ph khc sau tip tc tham gia ng
BHXH trn a bn TP.HCM th np h s ti c quan BHXH ni ang tham gia.
2. i vi trng hp c nhn ngi lao ng np h s cp mt s BHXH khi nhn kt qu gii quyt h s: Ngi
lao ng cung cp bn chnh giy CMND i chiu. Trng hp nhn thay th ngi nhn cung cp giy u quyn
theo ng quy nh km bn chnh CMND i chiu.
3. Nu np h s v nhn kt qu qua bu in th thi hn gii quyt h s s cng thm 02 ngy cho mi lt.

Ngy tr kt qu: ../../20.. (Qu hn tr h s 30 ngy, cc n v cha n nhn, c quan BHXH s

chuyn h s vo kho lu tr).

, ngy thng nm
Cn b tip nhn h s Ngi np h s
(K, ghi h tn) (K, ghi h tn)
 BO HIM X HI VIT NAM CNG HO X HI CH NGHA VIT NAM
c lp - T do - Hnh phc
Mu: TK1-TS
(Ban hnh km theo Q s: 959/Q-BHXH
ngy 09/9/2015ca BHXH Vit Nam)

T KHAI CUNG CP V THAY I

THNG TIN NGI THAM GIA BO HIM X HI, BO HIM Y T

Knh gi: ..............................................................................

[01]. H v tn (vit ch in hoa): ..

[02]. S nh danh:
[03]. Ngy thng nm sinh: [04]. Gii tnh: .[05]. Quc tch
[06]. Ni cp giy khai sinh: [06.1]. X (phng, th trn) ......
[06.2]. Huyn (qun, th x, thnh ph thuc tnh) .......
[06.3]. Tnh (thnh ph) ........
[07]. S chng minh th (H chiu):
[08]. a ch ni c tr: [08.1]. S nh, ng ph, thn xm: ....
[08.2]. X (phng, th trn) .... [08.3] Huyn (qun, th x, thnh ph
thuc tnh) ...... [08.4].Tnh (thnh ph) ..
[09]. a ch lin h: [09.1]. S nh, ng ph, thn xm: ....
[09.2]. X (phng, th trn) .... [09.3] Huyn (qun, th x, thnh ph
thuc tnh) ...... [09.4].Tnh (thnh ph) .
[10]. Mc tin ng: [11]. Phng thc ng: ..
[12]. Ni ng k khm bnh, cha bnh ban u: .......
[13]. Ni dung thay i, yu cu:
.
[14]. Ti liu km theo: ..
.

XC NHN CA N V Ti cam oan nhng ni dung k khai l ng v

(n v ch phi xc nhn khi ngi tham gia thay chu trch nhim trc php lut v nhng ni
i h, tn m, tn; ngy, thng, nm sinh) dung k khai
.........., ngy ....... thng ....... nm ...........
Ngi k khai
(K, ghi r h tn)
 Chi tit nh km mc 13 ca T khai cung cp
v thay i thng tin ngi tham gia BHXH,
BHYT (mu TK1-TS)

Thi gian Din gii Mc ng Ghi ch

(1) (2) (3) (4)

Cc ch BHXH, BHTN (5):

- Tr cp BHXH 1 ln ( hng hoc cha hng):
- Tr cp tht nghip ( hng hoc cha hng):

