43.

Th tc ng k tha k quyn s dng t v chuyn mc ch s dng t i vi

trng hp phi xin php.
- Trnh t thc hin:
Bc 1: Ngi nhn chuyn nhng v chuyn mc ch
c trch nhim hon chnh h s theo quy nh.
Bc 2: Np h s ti B phn Tip nhn h s v tr kt
qu ca UBND th x. Nu h s y , hp l cn b
tip nhn s ghi phiu hn, nu h s khng y , hp
l th s c hng dn b sung cho hon chnh.
Bc 3: n ngy ghi trong phiu hn, n B phn Tip
nhn h s v tr kt qu ca UBND th x xut trnh
phiu hn nhn thng bo thu thc hin ngha v ti
chnh ng thi n Kho bc nh nc hoc Ngn hng
nh nc ng tin theo thng bo nhn. Np li giy
np tin vo ngn sch nh nc cho B phn tip nhn
v tr kt qu nhn kt qu gii quyt v np l ph a
chnh (nu c).

- Cch thc thc hin: Np trc tip

- Thnh phn, s lng h s:

+ Thnh phn h s: - n ngh ng k bin ng v quyn s dng t,

quyn s hu nh v ti sn khc gn lin vi t
(Mu s 03/K-GCN);
- Giy t v quyn s dng t (Giy chng nhn quyn
s dng t, quyn s hu nh v ti sn khc gn
lin vi t hoc Giy chng nhn quyn s hu nh
v quyn s dng t hoc Giy chng nhn quyn
s dng t);
- Di chc hoc vn bn phn chia tha k hoc bn n,
quyt nh gii quyt tranh chp ca To n nhn dn
c hiu lc php lut hoc vn bn khai nhn ca
ngi tha k nu ngi tha k l ngi duy nht;
- Vn bn tha thun ca nhng ngi c tha k
xc nh v vic c ngi i din ghi tn vo Giy
chng nhn c cng chng, chng thc theo quy nh
ca php lut i vi trng hp nhiu ngi c
tha k m cha phn chia tha k cho tng ngi (nu
c);
- Bn trch o a chnh tha t v bn m t xc nh
ranh gii, mc gii tha t hoc bn trch lc a
chnh tha t;
- Giy cam kt nhn tha k quyn s dng t ln u
(nu c);
- Giy cam kt chuyn mc ch s dng t sang t

