CONG HoA xA HOI CHU NGHiA VI:E:TNAMDQc l~p - T1}'do - H,nh phuc

UY BAN BAu cuHUY:E:NTIEN LANG

S6: 03 ITB-UBBC TienLang, ngay;fG thang 02 ndm 2016

THONGBAovs vi~c DQPhA SO' .rng crr d~i bi~u HQi dAng nhan dan

huy~n Tien Lang nhi~m kY 2016-2021

Can cir DiSu 35,36, 37 Luat BAuClIQuoc hQiva dai biSu HDND nam 2015;Thirc hien Nghi quyet s6 41INQ-HDBCQG ngay 29/1/2016 cua HQi d6ng

b~u ell quoc gia quy dinh =.miu van ban tron& cong ,tae b~u ell; huang d~n vS ~6sa irng eu va thai han nQP ho sa irng cir dai bieu Quoc hQi khoa XIV va dai bieuHDND cac e~p nhiem ky 2016-2021, cac tnrong hop khuyet ngiroi irng ell dai bieuHDND. Uy ban b~u ell huyen Tien Ling thong bao vS viec nQPh6 sa irng ell daibieu HQid6ng nhan dan (HDND) huyen nhiem ky 2016-2021 cu thS nhu sau:

1.HB SO' .rng cfr d~i bi~u HDND huy~n gAm:

a) Dan irng ell dai bieu HDND nhiem ky 2016-2021 (theo m~u s65IBCDBHDND );

b) Sa y€u ly lieh d6i vai nguai (mg ell d~i biSu HDND (theo miu s66IBCDBHDND), eo dong d~u giap lai va xae nh~n eua ea quan, t6 ehile, dan vinai nguai Ung eu eong tae ho~e UBND e~p xii nai nguai Ung eu thuang tru;

e) TiSu su tom t~t d6i vai nguai Ung eu d~i biSu HDND (theo miu s67IBCDBHDND);

d) Ban ke khai tai san, thu nh~p eua nguai Ung ell d6i vai nguai Ung Clld~ibiSu HDND (theo m~u s6 8IBCDBHDND)

Nguai ilng ell th\l'e hi~n vi~e ke khai eae nQi dung d~y du, ehinh xae theahuang d~n trong eae m~u van ban Sll d\lng trong h6 sa Ung ell ban hanh kern theaNghi quy€t s6 41INQ-HDBCQG ngay 29/1/2016 eua HQi d6ng b~u ell qu6e gia.Vi~e ke khai eo thS th\Ie hi~n bAng eaeh viSt tay ho~e danh may, nhung phai dambao dung thea eae m~u van ban trong h6 sa Ung ell do HQi d6ng b~u ell qu6e giaban hanh (file di~n tll eae m~u van ban trong h6 sa Ung ell eo thS tai vS tir Trangthong tin di~n tll eua HQi d6ng b~u ell qu6e gia tren C6ng thong tin di~n tll euaQU6ehQihttp://www.quoehoi.vn). Nguai ilng ell kY vao tUng trang van ban eua h6sa (:engcu.

d) M6i bQ h6 sa Ung ell eua nguai Ung ell eo 3 anh ehan dung mau, nSntr~ng eO'4em x 6em (khong kS anh dan tren Sa y€u 1:9"lieh va TiSu su tom t~t).

Anh eua nguai Ung eu la anh eh\lp trong thai gian 6 thang tinh d€n ngay nQph6 sa. Trong Sa y€u ly Jieh, TiSu Sll tom t~t, anh eua nguai Ung ell phai duge dandung vi tri quy dinh va duge dong d~u giap lai eua ea quan, t6 ehile, dan vi nainguai (mg eu eong tae ho~e UBND e~p xii nai nguai Ung eu thuang tru.

2. Vi~c nQph8 so frng cirThuc hien theo quy dinh tai di~m b, c, Khoan 1, DiSu 3 Nghi quyet s6, "", "'''41INQ-HDBCQG cua HQi dong Bau cli quoc gia, cu the: Ho sa irng cli cua ngiroi

irng cir dtroc co quan, t6 chirc, dan vi gioi thieu img cu dai bieu HDND huyen vangiroi tu irng eli dai bieu HDND huyen (g6m 1 bo).

