̲ͲÑÒÅÐÑÒÂÎ ÏÐÀÖ² ÒÀ ÑÎÖ²ÀËÜÍί ÏÎ˲ÒÈÊÈ ÓÊÐÀ¯ÍÈ Í À Ê À Ç N 246 â³ä 18.09.2000 Çàðåºñòðîâàíî â ̳í³ñòåðñòâ³ þñòèö³¿ Óêðà¿íè 10 æîâòíÿ 2000 ð. çà N 693/4914 ( Íàêàç âòðàòèâ ÷èíí³ñòü íà ï³äñòàâ³ Íàêàçó ̳í³ñòåðñòâà ïðàö³ òà ñîö³àëüíî¿ ïîë³òèêè N 204 ( z0709-03 ) â³ä 22.07.2003 ) Ïðî çàòâåðäæåííÿ Äåêëàðàö³¿ ïðî äîõîäè òà ìàéíîâèé ñòàí ñ³ì'¿, ÿêà çâåðíóëàñÿ çà ïðèçíà÷åííÿì äåðæàâíî¿ ñîö³àëüíî¿ äîïîìîãè ìàëîçàáåçïå÷åíèì ñ³ì'ÿì ³äïîâ³äíî äî ñòàòò³ 4 Çàêîíó Óêðà¿íè "Ïðî äåðæàâíó ñîö³àëüíó äîïîìîãó ìàëîçàáåçïå÷åíèì ñ³ì'ÿì" ( 1768-14 ) Í À Ê À Ç Ó Þ: 1. Çàòâåðäèòè ôîðìó Äåêëàðàö³¿ ïðî äîõîäè òà ìàéíîâèé ñòàí ñ³ì'¿, ÿêà çâåðíóëàñÿ çà ïðèçíà÷åííÿì äåðæàâíî¿ ñîö³àëüíî¿ äîïîìîãè (äîäàºòüñÿ). 2. Êîíòðîëü çà âèêîíàííÿì öüîãî íàêàçó ïîêëàñòè íà çàñòóïíèêà ̳í³ñòðà â³äïîâ³äíî äî ðîçïîä³ëó îáîâ'ÿçê³â. ̳í³ñòð ².ß. Ñàõàíü ÇÀÒÂÅÐÄÆÅÍÎ Íàêàç ̳í³ñòåðñòâà ïðàö³ òà ñîö³àëüíî¿ ïîë³òèêè Óêðà¿íè 18.09.2000 N 246 Çàïîâíþºòüñÿ óïîâíîâàæåíîþ îñîáîþ ñ³ì'¿ Äî óïðàâë³ííÿ ïðàö³ òà ñîö³àëüíîãî çàõèñòó íàñåëåííÿ _____________ __________________________________________________________________ ÄÅÊËÀÐÀÖ²ß ïðî äîõîäè òà ìàéíîâèé ñòàí ñ³ì'¿, ÿêà çâåðíóëàñÿ çà ïðèçíà÷åííÿì äåðæàâíî¿ ñîö³àëüíî¿ äîïîìîãè ------------------------------------------------------------------ |Ðîçä³ë I. Çàãàëüí³ â³äîìîñò³ | |----------------------------------------------------------------| |1. _____________________________________________________________| | (ïð³çâèùå, ³ì'ÿ, ïî áàòüêîâ³ óïîâíîâàæåíî¿ îñîáè) | |2. ̳ñöå ïðîæèâàííÿ: ___________________________________________| | (ïîøòîâèé ³íäåêñ, îáëàñòü, ðàéîí, | |_______________________________________________________________ | | íàñåëåíèé ïóíêò, âóëèöÿ, áóäèíîê, êîðïóñ, êâàðòèðà) | | | |3. ×ëåíè ñ³ì'¿* | |----------------------------------------------------------------| | Ïð³çâèùå, ³ì'ÿ, ïî áàòüêîâ³ | Ñòóï³íü |²äåíòèô³êà- |Ïðèì³òêè | | |ðîäèííîãî|ö³éíèé íîìåð| | | | çâ'ÿçêó | | | |-------------------------------+---------+------------+---------| | 1 | 2 | 3 | 4 | |-------------------------------+---------+------------+---------| |-------------------------------+---------+------------+---------| |-------------------------------+---------+------------+---------| |-------------------------------+---------+------------+---------| |-------------------------------+---------+------------+---------| |-------------------------------+---------+------------+---------| |-------------------------------+---------+------------+---------| |-------------------------------+---------+------------+---------| |-------------------------------+---------+------------+---------| ------------------------------------------------------------------ _______________________________ * Îñîáè, ÿê³ ïåðåáóâàþòü íà ïîâíîìó äåðæàâíîìó óòðèìàíí³, íå âêëþ÷àþòüñÿ â äåêëàðàö³þ ------------------------------------------------------------------ |Ðîçä³ë II. Äîõîäè ñ³ì'¿ (íàðàõîâàí³) çà ïåð³îä | |ç _______ 200 __ ð. äî _______ 200 __ ð. | | | |----------------------------------------------------------------| | Ïð³çâèùå, | ³äîìîñò³ ïðî äîõîäè | | ³í³ö³àëè |----------------------------------------------| | | âèä | ðîçì³ð | äæåðåëî äîõîäó (íàçâà | | |äîõîäó | äîõîäó | ï³äïðèºìñòâà) | |-----------------+-------+-----------+--------------------------| | 1 | 2 | 3 | 4 | |-----------------+-------+-----------+--------------------------| |-----------------+-------+-----------+--------------------------| |-----------------+-------+-----------+--------------------------| |-----------------+-------+-----------+--------------------------| |-----------------+-------+-----------+--------------------------| |-----------------+-------+-----------+--------------------------| |-----------------+-------+-----------+--------------------------| |-----------------+-------+-----------+--------------------------| |-----------------+-------+-----------+--------------------------| |-----------------+-------+-----------+--------------------------| ------------------------------------------------------------------ ------------------------------------------------------------------ |Ðîçä³ë III. ³äîìîñò³ ïðî çåìåëüí³ ä³ëÿíêè ïëîùåþ ïîíàä 0,60 ãà,| |ùî ïåðåáóâàþòü ó âëàñíîñò³ àáî âîëîä³íí³ ñ³ì'¿ | |----------------------------------------------------------------| | Ïð³çâèùå, ³í³ö³àëè | Ïëîùà çåìåëüíî¿ ä³ëÿíêè | |-------------------------------+--------------------------------| | 1 | 2 | |-------------------------------+--------------------------------| |-------------------------------+--------------------------------| |-------------------------------+--------------------------------| |-------------------------------+--------------------------------| |-------------------------------+--------------------------------| |-------------------------------+--------------------------------| ------------------------------------------------------------------ ------------------------------------------------------------------ |Ðîçä³ë IV. ³äîìîñò³ ïðî ï³äñîáí³ ãîñïîäàðñòâà, ùî ïåðåáóâàþòü ó| |âëàñíîñò³ àáî âîëîä³íí³ ñ³ì'¿ | |----------------------------------------------------------------| | Ïð³çâèùå, ³í³ö³àëè | |----------------------------------------------------------------| | 1 | |----------------------------------------------------------------| |----------------------------------------------------------------| |----------------------------------------------------------------| |----------------------------------------------------------------| ------------------------------------------------------------------ ------------------------------------------------------------------ |Ðîçä³ë V. ³äîìîñò³ ïðî æèòëîâ³ ïðèì³ùåííÿ, ÿê³ ïåðåáóâàþòü ó | |âëàñíîñò³ àáî âîëîä³íí³ ñ³ì'¿ | |----------------------------------------------------------------| |Ïð³çâèùå, ³í³ö³àëè |Çàãàëüíà | ʳëüê³ñòü | Àäðåñà æèòëîâîãî | | | ïëîùà | îñ³á, | ïðèì³ùåííÿ | | |æèòëîâîãî |ïðîïèñàíèõ | | | |ïðèì³ùåííÿ| ó | | | | |æèòëîâîìó | | | | |ïðèì³ùåíí³ | | |-------------------+----------+-----------+---------------------| | 1 | 2 | 3 | 4 | |-------------------+----------+-----------+---------------------| |-------------------+----------+-----------+---------------------| |-------------------+----------+-----------+---------------------| |-------------------+----------+-----------+---------------------| |-------------------+----------+-----------+---------------------| ------------------------------------------------------------------ ------------------------------------------------------------------ |Ðîçä³ë VI. ³äîìîñò³ ïðî òðàíñïîðòí³ çàñîáè, ÿê³ çàðåºñòðîâàí³ â| |óñòàíîâëåíîìó ïîðÿäêó òà ïåðåáóâàþòü ó âëàñíîñò³ àáî âîëîä³íí³| |ñ³ì'¿ | |----------------------------------------------------------------| |Ïð³çâèùå, ³í³ö³àëè |Àâòîìîá³ëü| Äåðæàâíèé| гê | Àâòîìîá³ë³ | | | ìàðêè | íîìåðíèé | âèïóñêó| îòðèìàí³ | | | | çíàê | |÷åðåç îðãàíè | | | | | | ñîö³àëüíîãî | | | | | | çàõèñòó | | | | | | íàñåëåííÿ | |-------------------+----------+----------+--------+-------------| | 1 | 2 | 3 | 4 | 5 | |-------------------+----------+----------+--------+-------------| |-------------------+----------+----------+--------+-------------| |-------------------+----------+----------+--------+-------------| |-------------------+----------+----------+--------+-------------| |-------------------+----------+----------+--------+-------------| |-------------------+----------+----------+--------+-------------| ------------------------------------------------------------------ __________________________ __________________________ (ï³äïèñ) (äàòà) Íà÷àëüíèê Óïðàâë³ííÿ ïîë³òèêè àäðåñíî¿ äîïîìîãè Ò.À. ̳ùåíêî