Ti cam oan nhng ni dung k khai l ng

v chu trch nhim trc php lut v nhng
ni dung k khai
.........., ngy ....... thng ....... nm ...........
Ngi k khai
(K, ghi r h tn)
Lu : Mu ny p dng i vi phiu GNHS 305
- Ngi lao ng c qu trnh ng BHXH, BHTN tnh/thnh ph khc cn k khai y ni dung:
(1) Thi gian ng BHXH, BHTN BHXH tnh/thnh ph khc .
(2) Cng vic, chc danh, chc danh ngh, chc v, tn n v, a ch n v.
(3)Mc lng lm c s ng BHXH, BHTN
(4) S BHXH c cht hay cha ?
(5)Ghi r vic hng hoc cha hng tr cp tht nghip, tr cp BHXH mt ln.
 PH LC 01
CC LOI GIY T GI KM T KHAI CUNG CP V THAY I THNG TIN NGI
THAM GIA BHXH, BHYT (MU TK1-TS)
Ngi c cng ni thi gian nhng khng phi ng BHXH
1. Trng hp cp v ghi xc nhn thi gian ng BHXH cho ngi lao ng c thi
gian cng tc trc nm 1995 (khng bao gm ngi b k lut buc thi vic hoc t b
vic, b pht t giam trc ngy 01/01/1995), h s bao gm:
a) L lch gc v l lch b sung (nu c) ca ngi lao ng, quyt nh tip nhn,
hp ng lao ng, cc giy t c lin quan khc nh: quyt nh nng bc lng, quyt
nh iu ng hoc quyt nh chuyn cng tc, quyt nh phc vin xut ng, chuyn
ngnh, giy thi tr lng ...;
b) Ngi ngh ch vic t thng 11/1987 n trc ngy 01/01/1995: thm Quyt
nh ngh ch vic v Danh sch ca n v c tn ngi lao ng n ngy 31/12/1994
hoc cc giy t xc nh ngi lao ng c tn trong danh sch ca n v n ngy
31/12/1994.
- Trng hp khng c quyt nh ngh ch vic th phi c xc nhn bng vn bn
ca th trng n v ti thi im lp h s ngh cp s BHXH, trong m bo
ngi lao ng c tn trong danh sch ca n v ti thi im c quyt nh ngh ch vic
v cha hng cc khon tr cp mt ln.
- Trng hp n v gii th th do c quan qun l cp trn trc tip xc nhn.
2. Trng hp cp v ghi xc nhn thi gian ng BHXH i vi cn b, cng chc,
vin chc, cng nhn, qun nhn v cng an nhn dn thuc bin ch cc c quan Nh
nc, t chc chnh tr - x hi, doanh nghip Nh nc, n v lc lng v trang xut
cnh hp php nhng khng v nc ng hn (khng bao gm nhng trng hp vi phm
php lut ca nc ngoi b trc xut v nc hoc b k lut buc phi v nc hoc b t
giam trc ngy 01/01/1995):
a) H s km theo ca ngi lao ng c thi hn nc ngoi theo Hip nh ca
Chnh ph v ca ngi i lm i trng, phin dch, cn b vng do nc ngoi tr lng
bao gm:
- L lch gc, l lch b sung (nu c), cc giy t gc c lin quan n thi gian lm
vic, tin lng ca ngi lao ng trc khi i lm vic nc ngoi; quyt nh tip nhn
tr li lm vic i vi trng hp ngi lao ng v nc v tip tc lm vic trc ngy
01/01/1995. Trng hp khng c Quyt nh tip nhn th c thay th bng l lch do
ngi lao ng khai khi c tip nhn tr li lm vic hoc l lch ca ngi lao ng khai
c xc nhn ca n v tip nhn.
- Bn chnh Thng bo chuyn tr hoc Quyt nh chuyn tr ca Cc Hp tc
quc t v lao ng (nay l Cc Qun l lao ng ngoi nc) cp. Trng hp khng cn
bn chnh Thng bo chuyn tr hoc Quyt nh chuyn tr th phi c Giy xc nhn
v thi gian i hp tc lao ng gii quyt ch bo him x hi ca Cc Qun l lao
ng ngoi nc trn c s n ngh ca ngi lao ng.
 - Giy xc nhn cha nhn ch tr cp mt ln, tr cp phc vin, xut ng sau
khi v nc ca c quan, n v trc tip qun l ngi lao ng trc khi i cng tc, lm
vic c thi gian nc ngoi. Trng hp c quan, n v gii th th c quan, n v
qun l cp trn trc tip xc nhn.
b) H s km theo ca ngi i lm vic nc ngoi theo hnh thc hp tc trc
tip gia cc B, a phng ca Nh nc ta vi cc t chc kinh t ca nc ngoi bao
gm:
- L lch gc, l lch b sung (nu c), cc giy t gc c lin quan n thi gian lm
vic, tin lng ca ngi lao ng trc khi i lm vic nc ngoi; quyt nh tip nhn