+ S lng h s: 01 b
- Thi hn gii quyt:
- i tng thc hin TTHC: C nhn
- C quan thc hin TTHC:
- Kt qu thc hin TTHC:
- L ph (nu c):
- Tn mu n, mu t khai (nu
c):
- Yu cu, iu kin thc hin
trong hn mc c UBND x, phng ni thng tr
xc nhn (nu c).
- T khai l ph trc b nh, t (Mu s 01/LPTB)
(nu c);
- T khai np tin s dng t (Mu S 01/TSD) (nu
c);
- T khai thu thu nhp c nhn (Mu s 11/KK-TNCN)
(nu c);
- Bn sao cc giy t lin quan n vic thc hin ngha
v ti chnh theo quy nh ca php lut v giy t
chng minh vic min gim thu (nu c).
- Giy cam kt nhn tha k quyn s dng t ln u
(nu c);
- Giy cam kt chuyn mc ch s dng t sang t
trong hn mc c UBND cp x ni thng tr xc
nhn (nu c).
35 (ba mi lm) ngy lm vic
- C quan c thm quyn quyt nh theo quy nh:
UBND th x
- C quan trc tip thc hin TTHC: Vn phng ng
k quyn s dng t, Phng Ti nguyn v Mi
trng.
- C quan phi hp: Chi Cc thu, UBND cp x ni c
t
Giy chng nhn quyn s dng t, quyn s hu nh
v ti sn gn lin vi t.
L ph cp giy: 25.000 ng/giy v l ph chuyn mc
ch s dng t: 20.000 ng/ln.
- n ngh ng k bin ng v quyn s dng t,
quyn s hu nh v ti sn khc gn lin vi t
(Mu s 03 K-GCN)
- Giy cam kt chuyn mc ch s dng t sang t
trong hn mc (Mu giy cam kt theo Quyt nh
56/2011/Q-UBND)
- T khai l ph trc b nh, t (Mu s 01/LPTB)
- T khai thu thu nhp c nhn (Mu s 11/KK-TNCN)
- T khai np tin s dng t (Mu S 01/TSD).
- C Giy chng nhn quyn s dng t, quyn s hu
nh v ti sn khc gn lin vi t hoc Giy chng
 TTHC (nu c): nhn quyn s hu nh v quyn s dng t hoc
Giy chng nhn quyn s dng t.
- Khng c tranh chp v quyn s dng t v quyn s
hu; Quyn s dng t v ti sn gn lin vi t
khng b k bin m bo thi hnh n hoc chp
hnh quyt nh hnh chnh ca c quan nh nc c
thm quyn;
- Cn trong thi hn s dng t.
- Lut t ai ngy 26 thng 11 nm 2003.
- Cn c php l ca TTHC:
- Lut sa i, b sung mt s iu ca cc lut lin
quan n u t xy dng c bn ngy 19 thng 6 nm
2009.
- im b khon 1 v khon 2 iu 23 Thng t
17/2009/TT-BTNMT 21/10/2009 Quy nh v Giy
chng nhn quyn s dng t, quyn s hu nh v
ti sn khc gn lin vi t.
- iu 6, mc b khon 2 iu 10 Thng t s
16/2011/TT-BTNMT ca B Ti nguyn v Mi
trng ngy 20/05/2011 Quy nh sa i, b sung mt
s ni dung lin quan n th tc hnh chnh v lnh
vc t ai.
- iu 25, im b khon 1 v khon 2 iu 30 Quyt
nh s 71/2011/Q-UBND ca UBND tnh Bnh
Dng ngy 20/12/2011 ban hnh quy nh v mt s
vn lin quan n th tc cp Giy chng nhn
quyn s dng t, quyn s hu nh v ti sn khc
gn lin vi t trn a bn tnh Bnh Dng.
- Quyt nh s 36/2011/Q-UBND ngy 12/9/2011 ca
UBND tnh Bnh Dng v vic quy nh din tch ti
thiu cc loi t c php tch tha trn a bn tnh
Bnh Dng.
- Khon 1, khon 2 iu 4 Thng t 20/2010/TT-
BTNMT ca B Ti nguyn v Mi trng quy nh
b sung v Giy chng nhn quyn s dng t, quyn
s hu nh v ti sn khc gn lin vi t
- Quyt nh 45/Q-UBND ngy 22/12/2010 ca
UBND tnh Bnh Dng v vic ban hnh mc thu,
np, qun l v s dng l ph cp giy chng nhn
quyn s dng t, quyn s hu nh v ti sn gn
lin vi t trn a bn tnh Bnh Dng.
- Ngh nh 100/2008/N-CP ngy 08 thng 09 nm
2008 ca Chnh ph Quy nh chi tit mt s iu ca
Lut Thu thu nhp c nhn.
- Thng t 84/2008/TT-BTC ngy 30/09/2008 ca B
Ti chnh V vic hng dn thi hnh mt s iu ca
Lut Thu thu nhp c nhn v hng dn Ngh nh s
 100/2008/N-CP ngy 08/9/2008 ca Chnh ph quy
nh chi tit mt s iu ca Lut Thu thu nhp c
nhn.
- Ngh nh 106/2010/N-CP ngy 28 thng 10 nm
2010 ca Chnh ph v sa i b sung mt s iu
ca Ngh nh 85/2007/N-CP ngy 25 thng 05 nm
2007 ca Chnh ph quy nh chi tit mt s iu ca
Lut qun l thu v Ngh nh s 100/2008/N-CP