3. Ti~p nhin nQph8 so' frog cir- Don vi tiSpnhan; Phong NQivu - CO'quan tlnrong true cua Uy ban belu ell huyen,

s6 di~nthoai: 0313 883 262.- Dia diem: Tru sa Uy ban nhan dan huyen (s6 01, ph6 C\lU Doi, thi tran

Tien Lang, huyen Tien Lang).

4. Thiri gian ti~p nhin h8 SO' frng cirThai han nhan h6 SO'irng cir dai biSu HDND huyen nhiem ky 2016-2021 la

trong gia hanh chinh cac ngay trong tu§n, b~t d:1util ngay 17/2/2016 va kSt thucvao luc 17h ngay 13/3/2016. Rieng thu bay, ngay 12/3/2016 va chu nh~t, ngay13/3/2016, Uy ban bAucu huy~n cu nguai tf\lC dS nh~ h6 SO'(mg cu.

Tren day la thong bao vS vi~c nQP h6 salIng cli d~i bi~u HDND huy~nnhi~m ky 2016-2021. Trong qua trinh th\1'chi~n n~u co vu6ng m~c dS nghi cac CO'quan, dan vi, ca nhan nQp h6 SO'lien h~ vai Phong NQi V\l - CO'quan thuang tf\lCcua Uy ban b:1ucli huy~n dS kip thai giai quy~t./.V'NO'inh~n:- Uy ban bAueiTthfmh ph6;- S6NQi v\};- Thuemg tn,re HU;- Chu tieh, cae PCT UBND huy~n;- Cae thimh vien BCD Huy~n uy;- Cae thanh vien UBBC huy~n;- Cae phong, ban, dan vi huy~n lien quan;- HDND, UBND, UBMTTQ eae xli, thi tr~n;- Dai phat thanh, C6ng TIDT huy~n;- Luu: UBBC huy¢n, VT, NV.

TrAn Bioh Vioh

2

11

Mdu s6 51BCDBHDNDeQNG HOA xA nor em) NGHiA VJtT NAM

DQcl{ip- T\l' do - H~nh phuc

DON UNGcit D~I BIEU H(H DONG NHAN nAN (1) ..NHq:MKY 2016-2021

Kinh giri: Uy ban bAucir (2)~~ .

1. HQva ten thuong dung: (3) ·· ····· .2. HQva ten khai sinh: (4) ~ : ..3. Cac bi danh/ten goi khac: ..4. Ngay, thang, nam sinh: 5. Gioi tinh: ..6. Que qulin: (5) ..7.Noi dang leY thuong w:(6) .Noi a hien nay: (7) ..

8. seCMNDI HQchi~ulThe dill circe cong dan: (8) ..Ngay c~p Nai c~p .

9. Dan tQc: (9) 10. Ton giao: (10) ··11. Trinh dQhien nay:- Giao due ph6 thong: (11) ..- Chuyen mon, nghiep V1,1: (12) ~~ ..- HQcvi: (13) HQcham: (14) ..- Ly luan chinh tri: (15) .- Ngoai ngii: (16) ··· .

12.Ngh~ nghiep hien nay: (17) ..

13. Chirc V1,1: (17)- Clurc V\1 trong co quan, t6 chirc, dan vi cong tac: ..- Clnrc V1,1 trong Dang, doan th€: : ..

14.Noi lam viec: (18) ..15.Dia chi lien h~: .se di~n thoai co quan/nai lam viec: s6 dien thoai nha rieng: .s6 dien thoai di dQng: E-mail: ..

Can cu van Di~u 2, Di~u 3 cua Luat bAucir dai bieu Quoc hQiva dai bieu HQid6ng nhan danva Di~u 7 cua Lu~t t6 chuc chinh quy~n dia phuang, toi nh~ th~yminh co du di~u ki~n, tieu chufuIting cu d<;tibi€u HQid6ng nhan dan. V~y toi lam dan nay d€ ting Cll d(;libi€u HQid6ng nhan dan (1)............................... nhi~m ky 2016-2021 .

