สส สำนนักงสำนคณะกรรมกสำรชช่ วยเหลลือประชสำชนทสำงกฎหมสำย สภสำทนสำยควสำม

แบบคสสำปรรึกษสำ/แนะนสสำ

ลลลำดดับ....................../...................
วดันททท.................เดดือน....................พ.ศ. ...............เวลลำ.......................น.

คดด แพพง อลำญลำ แรงงลำน อดืทน ๆ

เรดืท อง......................................................................................................................
ผผขผู้ อคลลำปรรึ กษลำแนะนลลำชดืทอ...........................................อลำยย......................ปท ...................อลำชทพ.........................
อยผบพ ลำผู้ นเลขททท........................หมผพทท..................ซอย...................ถนน.........................ตลลำบล/แขวง..................
อลลำเภอ/เขต..............................จดังหวดัด.............................รหดัสไปรษณท ย.ย .....................โทรศดัพทย....................
ขข้ อเทท็จจรริงโดยยช่ อ.............................................................................................................................
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กสำรใหข้ คสสำปรรึกษสำ(ควสำมเหท็น) ...........................................................................................................
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ลงชดืทอ.....................................................ผผรผู้ ผู้อง ลงชดืทอ................................................ ทนลำยควลำมอลำสลำ/ผผใหผู้ ผู้ คลำล ปรรึกษลำ
(...................................................) (................................................)
ควลำมเหห็นของหดัวหนผู้ลำสลลำนดักงลำนคณะกรรมกลำรชพวยเหลดือประชลำชนทลำงกฎหมลำย
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ควลำมเหห็นของคณะกรรมกลำรชพวยเหลดือประชลำชนทลำงกฎหมลำย
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ลงชดืทอ...............................................................กรรมกลำรชพวยเหลดือฯ
( )
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สช.๑
แบบสอบขข้ อเทท็จจรริง

ทะเบทยนรดับเรดืท องททท......................
คดทชพวยเหลดือททท............................

สส สำนนักงสำนคณะกรรมกสำรชช่ วยเหลลือประชสำชนทสำงกฎหมสำย
 จนังหวนัด.....................................................
วดันททท......................เดดือน....................พ.ศ. .....................
เรดืท อง..................................................................................................................................................................
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ขผู้อ ๑ ผผมผู้ ลำรผู้องขอควลำมชพวยเหลดือ มลำรผู้องดผู้วยตนเอง มลำรผู้องแทน
ผผทผู้ ทมลำรผู้องชดืทอ.............................................อลำยย.......................ปท สดัญชลำตต................เชดืชอชลำตต..................
บดัตรประชลำชนเลขประจลลำตดัว..............................................รหดัส...........................บผู้ลำนเลขททท................หมผพ.......
ถนน......................................ซอย.......................ตลลำบล/แขวง...........................อลลำเภอ/เขต...............................
จดังหวดัด......................................................รหดัสไปรษณท ย.ย ..............................โทรศดัพทย....................................
สถลำนทททตตดตพอพตเศษ.............................................................................................................................
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กรณท มลำรผู้องแทน เพรลำะเหตยใด............................................................................................................
เกททยวขผู้องกดับผผรผู้ ผู้องอยพลำงไร.................................................................................................................................
ไดผู้รดับคลลำแนะนลลำจลำกใคร....................................................................................................................................
ผผมผู้ ลำรผู้องแทนใหผู้ขอผู้ มผลในขผู้อ ๒ และ ๓ ไดผู้หรดื อไมพ เพทยงใด..............................................................................
ขผู้อ ๒ อลำชทพ รลำยไดผู้ หนผู้ลำทททกลำรงลำน ของผผตผู้ อผู้ งกลำรควลำมชพวยเหลดือ
อลำชทพของผผรผู้ ผู้อง..................................................................มทเงตนเดดือนละ....................................บลำท
รลำยไดผู้พตเศษ คดือ...........................................................................มทรลำยไดผู้เดดือนละ...................................บลำท
บผู้ลำนทททอยผขพ องผผรผู้ ผู้อง เปห็ นบผู้ลำน.......ชดัชน ผผรผู้ ผู้องมทสตทธต อยผโพ ดยเปห็ น.........................................................................
ถผู้ลำเชพลำอยผพ เชพลำจลำก..................................................................................มทคพลำเชพลำเดดือนละ..................................
ขผู้อ ๓ สถลำนภลำพปดัจจยบนดั ในครอบครดัว
บตดลำชดืทอ...................................อลำยย.............ปท อลำชทพ............................รลำยไดผู้เดดือนละ..........................
หรดื อ มลำรดลำชดืทอ...................................อลำยย.............ปท อลำชทพ............................รลำยไดผู้เดดือนละ..........................
หรดื อ คผพสมรสชดืทอ...................................อลำยย.............ปท อลำชทพ............................รลำยไดผู้เดดือน
ละ..........................มทบยตร.......คน ใครอยปกลำระเลทชยงดผ............................................บยตรมทรลำยไดผู้
แลผู้ว..............คน รลำยไดผู้ของบยตร
รวมกดัน เดดือนละ (ประมลำณ)....................บลำท คพลำใชผู้จพลำยในครอบครดัว เดดือนละ (ประมลำณ).......................บลำท
กรณท กลำรดลลำเนตนคดทมทคพลำใชผู้จพลำย และหรดื อคพลำวลำงศลำล ผผรผู้ ผู้องสลำมลำรถทททจะเสท ยเงตนคพลำใชผู้จพลำยไดผู้..................บลำท
หรดื อถผู้ลำมทคพลำวลำงศลำล ผผรผู้ ผู้องสลำมลำรถทททจะเสท ยคพลำวลำงศลำลจลลำนวน............................................................................บลำท
โดยไมพตอผู้ งดลลำเนตนกระบวนกลำรพตจลำรณลำคดทอยพลำงคนอนลำถลำ