ngy 08/9/2008 ca Chnh ph quy nh chi tit mt s
iu ca Lut Thu thu nhp c nhn.
- Ngh nh 45/2011/N-CP ngy 17 thng 06 nm 2011
ca Chnh ph Quy nh v l ph trc b.
- Ngh nh s 23/2013/N-CP ngy 25/03/2013 ca
Chnh ph v sa i, b sung mt s iu ca Ngh
nh s 45/2011/N-CP ngy 17 thng 06 nm 2011
ca Chnh ph Quy nh v l ph trc b.
- Ngh nh s 42/2012/N-CP ngy 11/05/2012 ca
Chnh ph v qun l, s dng t trng la.
- Thng t 124/2011/TT-BTC ngy 31/08/2011 ca B
Ti chnh hng dn v l ph trc b.
- Thng t 28/2011/TT-BTC ngy 28/02/2011 ca B
Ti chnh v vic hng dn thi hnh Ngh nh
85/2007/N-CP ngy 25/5/2007 v Ngh nh
106/2010/N-CP ngy 28/10/2010 ca Chnh Ph.
- Quyt nh s 2732/Q-UBND ngy 22/09/2011 v
vic lun chuyn h s thc hin ngha v ti chnh
trong vic cp giy chng nhn quyn s dng t,
quyn s hu nh v ti sn khc gn lin vi t; th
tc ghi n v thanh ton n tin s dng
- iu 134 Ngh nh s 181/2004/N-CP ca Chnh
ph ngy 29 thng 10 nm 2004 V thi hnh Lut t
ai
- Khon 5 iu 29 Ngh nh s 88/2009/N-CP ca
Chnh ph ngy 19 thng 10 nm 2009 v cp Giy
chng nhn quyn s dng t, quyn s hu nh v
ti sn khc gn lin vi t.
- iu 15 Quyt nh s 88/2009/Q-UBND ca UBND
tnh Bnh Dng ngy 21/12/2009 ban hnh quy nh
v trnh t, th tc giao t, cho thu t, chuyn mc
ch s dng t trn a bn tnh Bnh Dng.
- iu 27 Ngh nh s 69/2009/N-CP ca Chnh ph
ngy 13 thng 8 nm 2009 Quy nh b sung v quy
hoch s dng t, gi t, thu hi t, bi thng, h
tr v ti nh c.
- Quyt nh s 05/2012/Q-UBND ngy 19/01/2012
ca UBND tnh Bnh Dng v vic chuyn giao thm
quyn chng thc hp ng, giao dch cho t chc
hnh ngh cng chng, tng thm quyn chng thc
bn sao, ch k ca phng T php trn a bn tnh
Bnh Dng.
- Ngh nh 198/2004/N-CP ngy 03 thng 12 nm
2004 ca Chnh ph Quy nh v thu tin s dng t.
- Thng t 117/2004/TT-BTC ca B Ti chnh ngy 07
thng 12 nm 2004 Hng dn thc hin Ngh nh
198/2004/N-CP v Thng t 70/2006/TT-BTC ngy
02 thng 8 nm 2006 ca B Ti chnh hng dn sa
i, b sung thng t 117/2004/TT-BTC.
- Ngh nh 120/2010/N-CP ngy 30 thng 12 nm
2010 ca Chnh ph Quy nh v sa i b sung mt
s iu ca Ngh nh 198/2004/N-CP ngy 03 thng
12 nm 2004 ca Chnh ph Quy nh v thu tin s
dng t.
- Thng t 93/2011/TT-BTC ngy 29 thng 06 nm
2011 ca B Ti chnh V vic sa i b sung Thng
t 117/2004/TT-BTC ngy 07/12/2004 hng dn thc
hin Ngh nh 198/2004/N-CP ngy 03 thng 12
nm 2004 ca Chnh ph Quy nh v thu tin s dng
t.
- Quyt nh 37/2011/Q-UBND ngy 12/09/2011 ca
UBND tnh Bnh Dng v vic quy nh hn mc
giao t v cng nhn t i vi tha t c vn,
ao trong khu dn c h gia nh c nhn trn a bn
tnh Bnh Dng.
- Quyt nh 2750/QC-UBND ngy 26/09/2011 ca
UBND tnh Bnh Dng v vic nh chnh Quyt nh
37/2011/Q-UBND ngy 12/09/2011 ca UBND tnh Bnh
Dng v vic quy nh hn mc giao t v cng nhn
t i vi tha t c vn, ao trong khu dn c h gia
nh c nhn trn a bn tnh Bnh Dng.
- Quyt nh 56/2011/Q-UBND ngy 19/12/2011 ca
UBND tnh Bnh Dng v vic ban hnh quy ch hng
dn h gia nh, c nhn t cam kt v t chu trch nhim
v vic k khai tin s dng t khi np h s xin cp giy
chng nhn quyn s dng t , xin chuyn mc ch s
dng t sang t trn a bn tnh Bnh Dng.
- Quyt nh s 68/2009/Q-UBND ngy 25/09/2009 ca y
ban nhn dn tnh ban hnh Quy nh v vic gii quyt
min, gim tin s dng t i vi ngi c cng vi cch
mng trn a bn tnh Bnh Dng.
CNG HO X HI CH NGHA VIT NAM
c lp - T do - Hnh phc
T KHAI L PH TRC B NH, T
Mu s: 01/LPTB
(Ban hnh km theo Thng t
s 28/ 2011/TT-BTC ngy
28/02 /2011 ca B Ti chnh)
 [01] K tnh thu: Theo tng ln pht sinh
[02] Ln u [03] B sung ln th

