̲ͲÑÒÅÐÑÒÂÎ ÏÐÀÖ² ÒÀ ÑÎÖ²ÀËÜÍί ÏÎ˲ÒÈÊÈ ÓÊÐÀ¯ÍÈ Í À Ê À Ç 22.07.2003 N 204 Çàðåºñòðîâàíî â ̳í³ñòåðñòâ³ þñòèö³¿ Óêðà¿íè 13 ñåðïíÿ 2003 ð. çà N 709/8030 Ïðî çàòâåðäæåííÿ ôîðìè Äåêëàðàö³¿ ïðî äîõîäè òà ìàéíîâèé ñòàí îñ³á, ÿê³ çâåðíóëèñÿ çà ïðèçíà÷åííÿì óñ³õ âèä³â ñîö³àëüíî¿ äîïîìîãè, òà äîâ³äêè ïðî ñêëàä ñ³ì'¿ àáî çàðåºñòðîâàíèõ ó æèòëîâîìó ïðèì³ùåíí³ / áóäèíêó îñ³á ³äïîâ³äíî äî ñòàòò³ 4 Çàêîíó Óêðà¿íè "Ïðî äåðæàâíó ñîö³àëüíó äîïîìîãó ìàëîçàáåçïå÷åíèì ñ³ì'ÿì" ( 1768-14 ) òà ïóíêòó 2 ïîñòàíîâè Êàá³íåòó ̳í³ñòð³â Óêðà¿íè â³ä 24 ëþòîãî 2003 ð. N 253 ( 253-2003-ï ) "Äåÿê³ ïèòàííÿ íàäàííÿ ñîö³àëüíî¿ äîïîìîãè" Í À Ê À Ç Ó Þ: 1. Çàòâåðäèòè ôîðìè Äåêëàðàö³¿ ïðî äîõîäè òà ìàéíîâèé ñòàí îñ³á, ÿê³ çâåðíóëèñÿ çà ïðèçíà÷åííÿì óñ³õ âèä³â ñîö³àëüíî¿ äîïîìîãè, òà äîâ³äêè ïðî ñêëàä ñ³ì'¿ àáî çàðåºñòðîâàíèõ ó æèòëîâîìó ïðèì³ùåíí³/ áóäèíêó îñ³á, ùî äîäàþòüñÿ. 2. Óïðàâë³ííþ ïîë³òèêè àäðåñíî¿ äîïîìîãè çàðåºñòðóâàòè öåé íàêàç ó ̳í³ñòåðñòâ³ þñòèö³¿ Óêðà¿íè. 3. Ââàæàòè òàêèì, ùî âòðàòèâ ÷èíí³ñòü, íàêàç ̳í³ñòåðñòâà ïðàö³ òà ñîö³àëüíî¿ ïîë³òèêè â³ä 18.09.2000 N 246 ( z0693-00 ) "Ïðî çàòâåðäæåííÿ Äåêëàðàö³¿ ïðî äîõîäè òà ìàéíîâèé ñòàí ñ³ì'¿, ÿêà çâåðíóëàñÿ çà ïðèçíà÷åííÿì äåðæàâíî¿ ñîö³àëüíî¿ äîïîìîãè ìàëîçàáåçïå÷åíèì ñ³ì'ÿì", çàðåºñòðîâàíèé ó ̳í³ñòåðñòâ³ þñòèö³¿ 10.10.2000 çà N 693/4914. 4. Êîíòðîëü çà âèêîíàííÿì öüîãî íàêàçó ïîêëàñòè íà çàñòóïíèêà Äåðæàâíîãî ñåêðåòàðÿ â³äïîâ³äíî äî ðîçïîä³ëó îáîâ'ÿçê³â. ̳í³ñòð Ì.Ïàﳺâ ÇÀÒÂÅÐÄÆÅÍÎ Íàêàç ̳í³ñòåðñòâà ïðàö³ òà ñîö³àëüíî¿ ïîë³òèêè Óêðà¿íè 22.07.2003 N 204 Çàïîâíþºòüñÿ çàÿâíèêîì / óïîâíîâàæåíèì ïðåäñòàâíèêîì ñ³ì'¿ / âëàñíèêîì, ñï³ââëàñíèêîì (íàéìà÷åì) æèòëà Äî îðãàíó ïðàö³ òà ñîö³àëüíîãî çàõèñòó íàñåëåííÿ_____________ __________________________________________________________________ ÄÅÊËÀÐÀÖ²ß ïðî äîõîäè òà ìàéíîâèé ñòàí îñ³á, ÿê³ çâåðíóëèñÿ çà ïðèçíà÷åííÿì óñ³õ âèä³â ñîö³àëüíî¿ äîïîìîãè ------------------------------------------------------------------ |ÐÎÇÄ²Ë I. Çàãàëüí³ â³äîìîñò³ | |----------------------------------------------------------------| |1.______________________________________________________________| | (ïð³çâèùå, ³ì'ÿ, ïî áàòüêîâ³ çàÿâíèêà / óïîâíîâàæåíîãî | | ïðåäñòàâíèêà ñ³ì'¿ / âëàñíèêà, ñï³ââëàñíèêà (íàéìà÷à) æèòëà) | | | |2. ̳ñöå ïðîæèâàííÿ:____________________________________________| | (ïîøòîâèé ³íäåêñ, îáëàñòü, ðàéîí, | | íàñåëåíèé ïóíêò, âóëèöÿ, áóäèíîê, êîðïóñ, | | êâàðòèðà) | |----------------------------------------------------------------| |3. ×ëåíè ñ³ì'¿ àáî çàðåºñòðîâàí³ ó æèòëîâîìó ïðèì³ùåíí³ /áóäèíêó| |îñîáè, ÷ëåíè ñ³ìåé, ùî ïðîæèâàþòü îêðåìî (äðóæèíà, ÷îëîâ³ê, | |íåïîâíîë³òí³ ä³òè) | |----------------------------------------------------------------| |Ïð³çâèùå, ³ì'ÿ, ïî áàòüêîâ³| Ñòóï³íü |²äåíòèô³êàö³éíèé|Ïðèì³òêè| | | ðîäèííîãî| íîìåð | | | | çâ'ÿçêó | | | |---------------------------+----------+----------------+--------| | 1 | 2 | 3 | 4 | |---------------------------+----------+----------------+--------| | | | | | |---------------------------+----------+----------------+--------| | | | | | |---------------------------+----------+----------------+--------| | | | | | |---------------------------+----------+----------------+--------| | | | | | |---------------------------+----------+----------------+--------| | | | | | |---------------------------+----------+----------------+--------| | | | | | |---------------------------+----------+----------------+--------| | | | | | |---------------------------+----------+----------------+--------| | | | | | |---------------------------+----------+----------------+--------| | | | | | |---------------------------+----------+----------------+--------| | | | | | |---------------------------+----------+----------------+--------| | | | | | ------------------------------------------------------------------ ------------------------------------------------------------------ |Ðîçä³ë II. Äîõîäè ÷ëåí³â ñ³ì'¿ àáî çàðåºñòðîâàíèõ ó æèòëîâîìó | |ïðèì³ùåíí³ / áóäèíêó îñ³á, ÷ëåí³â ñ³ì'¿, ùî ïðîæèâàþòü îêðåìî | |(äðóæèíè, ÷îëîâ³êà, íåïîâíîë³òí³õ ä³òåé) çà ïåð³îä ç | |_____200__ð. äî _______200__ð. (â³äïîâ³äíî äî Ìåòîäèêè | |îá÷èñëåííÿ ñóêóïíîãî äîõîäó ñ³ì'¿ äëÿ âñ³õ âèä³â ñîö³àëüíî¿ | |äîïîìîãè, çàòâåðäæåíî¿ íàêàçîì ̳íïðàö³, | |̳íåêîíîì³êè, ̳íô³íó, Äåðæêîìñòàòó, Äåðæêîìñ³ì'ÿìîëîä³ òà | |çàðåºñòðîâàíî¿ ó ̳í'þñò³ 07.02.2002 çà N 112/6400, ³ç çì³íàìè) | |----------------------------------------------------------------| |Ïð³çâèùå, | ³äîìîñò³ ïðî äîõîäè | |³í³ö³àëè |------------------------------------------------| | |Âèä äîõîäó|Ðîçì³ð äîõîäó| Äæåðåëî äîõîäó | |---------------+----------+-------------+-----------------------| | 1 | 2 | 3 | 4 | |---------------+----------+-------------+-----------------------| | | | | | |---------------+----------+-------------+-----------------------| | | | | | |---------------+----------+-------------+-----------------------| | | | | | |---------------+----------+-------------+-----------------------| | | | | | |---------------+----------+-------------+-----------------------| | | | | | |---------------+----------+-------------+-----------------------| | | | | | |---------------+----------+-------------+-----------------------| | | | | | |---------------+----------+-------------+-----------------------| | | | | | |---------------+----------+-------------+-----------------------| | | | | | |---------------+----------+-------------+-----------------------| | | | | | |---------------+----------+-------------+-----------------------| | | | | | |---------------+----------+-------------+-----------------------| | | | | | |---------------+----------+-------------+-----------------------| | | | | | |---------------+----------+-------------+-----------------------| | | | | | |---------------+----------+-------------+-----------------------| | | | | | ------------------------------------------------------------------ ------------------------------------------------------------------ |Ðîçä³ë III. ³äîìîñò³ ïðî æèòëîâ³ ïðèì³ùåííÿ, ùî ïåðåáóâàþòü ó | |âëàñíîñò³ àáî âîëîä³íí³ ÷ëåí³â ñ³ì'¿ àáî çàðåºñòðîâàíèõ ó | |æèòëîâîìó ïðèì³ùåíí³ / áóäèíêó îñ³á, ÷ëåí³â ñ³ì'¿, ùî ïðîæèâàþòü| |îêðåìî (äðóæèíè, ÷îëîâ³êà, íåïîâíîë³òí³õ ä³òåé) | |----------------------------------------------------------------| |Ïð³çâèùå, ³í³ö³àëè| Çàãàëüíà | ʳëüê³ñòü îñ³á, |Àäðåñà æèòëîâîãî| |âëàñíèêà (íàéìà÷à)| ïëîùà |çàðåºñòðîâàíèõ ó | ïðèì³ùåííÿ | | |æèòëîâîãî | æèòëîâîìó | | | |ïðèì³ùåííÿ| ïðèì³ùåíí³ | | |------------------+----------+-----------------+----------------| | 1 | 2 | 3 | 4 | |------------------+----------+-----------------+----------------| | | | | | |------------------+----------+-----------------+----------------| | | | | | |------------------+----------+-----------------+----------------| | | | | | |------------------+----------+-----------------+----------------| | | | | | |------------------+----------+-----------------+----------------| | | | | | ------------------------------------------------------------------ ------------------------------------------------------------------ |Ðîçä³ë IV. ³äîìîñò³ ïðî òðàíñïîðòí³ çàñîáè, ÿê³ çàðåºñòðîâàí³ â| |óñòàíîâëåíîìó ïîðÿäêó òà ïåðåáóâàþòü ó âëàñíîñò³ àáî âîëîä³íí³ | |÷ëåí³â ñ³ì'¿ àáî çàðåºñòðîâàíèõ ó æèòëîâîìó ïðèì³ùåíí³ / áóäèíêó| |îñ³á, ÷ëåí³â ñ³ì'¿, ùî ïðîæèâàþòü îêðåìî (äðóæèíè, ÷îëîâ³êà, | |íåïîâíîë³òí³õ ä³òåé) | |----------------------------------------------------------------| |Ïð³çâèùå, ³í³ö³àëè|Àâòîìîá³ëü|Äåðæàâíèé | гê | Àâòîìîá³ë³, | | âëàñíèêà | ìàðêè | íîìåðíèé |âèïóñêó |îòðèìàí³ ÷åðåç| | | | çíàê | | îðãàíè ïðàö³ | | | | | |òà ñîö³àëüíîãî| | | | | | çàõèñòó | | | | | | íàñåëåííÿ | |------------------+----------+----------+--------+--------------| | 1 | 2 | 3 | 4 | 5 | |------------------+----------+----------+--------+--------------| | | | | | | |------------------+----------+----------+--------+--------------| | | | | | | |------------------+----------+----------+--------+--------------| | | | | | | |------------------+----------+----------+--------+--------------| | | | | | | |------------------+----------+----------+--------+--------------| | | | | | | |------------------+----------+----------+--------+--------------| | | | | | | ------------------------------------------------------------------ ------------------------------------------------------------------ |Ðîçä³ë V. ³äîìîñò³ ïðî çåìåëüí³ ä³ëÿíêè, ùî ïåðåáóâàþòü ó | |âëàñíîñò³ àáî âîëîä³íí³ (êîðèñòóâàíí³) ÷ëåí³â ñ³ì'¿ àáî | |çàðåºñòðîâàíèõ ó æèòëîâîìó ïðèì³ùåíí³ / áóäèíêó îñ³á, ÷ëåí³â | |ñ³ì'¿, ùî ïðîæèâàþòü îêðåìî (äðóæèíè, ÷îëîâ³êà, íåïîâíîë³òí³õ | |ä³òåé) | |----------------------------------------------------------------| |Ïð³çâèùå, ³í³ö³àëè| Ïëîùà | Ôîðìà | Ïðèçíà÷åííÿ çåìåëüíî¿ | | âëàñíèêà |çåìåëüíî¿ |âëàñíîñò³ | ä³ëÿíêè | | (êîðèñòóâà÷à) | ä³ëÿíêè | | | |------------------+----------+----------+-----------------------| | 1 | 2 | 3 | 4 | |------------------+----------+----------+-----------------------| | | | | | |------------------+----------+----------+-----------------------| | | | | | |------------------+----------+----------+-----------------------| | | | | | |------------------+----------+----------+-----------------------| | | | | | |------------------+----------+----------+-----------------------| | | | | | ------------------------------------------------------------------ ------------------------------------------------------------------ |Ðîçä³ë VI. ³äîìîñò³ ïðî íàÿâí³ñòü äîäàòêîâèõ äæåðåë äëÿ | |³ñíóâàííÿ | |----------------------------------------------------------------| | Âèä äæåðåëà äëÿ | Õàðàêòåðèñòèêà çàñîá³â | ²íôîðìàö³ÿ ïðî | | ³ñíóâàííÿ | äëÿ îòðèìàííÿ | âèêîðèñòàííÿ | | | | íàÿâíèõ çàñîá³â | |-------------------+------------------------+-------------------| | 1 | 2 | 3 | |-------------------+------------------------+-------------------| | | | | |-------------------+------------------------+-------------------| | | | | |-------------------+------------------------+-------------------| | | | | |-------------------+------------------------+-------------------| | | | | |-------------------+------------------------+-------------------| | | | | ------------------------------------------------------------------ ------------------------------------------------------------------ |Ðîçä³ë VII. ³äîìîñò³ ïðî ïîêóïêó àáî îïëàòó ïîñëóã íà ñóìó, ùî | |ïåðåâèùóº 10 ïðîæèòêîâèõ ì³í³ìóì³â äëÿ ñ³ì'¿ | |----------------------------------------------------------------| |Ïð³çâèùå, ³í³ö³àëè|Âèä ìàéíà àáî ïîñëóã| Âàðò³ñòü | Äàòà | | îñîáè | | |çä³éñíåííÿ | | | | |ïîêóïêè àáî| | | | | îïëàòè | | | | | ïîñëóã | |------------------+--------------------+------------+-----------| | 1 | 2 | 3 | 4 | |------------------+--------------------+------------+-----------| | | | | | |------------------+--------------------+------------+-----------| | | | | | |------------------+--------------------+------------+-----------| | | | | | |------------------+--------------------+------------+-----------| | | | | | |------------------+--------------------+------------+-----------| | | | | | |------------------+--------------------+------------+-----------| | | | | | ------------------------------------------------------------------ Ïðî â³äìîâó â ïðèçíà÷åíí³ àáî ïðèïèíåííÿ âèïëàòè ñóáñè䳿 äëÿ â³äøêîäóâàííÿ âèòðàò íà îïëàòó æèòëîâî-êîìóíàëüíèõ ïîñëóã íà ïðèäáàííÿ ñêðàïëåíîãî ãàçó, òâåðäîãî òà ð³äêîãî ï³÷íîãî ïîáóòîâîãî ïàëèâà, à òàêîæ äåðæàâíî¿ ñîö³àëüíî¿ äîïîìîãè ìàëîçàáåçïå÷åíèì ñ³ì'ÿì â ðàç³ ïîäàííÿ íåïîâíèõ ÷è íåäîñòîâ³ðíèõ â³äîìîñòåé ïðî äîõîäè òà ìàéíîâèé ñòàí ÷ëåí³â ñ³ì'¿ àáî çàðåºñòðîâàíèõ ó æèòëîâîìó ïðèì³ùåíí³ / áóäèíêó îñ³á, ÷ëåí³â ñ³ì'¿, ùî ïðîæèâàþòü îêðåìî (äðóæèíè, ÷îëîâ³êà, íåïîâíîë³òí³õ ä³òåé) ìåíå ïîïåðåäæåíî. _______________________ _______________________________ (ï³äïèñ çàÿâíèêà) (äàòà) Íà÷àëüíèê Óïðàâë³ííÿ ïîë³òèêè àäðåñíî¿ äîïîìîãè ².Ã.Ïîë³ùóê ÇÀÒÂÅÐÄÆÅÍÎ Íàêàç ̳í³ñòåðñòâà ïðàö³ òà ñîö³àëüíî¿ ïîë³òèêè Óêðà¿íè 22.07. 2003 N 204 Çàïîâíþºòüñÿ â³äïîâ³äíèì ï³äïðèºìñòâîì (îðãàí³çàö³ºþ) àáî âèêîíàâ÷èì îðãàíîì ñ³ëüñüêî¿ (ñåëèùíî¿) ðàäè çà ì³ñöåì ðåºñòðàö³¿ ñ³ì'¿ ÄβÄÊÀ ïðî ñêëàä ñ³ì'¿ àáî çàðåºñòðîâàíèõ ó æèòëîâîìó ïðèì³ùåíí³ / áóäèíêó îñ³á Âèäàíà óïîâíîâàæåíîìó âëàñíèêó (ñï³ââëàñíèêó, íàéìà÷ó) æèòëîâîãî ïðèì³ùåííÿ (áóäèíêó), ÷ëåíîâ³ æèòëîâî-áóä³âåëüíîãî êîîïåðàòèâó __________________________________________________________________ (ïð³çâèùå, ³ì'ÿ, ïî áàòüêîâ³) àäðåñà____________________________________________________________ ïðîòå, ùî äî ñêëàäó ñ³ì'¿ / çàðåºñòðîâàíèõ / âõîäÿòü: ------------------------------------------------------------------ |Ïð³çâèùå, | Ðîäèíí³ | Äàòà | N, ñåð³ÿ | |³ì'ÿ, ïî áàòüêîâ³ | ñòîñóíêè |íàðîäæåííÿ|ïàñïîðòà àáî| | | | | ñâ³äîöòâà | | | | | ïðî | | | | | íàðîäæåííÿ | |--------------------------+-------------+----------+------------| | |óïîâíîâàæåíèé| | | | | âëàñíèê | | | | |(ñï³ââëàñíèê,| | | | | íàéìà÷) | | | 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Äîâ³äêà âèäàíà äëÿ ïðåä'ÿâëåííÿ äî îðãàíó ïðàö³ òà ñîö³àëüíîãî çàõèñòó íàñåëåííÿ. __________________________________________________________________ (íàçâà ï³äïðèºìñòâà/îðãàí³çàö³¿, âèêîíàâ÷îãî îðãàíó) __________________________________________________________________ (àäðåñà ï³äïðèºìñòâà/îðãàí³çàö³¿, âèêîíàâ÷îãî îðãàíó) Ïàñïîðòèñò _____________________ _____________ (ïð³çâèùå, ³í³ö³àëè) (ï³äïèñ) Ì.Ï. Íà÷àëüíèê _____________________ _____________ (Ãîëîâà) (ïð³çâèùå, ³í³ö³àëè) (ï³äïèñ) "___"________________200__ð. Íà÷àëüíèê Óïðàâë³ííÿ ïîë³òèêè àäðåñíî¿ äîïîìîãè ².Ã.Ïîë³ùóê