........., ngiry thcmg nam 2016Kyten

(Ky va ghi ro h9 ten)

12

Ghi chu:

(1) (2) Ghi ro ten tinh, huyen, xii noi minh img cu dai bieu HQid6ng nhan dan.(3) Ghi ho, chit d~m (neu co) va ten thuong dung bfulg chit in hoa, d6i voi ngiroi hoat dQng

ton giao thi ghi thee chirc danh ton giao (vi du: HOA THVQNG THicH THANH A... ).(4) Ghi dung ho, chu d~m va ten ghi trong Gifty khai sinh, bang chit in hoa (Vi du:

NGUYEN THI A)(5) Que quan la noi sinh cua cng nQihay noi sinh cua b6; tnrong hQ'Pca biet co thS ghi thee

que quan cua nguoi me hoac ngiroi nuoi duong minh til nho (neu khong biet ro b6, me); ghi ro xii(phirong, thi trAn), huyen (quan, thi xii, thanh ph6 thuoc tinh), tinh (thanh ph6 tnrc thuoc trunguong).

(6) Ghi thee noi dang ky he>khAu; (7) Ghi thee noi dang (1tam tru, Ghi ro s6 nha, dirong ph6,t6 dan ph6 (lang, xom, thon, ban, §.p ... ), xii (phuong, thi tran), huyen (qu~, thi xii, thanh ph6thuQctinh), tinh (thanh ph6 ttvc thuQc trung uong).

(8) Ghi mQt trong cac s6 chUng minh nhan dan, hQ chieu, s6 the can cu6e cong dan; truemghQP la Cong an nhan dan, sy quan Quful dQinhan dan thi ghi s6 gifty chUng minh Cong an nhandan ho~c gifty chUng minh sy quan Quan dQinhan dan Vi~t Nam.

(9) Ghi ten dan tQcg6c Clla ban than thee Gi§y khat sinh nhu: Kinh, Thai, Tay ....(10) Neu thee ton giao nao thi ghi ro, neu khong thee ton giao nao thi ghi "Khong".(11) Ghi ro dii t6t nghi~p lap mfty, h~ 10 nam hay 12 nam, hQcph6 thong hay b6 ruc. Vi d\l:

10/10 ph6 thong, 9/12 b6 tuc, ... ).(12) Ghi ro ~i hQc (cao dl1ngho~c trung cAp... ) chuyen nganh gi thi viet thee chUng chi, van

bfulg da duQ'ccAp.(13) Ghi ro hQcvi (nc3uco) la Ti~n sy khoa hQc,Tien sy, Th~c sy va chuyen nganh dao t~o;(14) Ghi ro danh hi~u duQ'cnha nu6c phong t~g nhu: Giao su, Pho giao su, Vi~n sy... ;(15) Ghi ro trinh dQ cao nhAt thee chUng chi, van bfulg dii dUQ'ccApnhu: sa cAp,trung cftp,

cao c§.p,Cll nhan;(16) Ghi ro biet tieng nu6c nao? vi d\l: d~i hQc tieng Anh, tieng Phap ... (neu t6t nghi~p d~

hQcngo~ ngit). D6i v6i h~ Mi dUOngthi viet la: Anh, Phap ... trinh dQA, B, C, D thee van bfulgho~c chUng nh~ dii duQ'cc§.p.Neu co chUng chi ngo~i ngit do cac t6 chuc qu6c te c§.pcon thm h~nhu: IELTS; TOEFL. .. ho~c khung B1, B2 chc1uAu thi khai thee chUng chi duQ'ccAp.Neu dii hQcd~ hQc,Th~c sy, Tien sy (1nu6c ngoro thi khai thee van b&ngdUQ'ccApva ngon ngit thee hQc (vid\l Th~c sy l~t - Ti~ng Anh ... ).

(17) Ghi ro ngh~ nghi~p dang lam; chilc V\lDang, chinh quy~n, doan th€, ton giao dang damnhi~m, ham cAp(quan dQi,cong an, ngo~i giao ... ).

(18) Truemg hQ'Pco nhi~u nm lam vi~c thi ghi nai lam vi~c thuemg xuyen (nm lam vi~c

chinh).

13

Mdu s6 61BCDBHDNDCONG HOA xA H(H CUU NGHIA VI¥T NAM

DQcl,p - T'1 do - H~nh phuc

Anh

4cmx6cm soYEU LY LICHCUA xotror UNG CUD';'I BIEU HOI DONG NHAN DAN

(1)...•...............NHI¥M KY 2016-2021

1. HQ va ten thtrong dung: (*) .2. HQ va ten khai sinh: (*) .3. Cac bi danh/ten goi khac: .4. Ngay, thang, nam sinh: 5. Gioi tinh: .6. Que quan: (*) .7. Noi dang ky thuong tni: (*) .N . , hie (*)01a €tnnay: .