[04] Tn ngi np thu: .....................................................................................

[05] M s thu: .............................................................................................
[06] a ch: ...................................................................................................
[07] Qun/huyn: ................... [08] Tnh/Thnh ph: .....................................
[09] in thoi: ..................... [10] Fax: .................. [11] Email: ..................
[12] i l thu (nu c) :.....................................................................................
[13] M s thu: .............................................................................................
[14] a ch: ...................................................................................................
[15] Qun/huyn: ................... [16] Tnh/Thnh ph: .....................................
[17] in thoi: ..................... [18] Fax: .................. [19] Email: ..................

C IM NH T:
1. t:
1.1 a ch tha t:

1.2. V tr tha t (mt tin ng ph hay ng, hm):

1.3. Mc ch s dng t:
1.4. Din tch (m2):
1.5. Ngun gc nh t: (t c Nh nc giao, cho thu; t nhn chuyn nhng; nhn tha
k, hoc nhn tng, cho):
a) Tn t chc, c nhn chuyn giao QSD:
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. Gi tr nh, t thc t nhn chuyn nhng, nhn tha k, nhn tng cho (ng):

4. Ti sn thuc din khng phi np hoc c min l ph trc b (l do):

5. Giy t c lin quan, gm:

-
-

Ti cam oan s liu khai trn l ng v chu trch nhim trc php lut v s liu khai./

NHN VIN I L THU Ngy......... thng........... nm..........

H v tn: NGI NP THU hoc
Chng ch hnh ngh s: I DIN HP PHP CA NGI NP THU
K, ghi r h tn, chc v v ng du (nu c)
 CNG HO X HI CH NGHA VIT NAM Mu s: 11/KK-TNCN
(Ban hnh km theo Thng t
c lp - T do - Hnh phc s 28/2011/TT-BTC ngy
28/02/2011 ca B Ti chnh)
T KHAI THU THU NHP C NHN
(Dnh cho c nhn c thu nhp t chuyn nhng bt ng sn;
thu nhp t nhn tha k v nhn qu tng l bt ng sn)

A - PHN C NHN T K KHAI

I. THNG TIN NGI CHUYN NHNG, CHO THA K, QU TNG
[01] H v tn: ..................................................................................................................................
[02] M s thu (nu c):
[03] S CMND/h chiu (trng hp cha c m s thu):.............................
Ngy cp...Ni cp .............................................................................
[04] Tn i l thu (nu c):...................................................
[05] M s thu:
[06] a ch: .
[07] Qun/huyn: ................... [08] Tnh/Thnh ph: ................................................................
[09] in thoi: ..................... [10] Fax: .......................... [11] Email: .......................................
[12] Hp ng i l thu: S: .......................................Ngy:...................................................
[13] Giy t v quyn s dng t, quyn s hu nh: ..
S Do c quan:. Cp ngy:..
[14] Cc ng ch s hu (nu c):

