̲ͲÑÒÅÐÑÒÂÎ ÏÐÀÖ² ÒÀ ÑÎÖ²ÀËÜÍί ÏÎ˲ÒÈÊÈ ÓÊÐÀ¯ÍÈ
 
                            Í À Ê À Ç
 
                        22.07.2003  N 205
 
                                      Çàðåºñòðîâàíî â ̳í³ñòåðñòâ³
                                      þñòèö³¿ Óêðà¿íè
                                      13 ñåðïíÿ 2003 ð.
                                      çà N 711/8032
 
 
           Ïðî çàòâåðäæåííÿ ôîðìè Çàÿâè ïðî ïðèçíà÷åííÿ
                  óñ³õ âèä³â ñîö³àëüíî¿ äîïîìîãè
 
 
     ³äïîâ³äíî äî âèìîã ïîñòàíîâè Êàá³íåòó ̳í³ñòð³â Óêðà¿íè  â³ä
17 ñåðïíÿ  2002  ð.  N  1146  (  1146-2002-ï  ) "Ïðî âäîñêîíàëåííÿ
ìåõàí³çìó íàäàííÿ ñîö³àëüíî¿ äîïîìîãè" Í À Ê À Ç Ó Þ:
 
     1. Çàòâåðäèòè  ôîðìó  Çàÿâè  ïðî   ïðèçíà÷åííÿ   óñ³õ   âèä³â
ñîö³àëüíî¿ äîïîìîãè (äîäàºòüñÿ)
 
     2. Óïðàâë³ííþ  ïîë³òèêè  àäðåñíî¿  äîïîìîãè çàðåºñòðóâàòè öåé
íàêàç ó ̳í³ñòåðñòâ³ þñòèö³¿ Óêðà¿íè.
 
     3. Ââàæàòè òàêèì,  ùî âòðàòèâ  ÷èíí³ñòü,  íàêàç  Ì³í³ñòåðñòâà
ïðàö³ òà  ñîö³àëüíî¿  ïîë³òèêè  â³ä  27.09.2002 N 499 ( z0873-02 )
"Ïðî  çàòâåðäæåííÿ  ôîðìè  çàÿâè  ïðî   ïðèçíà÷åííÿ   óñ³õ   âèä³â
ñîö³àëüíî¿   äîïîìîãè",   çàðåºñòðîâàíèé  ó  ̳í³ñòåðñòâ³  þñòèö³¿
06.11.2002 çà N 873/7161.
 
     4. Ñêàñóâàòè íàêàç ̳í³ñòåðñòâà ïðàö³ òà ñîö³àëüíî¿  ïîë³òèêè
â³ä 13.09.2000  N  237  "Ïðî  çàòâåðäæåííÿ  çàÿâè  äëÿ ïðèçíà÷åííÿ
äåðæàâíî¿ ñîö³àëüíî¿ äîïîìîãè ìàëîçàáåçïå÷åíèì ñ³ì'ÿì  òà  äîâ³äêè
ïðî ñêëàä ñ³ì'¿".
 
     5. 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 205
 
 
     Çàïîâíþºòüñÿ: çàÿâíèêîì  (óïîâíîâàæåíèì  ïðåäñòàâíèêîì ñ³ì'¿)
âëàñíèêîì, ñï³ââëàñíèêîì (íàéìà÷åì) æèòëà
 
     Äî îðãàíó ïðàö³ òà ñîö³àëüíîãî çàõèñòó
     íàñåëåííÿ ___________________________________________________
     â³ä ________________________________________________________,
 
     ïðîæèâàþ (çàðåºñòðîâàíèé) çà àäðåñîþ: _______________________
_____________________________, êîíòàêòíèé òåëåôîí ________________
 
     Êîðèñòóþñü ï³ëüãàìè ç îïëàòè æèòëîâî-êîìóíàëüíèõ ïîñëóã
                                            ----------------------
(êàòåãîð³ÿ) ______________________________  |³äñîòîê: ________ %|
                                            ----------------------
 
ïàñïîðò: ñåð³ÿ __________ N__________, âèäàíèé ___________________
 
______________________________________ "____"_____________ 200_ ð.
 
³äåíòèô³êàö³éíèé N ___________________          ------------------
                                                |N ______________|
                                                ------------------
 