8. S6CMNDIHQ chieu/The can circe cong dan: (*) .Ngay cAp Nai cAp .

9. Dan tQc: 10. Ton giao: .11. Trinh dQhien nay: (*)- Giao due ph6 thong: .- Chuyen men, nghiep V\l: .- HQc vi: HQc ham: , .- Ly luan chinh tri: .- Ngoai ngir: .12. Ngh~ nghiep hien nay: .Truong hop la can hQ, cong chirc, vien clnrc, thi ghi r5:- Ngach cong chirc, vien chirc: " M[ ngach .- B~c luang (neu c6): H~ so luong: Ngay huang .- Phu cApchirc V\l (n€u c6): .13.Chtrc vu trong co quan, t6 chirc, dan vi dang cong tac: (*) .14. Noi lam viec: .15.Truong hop la Dang vien Dang cong san Vi~t Nam, thi ghi r5: (2)Ngay vao Dang: .1 j .- Ngay chinh tlnrc: .1 .1 ; sf> the dang vien: .- Chirc vu trong Dang: .- Ngay ra khoi Dang (neu c6) .Ly do ra khoi Dang: .16. Tham gia lam thanh vien Clla cac t6 chuc doan th€ khac: (3) .- Ten t6 chuc doan th€ .

, ,- Chuc V\l trong tLrngto chuc doan the: .17. Tinh tr~g suc khoe:(4) .18. Cac hinh thuc khen thuang nha nu6c d[ duQ'ctrao $lg: (5) .~ •• ,. ••••••••••• o •••••••••••••••••••••••••••• ,. •••••••••••••••••••••••••••••••• ••••••••••••••••••••••••••••••••••••••••••••••••• .

14

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

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

.....................................................................................................................................................................19. Cac hinh thirc ky l~t, xu ly vi pham dlibi ap dung (Dang, chinh quyen, doan the): (6) ..................................................................................................................................................................... 0 •

.....................................................................................................................................................................20. La dai bieu Quoc hQikhoa (neu c6): .21. La dai bi~uHQid6ngnMndful(n~uc6) nhiem ky: ......................................................................................................................................................................

QUANH~ GIA BiND (7)22. HQva ten cha: Sinh ngay thang nam .+Que quan: .+Noi a hien nay: .+NghS nghiep, chirc \'\1: .+NCYilam viec: .+Dang vien (neu co): .

23. HQva ten me: Sinh ngay thang nam .+Que qulin: .+NCYia hien nay: .+Ngh€ nghiep, chirc \'\1: .+NCYilam viec: .+Dang vien (neu c6): .

24. HQva ten vc (chong): Sinh ngay thang nam .+Que quan: .+ NCYia hien nay: .+NghS nghiep, chirc \'\1: .+NCYilam viec: .+D' .~ (~ ')angvien neu co : .

25. HQva ten con thir nllftt: (6) Sinh ngay thang nam .+NCYia hien nay: .+Ngh€ nghiep, chirc \'\1 (neu c6): .+Noi lam vi~clhQct~p: .+Dang vien (neu c6): .

26. Con thir hai (tro len): ke khai nhu con thir nhat.

TOM TAT QuA TRiNH CONG TAc

Tir thang nam .d~nthang nam .

Lam cong viec, giU chirc vu, cap b~c gi? tai co quan,t6 chirc, dan vi nao? a dau?

ThOi gian

15

To;xin cam doannhimg n~i dung neu tren la tU1y ifu va ifung s,!'th~t, Il;U sai to; xinhoan toan chiu trach nhifm trubc phap lu~t

Xac nh~n cua CO' quan,tA chuc, don vi noi lam vi~e ho~eUy ban nhan dan dp xii not elf tru

... '.1 ngay ....... thdng ........ ndm 2016Kyten

(Ky vaghi ro ho ten)

Ghichu:

(1) Ghi ro ten tinh, huyen, xiinoi rna minh irng Cll

(*) Ghi thea cac hu6ng dfu!nrong irng cua M~u s6 5IBCDBHDND

(2) N~u khong la Dang vien thi ghi "Khong", N~u la Dang vien thi ghi ro ngay, thang, namduoc k~t nap vao Dang, ngay chinh thirc (nhu trong Iy lich Dang vien). N~u dii ra khoi Dang thi ghiro thang, nam nao va ly do ra khoi Dang.