S CMND/
STT H v tn M s thu T l s hu (%)
H chiu
1
2

[15] Hp ng chuyn nhng bt ng sn (nu l mua bn, i)

Ni lp ................................................................................... Ngy lp: ...........................................
C quan chng thc Ngy chng thc: ................................
II. THNG TIN NGI NHN CHUYN NHNG, NHN THA K, QU TNG
[16] H v tn: ..................................................................................................................................
[17] M s thu (nu c):
[18] S CMND/H chiu (trng hp cha c m s thu):.
[19] n xin chuyn nhng bt ng sn (nu l nhn tha k, nhn qu tng)
Ni lp h s nhn tha k, qu tng..................................... Ngy lp: ...........................................
C quan chng thc Ngy chng thc: ................................
III. LOI BT NG SN CHUYN NHNG, NHN THA K, QU TNG
[20] Quyn s dng t v ti sn gn lin trn t
[21] Quyn s hu hoc s dng nh
[22] Quyn thu t, thu mt nc
[23] Bt ng sn khc

IV. C IM BT NG SN CHUYN NHNG, NHN THA K, QU TNG

[24] t
a ch tha t, nh : .........................................................................................................
V tr (mt tin ng ph hay ng, hm): ...........................................................................
Loi t, loi nh: .................................................................................................................
Din tch (m2): ......................................................................................................................
[25] Ngun gc t: (t c nh nc giao, cho thu; t nhn chuyn nhng; nhn tha k,
hoc nhn tng, cho): ....................................................................................................................
[26] Gi tr t thc t chuyn giao (nu c): (ng) ........................................................................
[27] Nh v cc ti sn gn lin vi t (gi chung l nh)
Cp nh: ................................................................................................................................
Loi nh: ...............................................................................................................................
Din tch nh (m2 sn xy dng): .........................................................................................
[28] Ngun gc nh
T xy dng Nm hon thnh (hoc nm bt u s dng nh): .
Chuyn nhng Thi im lm giy t chuyn giao nh: .

[29] Gi tr nh (ng) : ................................................................................................................................