tr li lm vic i vi trng hp ngi lao ng v nc v tip tc lm vic trc ngy
01/01/1995. Trng hp khng c Quyt nh tip nhn th c thay th bng L lch do
ngi lao ng khai khi c tip nhn tr li lm vic hoc l lch ca ngi lao ng khai
c xc nhn ca n v tip nhn.
- Giy xc nhn cha nhn ch tr cp mt ln, tr cp phc vin, xut ng sau
khi v nc ca c quan, n v trc tip qun l ngi lao ng trc khi i cng tc, lm
vic c thi gian nc ngoi. Trng hp c quan, n v gii th th c quan, n v
qun l cp trn trc tip xc nhn.
- Bn chnh Quyt nh c i cng tc, lm vic c thi hn nc ngoi hoc bn
sao Quyt nh trong trng hp ngi lao ng c c i cng tc, lm vic c thi hn
nc ngoi bng mt Quyt nh chung cho nhiu ngi.
+ Trng hp khng cn bn chnh Quyt nh c i cng tc, lm vic c thi hn
nc ngoi th c thay th bng bn sao Quyt nh c xc nhn ca n v c i.
+ Trng hp khng c Quyt nh c i cng tc, lm vic, hc tp, thc tp c thi
hn nc ngoi th phi c xc nhn bng vn bn ca th trng c quan, n v c
ngi lao ng, trong ghi r thi gian ngi lao ng c c i cng tc, lm vic, hc
tp, thc tp c thi hn nc ngoi v phi chu trch nhim trc php lut v ni dung
xc nhn. Trng hp c quan, n v c i khng cn tn ti th c quan qun l cp trn
trc tip xc nhn v chu trch nhim trc php lut v ni dung xc nhn.
c) H s km theo ca ngi i hc tp, thc tp nc ngoi bao gm:
- L lch gc, l lch b sung (nu c), cc giy t gc c lin quan n thi gian lm
vic, tin lng ca ngi lao ng trc khi i lm vic nc ngoi; quyt nh tip
nhn tr li lm vic i vi trng hp ngi lao ng v nc v tip tc lm vic trc
ngy 01 thng 01 nm 1995. Trng hp khng c Quyt nh tip nhn th c thay th
bng L lch do ngi lao ng khai khi c tip nhn tr li lm vic hoc l lch ca
ngi lao ng khai c xc nhn ca n v tip nhn.
- Giy xc nhn cha nhn ch tr cp mt ln, tr cp phc vin, xut ng sau
khi v nc ca c quan, n v trc tip qun l ngi lao ng trc khi i cng tc, lm
vic c thi gian nc ngoi. Trng hp c quan, n v gii th th c quan, n v
qun l cp trn trc tip xc nhn.
 - Bn chnh Quyt nh c i hc tp, thc tp c thi hn nc ngoi hoc bn sao
Quyt nh trong trng hp ngi lao ng c c i hc tp, thc tp c thi hn
nc ngoi bng mt Quyt nh chung cho nhiu ngi.
+ Trng hp khng cn bn chnh Quyt nh c i hc tp, thc tp c thi hn
nc ngoi th c thay th bng bn sao Quyt nh c xc nhn ca n v c i.
+ Trng hp khng c Quyt nh c i cng tc, lm vic, hc tp, thc tp c thi
hn nc ngoi th phi c xc nhn bng vn bn ca th trng c quan, n v c
ngi lao ng, trong ghi r thi gian ngi lao ng c c i cng tc, lm vic, hc
tp, thc tp c thi hn nc ngoi v phi chu trch nhim trc php lut v ni dung
xc nhn. Trng hp c quan, n v c i khng cn tn ti th c quan qun l cp trn
trc tip xc nhn v chu trch nhim trc php lut v ni dung xc nhn.
d) H s km theo ca ngi i lm chuyn gia theo Hip nh ca Chnh ph bao
gm:
- L lch gc, l lch b sung (nu c), cc giy t gc c lin quan n thi gian lm
vic, tin lng ca ngi lao ng trc khi i lm vic nc ngoi; quyt nh tip nhn
tr li lm vic i vi trng hp ngi lao ng v nc v tip tc lm vic trc ngy
01/01/1995. Trng hp khng c Quyt nh tip nhn th c thay th bng L lch do
ngi lao ng khai khi c tip nhn tr li lm vic hoc l lch ca ngi lao ng khai
c xc nhn ca n v tip nhn.
- Giy xc nhn cha nhn ch tr cp mt ln, tr cp phc vin, xut ng sau
khi v nc ca c quan, n v trc tip qun l ngi lao ng trc khi i cng tc, lm
vic c thi gian nc ngoi. Trng hp c quan, n v gii th th c quan, n v
qun l cp trn trc tip xc nhn.