(3) Ghi ro la thanh vien cua cac t6 chirc chinh tri - xii hQi, t6 chuc chinh trt - xii hQi - ngh~nghi~p, t6 chuc xii hQi - ngh~ nghi~p, t6 chuc xii hQi nao; chuc V\ltrong t6 chuc (n~u co).

(4) Ghi tinh hinh suc kh6e ban than hi~n nay: t6t, trung binh, kern.

(5) Chi khai nhfrng hinh thuc khen thuang cho ca nhan va vi~t ro ten, h~g, duQ'ct~g nam nao(Vi d\l: DuQ'ct~g huful chuang lao dQng~g 2, 3 ho~c duQ'c~g huan chuang dQcI~ph~ng 1,2,3... ho~c danh hi~u duQ'cphong ~g: Anh hUng lao dQng,Anh hUng hJc IUQ'llgvii trang, Nha giaonh§n dan, NgM sy nhan dan, Nha giao uu tU, Th~y thu6c nhan dan, Th~y thu6c uu tU, Ngh~ sy uutU, Chi~n sy thi dua toan qu6c ... ).

(6) TruOng hQ'Pbi kY l~t dang, ky lu~t hanh chinh trong thm gian 01 nam tinh d~n ngay lamh6 sa (mg cu thi ghi ro ten ca quan ra quy~t dinh kY lu~t, thm gian bi ky l~t, ly do bi ky l~t, hinhthuc ky l~t.

TruOng hQ'Pbi k~t an v~ hinh Sl,l rna chua duQ'cxoa an tich thi ghi ro tQidanh, hinh ph~t bi apd\lI1gva thm gian bi k~t an.

N~u khong co ho~c dii bi xu Iy nhung khong thuQc cac truOng hQ'Pk~ tren thi ghi "Khong biky lu~t, khong co an tich".

(7) Ghi My dli thong tin v~ nhUngngum than thich (b6 rn¥ de, b6 rn¥ nuoi, VQ'(ch6ng), con de,con nuoi thea quy dinh Clla phap I~t). TruOng hQ'PnhUng ngum than thich dii nghi huu ho~ckhong con c6ng mc, lam vi~c thi ghi ro ngh~ nghi~p, chuc V\l, nm cong mc, lam vi~c cu6i cUngtruac khi nghi huu ho~c thoi cong mc, lam vi~c; truOng hQ'Pdii rnfit thi ghi ro rnfit nam nao, ngh~nghi~p, chuc V\l, nm cong mc, lam vi~c, nai a cu6i cimg truac khi rnfit. TruOng hQ'PnhUng ngumthan thich dii tUng la dang vien nhung bi khai tm, b6 sinh ho~t ho~c xin ra kh6i Dang thi phai ghiro trong Sa y~u I)' lich.

16

Mdu s6 71BCDBHDND

TIEUSUTOMTATCUA NGUOl: UNG err I)~I BIEU HQI DONG NHAN DAN

(1) NHI~M KY 2016-2021

Anh

4cm x6cm

1. HQva ten thirong dung: (*) ..2. HQva ten khai sinh: (*) .3. Cac bi danh/ten gQi khac: ..4. Ngay, thang, nam sinh: 5. Gioi tinh: .6. Que quan: (*) )7. NN~~anhi~Icy thu(a:)g tru: (*) :.

01 (J en nay: .8. sf> CMNDI HQchi€u/The can cuoc cong dan: (*) .Ngay c~p Nai c~p .

9. Dan tQc:(*) 10. Ton giao: (*) ..11. Trinh eo hien nay: (*)- Giao due pho thong: .- Chuyen mon, nghiep Vl): ..

- HQc vi: HQc ham: ..- Ly luan chinh tri: .- Ngoai ngir: .