[

V. THU NHP T CHUYN NHNG BT NG SN; T NHN THA K, QU TNG

L BT NG SN
[30] Gi tr bt ng sn thc t chuyn nhng, nhn tha k, qu tng (ng): ..............................
VI. CCH XC NH S THU PHI NP
[31] Thu nhp chu thu t chuyn nhng bt ng sn (ng): ..
Cch 1: Trng hp xc nh c gi mua, gi bn bt ng sn
Thu thu nhp phi np = (Gi bn BS - Gi mua BS) x 25%.
Cch 2: Trng hp khng xc nh c gi mua, gi bn bt ng sn
Thu thu nhp phi np = Gi tr BS chuyn nhng x 2%.
[32] Thu nhp chu thu t nhn tha k, qu tng l bt ng sn (ng): ..
Thu thu nhp phi np = (Gi tr BS nhn tha k, qu tng - 10.000.000) x 10%.
[33] Thu nhp c min thu (ng) ........................................................................................................
(i vi c nhn c min thu theo iu 4 Lut Thu thu nhp c nhn)
[34] Thu thu nhp phi np i vi chuyn nhng bt ng sn = ([31] - [33]) x thu sut
[35] Thu thu nhp phi np i vi nhn tha k, qu tng = ([32] - [33] - 10.000.000) x 10%
VII. GIY T KM THEO GM:
-
-
Ti cam oan nhng ni dung k khai l ng v chu trch nhim trc php lut v
nhng ni dung khai./.
Ngy ......thng .....nm ....
NHN VIN I L THU NGI NP THU hoc
H v tn: I DIN HP PHP CA NGI NP THU
Chng ch hnh ngh s:..........
K, ghi r h tn; chc v v ng du (nu c)
B - PHN XC NH GI TR BT NG SN V TNH THU CA C QUAN THU
1. Tn ngi np thu: ......................................................................................................................
2. M s thu (nu c):
I. Loi bt ng sn chuyn nhng:
1. Quyn s dng t v ti sn gn lin trn t
2. Quyn s hu hoc s dng nh
3. Quyn thu t, thu mt nc
4. Cc bt ng sn khc
II. c im bt ng sn chuyn nhng:
1. Tha t s:T bn s: ....................................................................
S nh, ng ph.................................................................................................................
Thn, xm...................................................................................................
Phng/x:...............................................................................................................................
Qun/huyn..............................................................................................................................
Tnh/ thnh ph.......................................................................................................................
2. Loi t:....................................................................................................................................
3. Loi ng/khu vc: ...............................................................................................................
4. V tr (1, 2, 3, 4):..................................................................................................................
5. Cp nh:..Loi nh:...................................................................
6. Hng nh:..................................................................................................................................
7. T l (%) cht lng cn li ca nh:.......................................................................................
8. Din tch t, nh tnh thu (m2):
8.1. t:..................................................................................................................................
8.2. Nh (m2 sn nh):............................................................................................................
9. n gi mt mt vung t, sn nh tnh thu (ng/m2):
9.1. t:..................................................................................................................................
 9.2. Nh (theo gi xy dng mi):...........................................................................................
III. Thu nhp t chuyn nhng, nh tha k, qu tng l bt ng sn (ng Vit Nam)
1. i vi chuyn nhng:
1.1. Gi chuyn nhng bt ng sn (ng) : ...........................................................................
1.2. Gi mua bt ng sn (ng) : .............................................................................................
1.3. Cc chi ph khc lin quan n gi bt ng sn chuyn nhng c loi tr (ng): .....
1.4. Thu nhp t chuyn nhng bt ng sn = (1.1) (1.2) (1.3) (1.4)
2. i vi nhn tha k, qu tng:
Thu nhp t nhn tha k, qu tng l bt ng sn = (n gi mt mt vung t, sn nh)
x (din tch t, din tch sn nh) + (gi tr cc bt ng sn khc gn vi t) ....................
(ng)
IV. Thu thu nhp phi np (i vi trng hp phi np thu):
1. i vi thu nhp chuyn nhng bt ng sn:
Cch 1: Trng hp xc nh c gi mua bt ng sn
Thu thu nhp phi np = Thu nhp t chuyn nhng bt ng sn x 25%.
Cch 2: Trng hp khng xc nh c gi mua bt ng sn
Thu thu nhp phi np = Gi bt ng sn chuyn nhng x 2%.
S thu thu nhp pht sinh (ng): .................
(Vit bng ch:.)

2. i vi thu nhp t nhn tha k, qu tng l bt ng sn:

Thu thu nhp phi np = (Thu nhp t bt ng sn nhn tha k, qu tng 10.000.000) x
10%.
S thu thu nhp pht sinh (ng): ................
(Vit bng ch:.)

V. Xc nhn ca c quan thu i vi trng hp c min thu i vi thu nhp t

chuyn nhng bt ng sn:
Cn c vo t khai v cc giy t c lin quan n vic chuyn nhng bt ng sn gia ng
(b)....................... v ng (b)......................., c quan thu kim
tra v xc nhn khon thu nhp t chuyn nhng bt ng sn ca ng
(b)........... thuc din thu nhp min thu thu nhp c nhn theo quy nh
ti khon .....................iu 4 Lut Thu thu nhp c nhn vi s tin c min l..................../.

