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Mu s 1
(Ban hnh km theo Thng t s 24 /2014/TT-BLTBXH ngy 6 thng 9 nm 2014 ca B Lao
ng - Thng binh v X hi)
CNG HA X HI CH NGHA VIT NAM
c lp - T do - Hnh phc
------------------------
GIY NGH XT DUYT B SUNG H NGHO, H CN NGHO
Knh gi: y ban nhn dn x ..........................................................

H v tn: ................................................................., Gii tnh: Nam, N

Sinh ngy............. thng .......... nm ............, Dn tc: ...........
S CMTND: ............................... Ni cp: ...................... Ngy cp: ...../...../20......
Ni ng k h khu thng tr: .............................................................................
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Ch hin ti: .........................................................................................................
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Thng tin cc thnh vin ca h:
Quan h vi ch h
S TT H v tn Ngh nghip
(V, chng, con...)
01
02
03

L do ngh xt duyt b sung h ngho/h cn ngho: ..................................
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Xc nhn ca trng thn/p: ..........., ngy ...... thng ...... nm

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20....
(Xc minh thng tin v h gia nh, Ngi vit n
xut UBND x tip nhn, x l)
(K, ghi r h v tn)

Xc nhn ca UBND cp x:
(Tip nhn, x l ngh)

TM. UBND x ....................

(K tn v ng du)

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1900 6162