12.Ngh@nghiep hien nay: (*) ..13. Chirc vu trong C(Jquan, t6 chirc, dan vi cong tic: (*) ..14.Noi lam viec: ..15.Ngay vao Dang: (**) .1 .1 ; S6 the dang vien ..- Ngay chinh tlnrc: .1 .1 ..- Chirc Vl) trong Dang: ..- Ngay ra khoi Dang (neu co) ..Ly do ra khoi Dang: ..

, ,16. Tham gia lam thanh vien cua cac to chirc doan the: .- Ten t6 chirc doan th~ ..- Chirc V1) trong tung t6 clurc doan th~: .17. Tinh trang sire khoe: (**) .18. Cac hinh thuc khen thuang nha nu6c da duQ'ctrao $lg: (**) ..••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• 0 •

.....................................................................................................................................................................19. Cac hinh thuc ky lu~t, xu ly vi ph~ da bi ap d1)llg(Dang, chinh quy@n,doan th€): (**) ..••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• 0 •

.....................................................................................................................................................................20. La d~ bi~u Qu6c h(>ikhoa (n~u co): ..

17

23. La dai bieu Hoi d6ng nhan dan (neu co) nhiem ky:

TOM TAT QuA TRiNH CONG TAc

TiT thang nam .d~nthang nam ..

Lam cong viec, giu clnrc vu, cap b~c gi? tai co quan, t6 chirc,dan vi nao? (y dau?

Thai gian

'" """ ngay ....... thang ........ nam 2016Kyten

(Ky va ghi rii ho, ten)

Ghi chu:(1) Ghi r5 ten tinh, huyen, xli noi minh irng cu.(*) Ghi thea cac hu6ng dful nrong img cua M~u s6 5IBCDBHDND.(**) Ghi thea cac hu6ng dfu1nrong irng cua M~u s6 6IBCDBHDND.

18

Mdu s6 81BCDH DND

BAN KE KHAI TAI SAN, THU NH~PCllA NGUilI UNG ctr Il~1BIEU H(H DONG NHAN DAN

••••.• (1) •.•....•..••..... NHI.t::MKY 2016-2021

I. THONG TIN CHUNGl.Nguoi ke khai tai san, thu nhap

- HQ va ten: Nfun sinh: .- Chirc vu/chirc danh cong tac: .- Co quan/don vi cong tac: .- HQkhdu thirong tni: .Ch~ , hie .- 0 0 €tn tai: .

2. Vq hoac chong cua ngiroi ke khai tai san, thu nhap- HQ va ten: Nam sinh: .- Chirc vu/chirc danh cong tac: .- Co quan/don vi cong tac: .- HQkhau thuong tru: ..Ch~"A .- 0 0hien tai: .

3. Con chua thanh nien (con de, con nuoi theo quy dinh cua phap luat)a) Con thir nhat:- HQ va ten: .- Ngay, thang, nam sinh: .- HQkhau thuong tru: ..- Cho a hien tai: ..b) Con thir hai (tro len): Ke khai nhu con thir nhat, ..

........................................................................................................................................................II. THONG TIN MO TA vE TINH HINH THU NH~P vA TAl sAN1.Nha 0', cong trinh xiy d1}1lg:a) Nha a:- Nha tlnr nhat: ..+ Lo~i nha: clip cong trinh .+ Dien tich xay dung: ..+ Gia tri: ., ,+ Giay clnrng nhan quyen sa hfru: ..+ Thong tin khac (neu co): ..- Nha thu hai (tr6 len): Ke khai tuang tIJ nhu nha thfr nhk ..b) Cong trinh xclydl,lIlgkhac:- Cong trinh thfr nhlit: .+Lo~i cong trinh clip cong trinh .+Di~n tich: .+ Gia tri: ., ,+Gicly chUng nh~ quyen sa hfru: .+ Thong tin khac (n€u co): ..- Cong trinh thfr hai (Tra len): Ke khai tuang 1\l nhu cong trinh thir nhlit.

