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CNG HO X HI CH NGHA VIT NAM

c lp - T do - Hnh phc

T KHAI L PH TRC B NH, T

[01] Ngi np thu: .....................................................................................

[02] M s thu: .............................................................................................

[03] a ch: ...................................................................................................

[04] Qun/huyn: ................... [05] Tnh/Thnh ph: .....................................

[06] in thoi: ..................... [06] Fax: .................. [08] Email: ..................

C IM NH T:

1. t:

1.1 a ch tha t:

1.2. V tr (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. Tr gi tr nh, t thc t nhn chuyn nhng, nhn tha k, nhn tng cho (ng):

4. Ti sn thuc din khng phi np 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./

..........................., ngy......... thng........... nm..........

NGI NP THU hoc

I DIN HP PHP CA NGI NP THU

K tn, ng du (ghi r h tn v chc v)

Mu s: 01/LPTB

(Ban hnh km theo Thng t s 60/2007/TT-BTC ngy

14/6/2007 ca B Ti chnh)