ขผู้อ ๔ คผพกรณท ของผผรผู้ ผู้อง

คผพกรณท ของผผรผู้ ผู้อง
ชดืทอ........................................................................................................................อลำยย................ปท
สดัญชลำตต..................เชดืชอชลำตต.................อยผทพ ท เลขททท..................หมผพทท.............ถนน...................
ซอย...................................................ตลลำบล/แขวง..................................อลลำเภอ/เขต.......................................
จดังหวดัด................................................รหดัสไปรษณท ย.ย .............................โทรศดัพทย.........................................
สถลำนทททตตดตพอพตเศษ............................................................................................................................
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ขข้ อเทท็จจรริง
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(ตพอ สช. ๒)

สช. ๒
(แบบสอบขข้ อเทท็จจรริง)
สส สำนนักงสำนคณะกรรมกสำรชช่ วยเหลลือประชสำชนทสำงกฎหมสำย สภสำทนสำยควสำม
จนังหวนัด...................................................

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....................................................................................................สลลำเนลำเอกสลำรตพลำง ๆ......................................
....................................................................................................ทททมอบใหผู้สลำล นดักงลำนฯ....................................
.....................................................................................................ขผู้ลำพเจผู้ลำไมพประสงคยจะเรท ยกคดืน.....................
.......................................................................................ลงชดืทอ................................................................ผผรผู้ ผู้อง.
..............................................................................................วดันททท..........เดดือน..................พ.ศ. .......................
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ขผู้ลำพเจผู้ลำขอรดับรองวพลำ ขผู้อควลำมทททกลพลำวขผู้ลำงตผู้นเปห็ นควลำมจรต งทยกประกลำร หลำกตพอมลำ ปรลำกฏวพลำ ขผู้อควลำมททท
กลพลำวไมพเปห็ นควลำมจรต ง เกททยวกดับบลำนะรลำยไดผู้กดห็ ท ขผู้อเทห็จจรต งแหพ งคดทกดห็ ท ขผู้ลำพเจผู้ลำยตนยอมใหผู้คณะกรรมกลำรฯ
ของสภลำทนลำยควลำม ยกคลลำรผู้องฉบดับนทช เสท ย และเพตกถอนทนลำยควลำมไดผู้ดวผู้ ย.
ลงชดืทอ..................................................ผผรผู้ ผู้อง/ผผรผู้ ผู้องแทน
(................................................)

สช. ๓
(แบบสอบขข้ อเทท็จจรริง)
สส สำนนักงสำนคณะกรรมกสำรชช่ วยเหลลือประชสำชนทสำงกฎหมสำย สภสำทนสำยควสำม
จนังหวนัด...................................................

ควสำมเหท็นของผผข้สอบขข้ อเทท็จจรริง
สมควรรนับเรลืรื่องนดไนี้ วข้ ดสสำเนรินกสำร ไมช่ สมควรรนับเรลืรื่องนดไนี้ วข้ ดสสำเนรินกสำร
ผผข้รข้องประสงคค์ไกลช่เกลดยรื่ ขข้ อพริพสำท ผผข้รข้องไมช่ ประสงคค์ ไกลช่ เกลดยรื่ ขข้ อพริพสำท
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ลงชดืทอ..............................................ผผสผู้ อบขผู้อเทห็จจรต ง
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ควสำมเหท็นหนัวหนข้ สำสส สำนนักงสำนคณะกรรมกสำรชช่ วยเหลลือฯประธสำนสภสำทนสำยควสำมจนังหวนัด ...................
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ลงชดืทอ..............................................หสช. / ประธลำน
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ควสำมเหท็นของกรรมกสำรชช่ วยเหลลือประชสำชนทสำงกฎหมสำย (กลสำง)
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ลงชดืทอ..............................................กรรมกลำร
(..............................................)
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ขข้ อ ๕ เอกสสำรทดรื่ผข้ ผรข้องนสสำมสำใชข้ ประกอบขข้ อเทท็จจรริง มดดนังนดนี้

๕.๑ .....................................................................................................................................................
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๕.๒ ...................................................................................................................................................
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ขข้ อ ๖ พยสำนบบคคลทดรื่ใชข้ อข้สำงอริง และสถสำนทดรื่ตริดตช่ อพยสำน

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กสำรปรนับขข้ อเทท็จจรริง - ขข้ อกฎหมสำย

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(ตพอ สช. ๓)