19

2. Quyen sir dung dAt:a) DAta:- Manh thir nhat: .+Dia chi: .+Di~n tich: .+ Gia tri: ., ,+ Giay chimg nhan quyen sir dung: .+Thong tin khac (neu co): .- Manh thir 2: (Mo ta nhu manh thir nhat),b) Cac loai dit khac:- Manh thir nhAt: , , " " .., " , ..+Dia chi: .+Di~n tich: .+Gicitri: ., ,+Giay chimg nhan quyen sir dung: ..+Thong tin khac (neu co): ..- Manh thir hai: (Mo ta nhu manh thir nhat).3. Ti~n (tien Vi~t Nam, ngoai t~) g6m tien mat, tien cho vay, ti~n giri ca nhan, t6 chirc

trong mroc, t6 clurc nuoc ngoai tai Viet Nam rna t6ng gia tri quy d6i ill50 trieu d6ng tro len.t I ••••••••••••••••••• I • I ••• II I •• I 1111 ...................................................................................•••••••••••••••••••••••••••••••• ~ ."

4.0_ to, mo to, xe g~n may, xe may (may ill,may xuc, cac loai xe may khac), t~u thuy, t~ubay, thuyen va nhtrng dQng san khac rna Nha mroc qulin ly (theo quy dinh cua phap lu~t phaidang ky sir dl,U1gva duQ'ccc1pgiiy dang ky) co t6ng gia tri m6i lo~i ill 50 tri~u d6ng tra len.

-6 to- Moto-Xeg~may- Xe may (may ui, may xilc, cac lo~i xe may khac)- T~u thuy- T~u bay- Thuy€n- Nhung dQng san khac rna Nha nuac quan ly (theo quy dinh cua phap lu~t phai dang ky

sir dl,U1gva dUQ'ccc1pgiiy dang ky)

5. Kim lo~i quy, da quy, c6 phi€u, v6n gop vao cac cO'sa kinh doanh, cac lo~i giiy to cogia tri chuy€n nhugng khac co t6ng gia tri quy d6i m6i lo~i ill50 tri~u d6ng tra len.

- Kim lo~i quy- Da quy- C6 phi~u- V6n gop vao cac cO'sa kinh doanh- Cac lo~i giAy to co gia tri chuy€n nhugng khac

................................................................................................................................................... ~ .

20

6. Ole loai tai san khac rna gia tri quy d6i m6i loai nr 50 trieu d6ng tro len (nhu cay canh,bQban gh~, tranh, anh, d6 my nghe va cac loai tai san khac) ................................................................................................................................................................................................................................................................................................................................................................................................ .

7. Tai san, tai khoan a nuoc ngoai g6m tftt ca tai san quy dinh illKhoan 1 d~n Khoan 6noi tren nam ngoai lanh th6 Vi~t Nam ............................................................................................................................................................................................................................................................................................................................................................................. .

8. Cac khoan no g6m: cac khoan phai tra, gia tri cac tai san quan ly hQ, gift hQ co t6ng giatri quy d6i til 50 trieu d6ng tro len............................................................................................................................................................................................................................................................................................................................................................................................................................................................................

9. Tang tho nh~p trong nam quy d6i thanh tien Vi~t Nam g6m cac khoan luong, phudp, tro dp, thirong, thu lao, cho, tang, bieu, thira k~, thu nhap huang 19i til cac khoan diu tu,phat minh, sang che, cac khoan thu nhap khac,

- Luong thang tai thai diem ke khai: .(Df>ivoi nguai dang la can bQ, cong chilc, vien chilc, ghi r5 rna ng~ch cong chilc, vien

chilc, h~ sf>luong, ph\} dp chilc V\l va cac khoan ph\} dp khac).- T6ng sf>luong, cac khoan ph\} cftp thea luong va cac khoan thu nh~p co t1nh chAt ti€n

luong, ti~n cong khac trong 01 nam: .........................................................................................................................................................

Toi xin cam iloan nhiing n~i dung neu tren LaMy au va aung slf thq.t, n€u sai toi xin hoantoan chiu trach nhi?m trU'ucphap Luq.t

Ngay hoem thanh Ban ke khai tili san, thu nhg,p, th' ~ .... , ngay...... ang nam .

NgU'Oi ke khai tai san(Ky, ghi ro h9 ten)

Ghi chu:

(1) Ghi r5 ten tinh, huy~n, xii nai minh (mg cu.

- NguCri (mg cu thlJc hi~n ke khai thea huang d~n t~i Thong tu sf>08/2013/TT-TTCPngay 31 thang 10 nam 2013 cua Thanh tra Chinh phu huang dfu1 thi hanh cac quy dinh v~ minhb~chmi san, thu nh~p.