̲ͲÑÒÅÐÑÒÂÎ ÏÐÀÖ² ÒÀ ÑÎÖ²ÀËÜÍί ÏÎ˲ÒÈÊÈ ÓÊÐÀ¯ÍÈ Í À Ê À Ç 28.04.2004 N 95 Çàðåºñòðîâàíî â ̳í³ñòåðñòâ³ þñòèö³¿ Óêðà¿íè 8 ÷åðâíÿ 2004 ð. çà N 703/9302 Ïðî çàòâåðäæåííÿ ôîðìè Àêòà îáñòåæåííÿ ìàòåð³àëüíî-ïîáóòîâèõ óìîâ ñ³ì'¿ ³äïîâ³äíî äî ïóíêòó 35 Ïîðÿäêó ïðèçíà÷åííÿ ³ âèïëàòè äåðæàâíî¿ äîïîìîãè ñ³ì'ÿì ç ä³òüìè, çàòâåðäæåíîãî ïîñòàíîâîþ Êàá³íåòó ̳í³ñòð³â Óêðà¿íè â³ä 27 ãðóäíÿ 2001 ðîêó N 1751 ( 1751-2001-ï ), ïóíêò³â 4, 10 Ïîðÿäêó ïðèçíà÷åííÿ ³ âèïëàòè äåðæàâíî¿ ñîö³àëüíî¿ äîïîìîãè ìàëîçàáåçïå÷åíèì ñ³ì'ÿì, çàòâåðäæåíîãî ïîñòàíîâîþ Êàá³íåòó ̳í³ñòð³â Óêðà¿íè â³ä 24 ëþòîãî 2003 ðîêó N 250 ( 250-2003-ï ), ïóíêò³â 5-1, 6 Ïîëîæåííÿ ïðî ïîðÿäîê ïðèçíà÷åííÿ òà íàäàííÿ íàñåëåííþ ñóáñèä³é äëÿ â³äøêîäóâàííÿ âèòðàò íà îïëàòó æèòëîâî-êîìóíàëüíèõ ïîñëóã, ïðèäáàííÿ ñêðàïëåíîãî ãàçó, òâåðäîãî òà ð³äêîãî ï³÷íîãî ïîáóòîâîãî ïàëèâà, çàòâåðäæåíîãî ïîñòàíîâîþ Êàá³íåòó ̳í³ñòð³â Óêðà¿íè â³ä 21 æîâòíÿ 1995 ðîêó N 848 ( 848-95-ï ) (ó ðåäàêö³¿ ïîñòàíîâè Êàá³íåòó ̳í³ñòð³â Óêðà¿íè â³ä 22 âåðåñíÿ 1997 ðîêó N 1050 ( 1050-97-ï ), òà ïóíêòó 4 Ïîëîæåííÿ ïðî ñîö³àëüíîãî ³íñïåêòîðà, çàòâåðäæåíîãî ïîñòàíîâîþ Êàá³íåòó ̳í³ñòð³â Óêðà¿íè â³ä 21 ñåðïíÿ 2001 ðîêó N 1091 ( 1091-2001-ï ), Í À Ê À Ç Ó Þ: 1. Çàòâåðäèòè ôîðìó Àêòà îáñòåæåííÿ ìàòåð³àëüíî-ïîáóòîâèõ óìîâ ñ³ì'¿. 2. Óâàæàòè òàêèì, ùî âòðàòèâ ÷èíí³ñòü, íàêàç ̳íïðàö³ â³ä 19.12.2000 N 350 ( z0028-01 ) "Ïðî çàòâåðäæåííÿ Ïîðÿäêó â³äìîâè â íàäàíí³ äåðæàâíî¿ ñîö³àëüíî¿ äîïîìîãè, ïðèïèíåííÿ âèïëàòè òà çìåíøåííÿ ðîçì³ðó ïðèçíà÷åíî¿ äåðæàâíî¿ ñîö³àëüíî¿ äîïîìîãè", çàðåºñòðîâàíèé ó ̳í'þñò³ 16.01.2001 çà N 28/5219. 3. Óïðàâë³ííþ ïîë³òèêè àäðåñíî¿ äîïîìîãè ̳í³ñòåðñòâà ïðàö³ òà ñîö³àëüíî¿ ïîë³òèêè Óêðà¿íè çàðåºñòðóâàòè öåé íàêàç ó ̳í³ñòåðñòâ³ þñòèö³¿ Óêðà¿íè. 4. Êîíòðîëü çà âèêîíàííÿì öüîãî íàêàçó ïîêëàñòè íà çàñòóïíèêà ̳í³ñòðà Â.Äüÿ÷åíêà. ̳í³ñòð Ì.Ïàﳺâ ÇÀÒÂÅÐÄÆÅÍÎ Íàêàç ̳í³ñòåðñòâà ïðàö³ òà ñîö³àëüíî¿ ïîë³òèêè Óêðà¿íè 28.04.2004 N 95 ÀÊÒ îáñòåæåííÿ ìàòåð³àëüíî-ïîáóòîâèõ óìîâ ñ³ì'¿ I. ³äîìîñò³ ïðî óïîâíîâàæåíîãî ïðåäñòàâíèêà ñ³ì'¿ Ïð³çâèùå, ³ì'ÿ, ïî áàòüêîâ³ ______________________________________ Àäðåñà, çà ÿêîþ ìåøêຠ___________________________________________ II. Õàðàêòåðèñòèêà óìîâ ïðîæèâàííÿ òà íàÿâí³ñòü ï³ëüã òàê í³ 1. Ïðîæèâàííÿ íà òåðèòî𳿠ðàä³îàêòèâíîãî ------ ----- çàáðóäíåííÿ | | | | |----| |---| 2. Ïðîæèâàííÿ íà òåðèòî𳿠íàñåëåíîãî ïóíêòó, ÿêîìó | | | | íàäàíî ñòàòóñ ã³ðñüêîãî |-----------| | ³äñîòîê | 3. ϳëüãè ç îïëàòè æèòëîâî-êîìóíàëüíèõ ïîñëóã, | çìåíøåííÿ | |-----------| êàòåãîð³ÿ _________________________________________ | | ------------- III. ³äîìîñò³ ïðî ñ³ì'þ --------- 1. ʳëüê³ñòü ÷ëåí³â ñ³ì'¿, ùî ìåøêàþòü ðàçîì | | |-------| 2. Íîðìà âîëîä³ííÿ æèòëà íà ñ³ì'þ | | -----------------------------------------------------------------| |Ïð³çâèùå, ³ì'ÿ, |Ðîäèííèé |̳ñöå |Äîäàòêîâà | |ïî áàòüêîâ³ |çâ'ÿçîê |ïðîæèâàííÿ |³íôîðìàö³ÿ | | |(ñòîñîâíî | | | | |óïîâíîâà- | | | | |æåíîãî | | | | |ïðåäñòàâíèêà | | | | |ñ³ì'¿) | | | |----------------+-------------+---------------+-----------------| |----------------+-------------+---------------+-----------------| |----------------+-------------+---------------+-----------------| ------------------------------------------------------------------ IV. ³äîìîñò³ ïðî íàâ÷àííÿ ä³òåé ------------------------------------------------------------------ |Ïð³çâèùå, ³ì'ÿ, |Íàéìåíóâàííÿ íàâ÷àëüíîãî |Äîäàòêîâà | |ïî áàòüêîâ³ |çàêëàäó |³íôîðìàö³ÿ (ôîðìà | | | |íàâ÷àííÿ, îòðèìóº,| | | |íå îòðèìóº | | | |ñòèïåíä³þ) | |-------------------+-------------------------+------------------| |-------------------+-------------------------+------------------| |-------------------+-------------------------+------------------| ------------------------------------------------------------------ V. ³äîìîñò³ ïðî ìàéíî, ùî ïåðåáóâຠó âëàñíîñò³, âîëîä³íí³ ÷è êîðèñòóâàíí³ ñ³ì'¿ ------------------------------------------------------------------ |1. Æèòëîâå ïðèì³ùåííÿ, êâàðòèðà (áóäèíîê) |Ìîæëèâ³ñòü | | |îòðèìàííÿ | | |äîäàòêîâèõ | | |äîõîä³â | |-----------------------------------------------+----------------| |Ïð³çâèùå, ³ì'ÿ, |Õàðàêòåðèñòèêà æèòëîâîãî |òàê |í³ | |ïî áàòüêîâ³ |ïðèì³ùåííÿ, êâàðòèðè | | | | |(áóäèíêó), ïëîùà | | | |---------------------+-------------------------+--------+-------| |---------------------+-------------------------+--------+-------| |---------------------+-------------------------+--------+-------| |-----------------------------------------------+----------------| |2. Çåìåëüí³ ä³ëÿíêè, ïà¿ |Ìîæëèâ³ñòü | | |îòðèìàííÿ | | |äîäàòêîâèõ | | |äîõîä³â | |-----------------------------------------------+----------------| |Âëàñíèê (ïð³çâèùå, |Õàðàêòåðèñòèêà (ïëîùà, |òàê |í³ | |³ì'ÿ, ïî áàòüêîâ³) |ïðèçíà÷åííÿ) | | | |---------------------+-------------------------+--------+-------| |---------------------+-------------------------+--------+-------| |---------------------+-------------------------+--------+-------| |-----------------------------------------------+----------------| |3. Òðàíñïîðòí³ çàñîáè |Ìîæëèâ³ñòü | | |îòðèìàííÿ | | |äîäàòêîâèõ | | |äîõîä³â | |-----------------------------------------------+----------------| |Òðàíñïîðòíèé çàñ³á, |Õàðàêòåðèñòèêà |гê |òàê |í³ | |ðîáî÷à òà ñèëîâà |òðàíñïîðòíîãî |âèïóñêó| | | |ìàøèíè |çàñîáó, ðîáî÷î¿ | | | | | |òà ñèëîâî¿ ìàøèíè| | | | |---------------------+-----------------+-------+--------+-------| |---------------------+-----------------+-------+--------+-------| |---------------------+-----------------+-------+--------+-------| ------------------------------------------------------------------ VI. ³äîìîñò³ ïðî äîäàòêîâ³ äæåðåëà äëÿ ³ñíóâàííÿ ------------------------------------------------------------------ |1. Òâàðèííèöòâî |Ìîæëèâ³ñòü | | |îòðèìàííÿ | | |äîäàòêîâèõ | | |äîõîä³â | |-----------------------------------------------+----------------| |Íàÿâíà õóäîáà òà |ʳëüê³ñòü |òàê |í³ | |ïòèöÿ | | | | |---------------------+-------------------------+-------+--------| |ê³íü | | | | |---------------------+-------------------------+-------+--------| |êîðîâà | | | | |---------------------+-------------------------+-------+--------| |ñâèíÿ | | | | |---------------------+-------------------------+-------+--------| |ïòèöÿ | | | | |---------------------+-------------------------+-------+--------| | | | | | |-----------------------------------------------+----------------| |2. Ðîñëèííèöòâî (òåïëèö³) |Ìîæëèâ³ñòü | | |îòðèìàííÿ | | |äîäàòêîâèõ | | |äîõîä³â | |-----------------------------------------------+----------------| |Íàÿâí³ñòü òåïëèö³ |Õàðàêòåðèñòèêà (ïëîùà) |òàê |í³ | |---------------------+-------------------------+-------+--------| |---------------------+-------------------------+-------+--------| |---------------------+-------------------------+-------+--------| |-----------------------------------------------+----------------| |3. Íàðîäí³ ïðîìèñëè |Ìîæëèâ³ñòü | | |îòðèìàííÿ | | |äîäàòêîâèõ | | |äîõîä³â | |-----------------------------------------------+----------------| |Âèä |Õàðàêòåðèñòèêà íàÿâíèõ |òàê |í³ | | |çàñîá³â äëÿ âèðîáíèöòâà| | | |-----------------------+-----------------------+-------+--------| |-----------------------+-----------------------+-------+--------| |-----------------------+-----------------------+-------+--------| |-----------------------------------------------+-------+--------| |4. Ïðàöþº áåç óêëàäåííÿ òðóäîâî¿ óãîäè | | | ------------------------------------------------------------------ VII. ³äîìîñò³ ïðî ïîêóïêó àáî îïëàòó ïîñëóã, âàðò³ñòü ÿêèõ ïåðåâèùóº 10-êðàòíó âåëè÷èíó ïðîæèòêîâîãî ì³í³ìóìó äëÿ ñ³ì'¿ ------------------------------------------------------------------ |Ïåðåë³ê ìàéíà (ïîñëóã) |Õàðàêòåðèñòèêà ìàéíà |Âàð- |Äàòà | | |(ïîñëóã) |ò³ñòü |ïðèä- | | | |êóïëå- |áàííÿ | | | |íîãî |(îïëà- | | | |ìàéíà |òè) | | | |(ïîñ- | | | | |ëóã) | | |------------------------+-----------------------+-------+-------| |------------------------+-----------------------+-------+-------| |------------------------+-----------------------+-------+-------| ------------------------------------------------------------------ VIII. Äîäàòêîâà ³íôîðìàö³ÿ (óçàãàëüíåíà ³íôîðìàö³ÿ ùîäî íóæäåííîñò³ ñ³ì'¿ àáî ìîæëèâîñò³ çíàõîäæåííÿ äîäàòêîâèõ äæåðåë äëÿ ³ñíóâàííÿ) _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ Ñîö³àëüíèé ³íñïåêòîð _____________________ Óïîâíîâàæåíèé ïðåäñòàâíèê ñ³ì'¿ (âëàñíèê/ñï³ââëàñíèê, íàéìà÷ æèòëà) _____________________ ²íøà îñîáà, ÿêà ìîæå çàñâ³ä÷èòè äîñòîâ³ðí³ñòü äàíèõ, íàâåäåíèõ â àêò³ _____________________