- Bn chnh Quyt nh c i lm chuyn gia nc ngoi hoc bn sao Quyt nh
trong trng hp ngi lao ng c c i lm chuyn gia bng mt Quyt nh chung
cho nhiu ngi.
+ Trng hp khng cn bn chnh Quyt nh c i lm chuyn gia nc ngoi th
c thay th bng bn sao Quyt nh c xc nhn ca n v c i.
+ Trng hp khng c Quyt nh c i cng tc, lm vic, hc tp, thc tp c thi
hn nc ngoi th phi c xc nhn bng vn bn ca th trng c quan, n v c
ngi lao ng, trong ghi r thi gian ngi lao ng c c i cng tc, lm vic, hc
tp, thc tp c thi hn nc ngoi v phi chu trch nhim trc php lut v ni dung
xc nhn. Trng hp c quan, n v c i khng cn tn ti th c quan qun l cp trn
trc tip xc nhn v chu trch nhim trc php lut v ni dung xc nhn.
- Giy xc nhn ca c quan qun l chuyn gia v vic hon thnh ngha v ng
gp cho ngn sch nh nc v ng BHXH theo quy nh ca Nh nc ca chuyn gia
trong thi gian lm vic nc ngoi.
3. Cp v ghi xc nhn thi gian ng BHXH i vi cn b c thi gian lm vic
x, phng, th trn, bao gm c chc danh khc theo quy nh ti Khon 4, iu 8 Thng
t lin tch s 03/2010/TTLT-BNV-BTC-BLTBXH; ngi lm chuyn trch cng tc
ng, chnh quyn, Mt trn T quc phng x theo Quyt nh 1674/Q-TTg ngy
08/11/2012 ca Th tng Chnh Ph, h s km theo bao gm:
- H s, l lch gc ca c nhn;
- Cc giy t lin quan chng minh thi gian lm vic x, phng, th trn (danh
sch, Quyt nh phn cng, Quyt nh hng sinh hot ph...);
4. Trng hp cp v ghi xc nhn thi gian ng BHXH i vi ngi c thi gian
lm Ch nhim Hp tc x nng nghip, ng nghip, dim nghip c quy m ton x, h s
km theo bao gm:
- H s l lch gc ca c nhn, h s ng vin khai trong thi gian lm Ch nhim
hp tc x, s sch hoc giy t lin quan nh: danh sch trch ngang, danh sch chi tr sinh
hot ph, danh sch hoc Quyt nh ph duyt, cng nhn kt qu bu c th hin c thi
gian lm Ch nhim Hp tc x t ngy 01/7/1997 tr v trc. Trng hp khng c giy
t nu trn nhng c c s xc nh ngi lao ng c thi gian lm Ch nhim Hp tc x
th UBND cp x phi hp vi ng y, HND x ni ngi lao ng k khai c thi gian
lm Ch nhim hp tc x cc minh, nu cn c xc nh ngi lao ng c thi gian
lm Ch nhim hp tc x th c vn bn (bin bn) xc nhn v thi gian lm Ch nhim
Hp tc x, thi gian cng tc gi chc danh, chc v theo quy nh ti iu 1, Quyt nh
s 250/Q-TTg v cam kt chu trch nhim trc php lut v ni dung xc nhn.
- Danh sch ph duyt ca UBND tnh, thnh ph trc thuc Trung ng (gi tt
UBND tnh) i vi ngi lao ng c thi gian lm Ch nhim hp tc x c quy m ton
x t ngy 01/7/1997 tr v trc (Mu do UBND tnh ban hnh).
- Danh sch ph duyt h s tnh thi gian lm Ch nhim Hp tc x ca UBND
tnh.
- Giy xc nhn v thi gian lm Ch nhim Hp tc x (Mu s 02-Q250 km
theo Quyt nh s 250/Q-TTg ngy 29/01/2013 ca Th tng Chnh ph) i vi ngi
khng c tr ti tnh, thnh ph c thi gian lm ch nhim Hp tc x.
5. Trng hp cp v ghi xc nhn thi gian ng BHXH theo quy nh ti Khon 8
iu 1 Ngh nh s 153/2013/N-CP ngy 08/11/2013 ca Chnh ph, h s bao gm:
- Quyt nh phc vin, xut ng;
- Giy xc nhn cha hng ch tr cp theo Quyt nh s 47/2002/Q-TTg ngy
11/4/2002; im a Khon 1 iu 1 Quyt nh s 290/2005/Q-TTg ngy 08/11/2005;
Quyt nh s 92/2005/Q-TTg ngy 29/4/2005; Quyt nh s 142/2008/Q-TTg ngy
2/10/2008; Quyt nh s 38/2010/Q-TTg ngy 06/5/2010; Quyt nh s 53/2010/Q-TTg
ngy 20/8/2010 v Quyt nh s 62/2011/Q-TTg ngy 09/11/2011 ca Th tng Chnh
ph;
- Quyt nh v vic thu hi Quyt nh hng ch v s tin tr cp mt ln theo
Quyt nh s 142/2008/Q-TTg ngy 27/10/2008 v Quyt nh s 38/2010/Q-TTg
ngy 06/5/10 ca Th tng Chnh ph (nu c).