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CNG HO X HI CH NGHA VIT NAM

c lp - T do - Hnh phc N XIN TCH THA T, HP THA T

Knh gi: ..Mu s 16/K

PHN GHI CA NGI NHN H S

Vo s tip nhn h s:

.....Gi.pht, ngy//.

Quyn s , S th t..

Ngi nhn h s

(K, ghi r h tn)

I- K KHAI CA NGI S DNG T

(Xem k hng dn cui n ny trc khi vit n; khng ty xo, sa cha ni dung vit )

1. Ngi s dng t: 1.1 Tn ngi s dng t (Vit ch in hoa):...........................................................................

1.2 a ch........................................................................................................................... .....

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

2. Xin tch, hp tha t nh sau:

2.1. Xin tch thnh . tha t i vi tha t di y:

a) Tha t s:.....; b) T bn s:................;

c) a ch tha t:.........

d) S pht hnh Giy chng nhn: .......................................................................

S vo s cp Giy chng nhn :..................................; ngy cp ...../...../.......

2.2. Xin hp cc tha t di y thnh mt tha t:

Tha t sT bn sa ch tha tS pht hnh

Giy chng nhnS vo s cp giy

chng nhn

3. L do tch, hp tha t...................................................................................................... .....................................................................................................................................................

4. Giy t np km theo n ny gm c: - Giy chng nhn quyn s dng t ca tha t trn;

- S d kin phn chia cc tha t trong trng hp tch tha (nu c);

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

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

, ngy .... thng ... nm ...... Ngi vit n

(k, ghi r h tn) II- KIN CA C QUAN TI NGUYN V MI TRNG

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

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Ngy.. thng. nm ..Ngi thm tra

(K, ghi r h tn, chc v)

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

(K tn, ng du)

Hng dn vit n: - n ny dng trong trng hp ngi s sng t xin tch mt tha t thnh nhiu tha t mi hoc xin hp nhiu tha t thnh mt tha t;

- gi n: H gia nh, c nhn, cng ng dn c th gi U ban nhn dn cp huyn ni c t; t chc, c s tn gio, t chc v c nhn nc ngoi, ngi Vit Nam nh c nc ngoi th gi U ban nhn dn cp tnh ni c t;

- im 1 ghi tn v a ch ca ngi s dng t nh trn giy chng nhn quyn s dng t gm cc thng tin nh sau: i vi c nhn ghi r h, tn, nm sinh, s giy CMND, ngy v ni cp giy CMND; i vi ngi Vit Nam nh c nc ngoi v c nhn nc ngoi ghi h, tn, nm sinh, s h chiu, ngy v ni cp h chiu, quc tch; i vi h gia nh ghi ch H ng/b v ghi h, tn, nm sinh, s giy CMND, ngy v ni cp giy CMND ca c v v chng ngi i din cng s dng t; trng hp quyn s dng t l ti sn chung ca c v v chng th ghi h, tn, nm sinh, s giy CMND, ngy v ni cp giy CMND ca v v ca chng; i vi t chc th ghi tn t chc, ngy thng nm thnh lp, s v ngy, c quan k quyt nh thnh lp hoc s giy ng k kinh doanh, giy php u t ca c quan nh nc c thm quyn cp;

- im 2 ghi cc thng tin v tha t nh trn giy chng nhn quyn s dng t;

- Ngi vit n k v ghi r h tn cui "Phn khai ca ngi s dng t"; trng hp y quyn vit n th ngi c y quyn k, ghi r h tn v ghi (c u quyn); i vi t chc s dng t phi ghi h tn, chc v ngi vit n v ng du ca t chc.