CN B KIM TRA TNH THU Ngy thng nm

(K, ghi r h tn) TH TRNG C QUAN THU
(K, ghi r h tn v ng du)
 CNG HO X HI CH NGHA VIT NAM Mu s 03/K-GCN
c lp - T do - Hnh phc
PHN GHI CA NGI
NHN H S
N NGH NG K BIN NG Vo s tip nhn h
V QUYN S DNG T, QUYN S HU NH V TI s:
SN KHC GN LIN VI T Ngy.. / .. /
....
Knh gi: UBND ......................................................................... Quyn s , S th
t..
Ngi nhn h s
(K v ghi r h, tn)
I. PHN K KHAI CA NGI S DNG T, CH S HU TI SN GN LIN VI T
(Xem hng dn vit n trc khi k khai; khng ty xo, sa cha trn n)
1. Ngi s dng t, ch s hu ti sn gn lin vi t
1.1. Tn (vit ch in hoa):....
....................................................................................................................................................
...................................................................................................................................................
1.2. a ch :.
(K khai theo ng tn v a ch nh trn GCN cp, trng hp c thay i tn th ghi
c thng tin trc v sau khi thay i v np giy t chng minh s thay i).
2. Giy chng nhn cp
2.1. S vo s cp GCN:.; 2.2. S pht hnh GCN:;
2.3. Ngy cp GCN / .. / .;
3. Ni dung bin ng
3.1. Ni dung trn GCN trc khi bin ng: 3.2. Ni dung sau khi bin ng:
-. -.
-. -.
-.. -..
-. -.
4. L do bin ng
............................................................................................................................................................
............................................................................................................................................................
..........................................................

5. Giy t tin quan n ni dung thay i np km theo n ny gm c:

- Giy chng nhn cp;
 ...............................................................................................................................................
..........................................................................................................................................

Ti xin cam oan ni dung k khai trn n l ng s tht.

, ngy .. .. / .. . /.... ..
Ngi vit n
(K v ghi r h tn, ng du nu
c)

II. XC NHN CA U BAN NHN DN X, PHNG, TH TRN

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Ngy ./ / .. Ngy ./ / ..
Cn b a chnh TM. U ban nhn dn
(K, ghi r h, tn) Ch tch
(K tn, ng du)

III- KIN CA VN PHNG NG K QUYN S DNG T

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Ngy.. thng. nm .. Ngy.. thng. nm ..

Ngi thm tra Gim c
(K, ghi r h tn, chc v) (K tn, ng du)

IV- KT QU THM TRA CA C QUAN TI NGUYN V MI TRNG

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Ngy.. thng. nm ..
Th trng c quan ti nguyn v mi trng

CNG HA X HI CH NGHA VIT NAM

c lp - T do - Hnh phc
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GIY CAM KT

Knh gi: y ban nhn dn x (phng, th trn)

Ti tn: Sinh nm:...........
CMND s: . Ngy cp: .. Ti:...................................
M s thu: , in thoi lin h:...........................
L ch h gia nh (c nhn) ng k h khu thng tr ti:..................................
....................................................................................................................................
Hin c ng ti:..........................................................................................................
Ti c ngha v np tin s dng t khi xin cp giy chng nhn quyn s dng t
i vi t ang s dng m cha c cp giy chng nhn (xin chuyn mc ch s
dng i vi t ang s dng khng phi t sang t ), i vi din tch t
.m2, thuc tha t s: , t bn s:
a ch tha t:..........................................................................................................
Theo quy nh h gia nh, c nhn c nhiu tha t th c la chn mt tha t
xc nh din tch t trong hn mc s dng t .
Ti xin chn tha t nu trn khi xc nh tin s dng t c tnh theo trng hp
t trong hn mc s dng t .
Ti cam kt n thi im ny, ngoi tha t nu trn, ti khng chn tha t no khc
khi xc nh tin s dng t c tnh theo trng hp t trong hn mc s dng t
.
Ti hon ton chu trch nhim v tnh chnh xc ca thng tin nu trn, nu c g sai tri
ti s chu x l theo quy nh ca php lut./.
 Ngy thng nm
NGI CAM KT
(K, ghi r h tn)

Xc nhn ca UBND x (phng, th trn) ni ng k h khu thng tr:

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