 
                              ÇÀßÂÀ
          ïðî ïðèçíà÷åííÿ óñ³õ âèä³â ñîö³àëüíî¿ äîïîìîãè
 
 
-----------------------------------------------------------------
|  Ïðîøó ïðèçíà÷èòè (ïåðåðàõóâàòè) |  Ïðèçíà÷èòè   |Ïåðåðàõóâàòè|
|                                  |---------------|            |
|                                  |ïîâòîðíî|óïåðøå|            |
|---------------------------------------------------------------|
|Äåðæàâíó äîïîìîãó ñ³ì'ÿì ç ä³òüìè, à ñàìå:                     |
|---------------------------------------------------------------|
|äîïîìîãó ó çâ'ÿçêó ç âàã³òí³ñòþ òà|        |      |            |
|ïîëîãàìè                          |        |      |            |
|----------------------------------+--------+------+------------|
|îäíîðàçîâó äîïîìîãó ïðè íàðîäæåíí³|        |      |            |
|äèòèíè                            |        |      |            |
|----------------------------------+--------+------+------------|
|äîïîìîãó ïî äîãëÿäó çà äèòèíîþ äî |        |      |            |
|äîñÿãíåííÿ íåþ òðèð³÷íîãî â³êó    |        |      |            |
|----------------------------------+--------+------+------------|
|äîïîìîãó íà ä³òåé, ÿê³ ïåðåáóâàþòü|        |      |            |
|ï³ä îï³êîþ ÷è ï³êëóâàííÿì         |        |      |            |
|----------------------------------+--------+------+------------|
|äîïîìîãó íà ä³òåé îäèíîêèì ìàòåðÿì|        |      |            |
|---------------------------------------------------------------|
|Äåðæàâíó ñîö³àëüíó äîïîìîãó ³íâàë³äàì ç äèòèíñòâà òà           |
|ä³òÿì-³íâàë³äàì, à ñàìå:                                       |
|---------------------------------------------------------------|
|äîïîìîãó ³íâàë³äàì ç äèòèíñòâà    |        |      |            |
|I ãðóïè                           |        |      |            |
|----------------------------------+--------+------+------------|
|äîïîìîãó ³íâàë³äàì ç äèòèíñòâà    |        |      |            |
|II ãðóïè                          |        |      |            |
|----------------------------------+--------+------+------------|
|äîïîìîãó íåïðàöþþ÷èì ³íâàë³äàì    |        |      |            |
|ç äèòèíñòâà III ãðóïè             |        |      |            |
|----------------------------------+--------+------+------------|
|äîïîìîãó íà ä³òåé-³íâàë³ä³â â³êîì |        |      |            |
|äî 16 ðîê³â                       |        |      |            |
|----------------------------------+--------+------+------------|
|íàäáàâêó íà äîãëÿä çà ³íâàë³äîì   |        |      |            |
|ç äèòèíñòâà I ãðóïè               |        |      |            |
|----------------------------------+--------+------+------------|
|íàäáàâêó íà äîãëÿä çà             |        |      |            |
|äèòèíîþ-³íâàë³äîì â³êîì äî 6 ðîê³â|        |      |            |
|----------------------------------+--------+------+------------|
|íàäáàâêó íà äîãëÿä çà             |        |      |            |
|äèòèíîþ-³íâàë³äîì â³êîì           |        |      |            |
|äî 16 ðîê³â                       |        |      |            |
|----------------------------------+--------+------+------------|
|Äîïîìîãó íà äîãëÿä (ùîì³ñÿ÷íó     |        |      |            |
|ãðîøîâó äîïîìîãó ìàëîçàáåçïå÷åí³é |        |      |            |
|îñîá³, ÿêà ïðîæèâຠðàçîì ç       |        |      |            |
|³íâàë³äîì I ÷è II ãðóïè âíàñë³äîê |        |      |            |
|ïñèõ³÷íîãî ðîçëàäó, ÿêèé çà       |        |      |            |
|âèñíîâêîì ë³êàðñüêî¿ êîì³ñ³¿      |        |      |            |
|ìåäè÷íîãî çàêëàäó ïîòðåáóº        |        |      |            |
|ïîñò³éíîãî ñòîðîííüîãî äîãëÿäó,   |        |      |            |
|íà äîãëÿä çà íèì)                 |        |      |            |
|----------------------------------+--------+------+------------|
|Äåðæàâíó ñîö³àëüíó äîïîìîãó       |        |      |            |
|ìàëîçàáåçïå÷åíèì ñ³ì'ÿì           |        |      |            |
|----------------------------------+--------+------+------------|
|Ñóáñèä³þ äëÿ â³äøêîäóâàííÿ âèòðàò |        |      |            |
|íà îïëàòó æèòëîâî-êîìóíàëüíèõ     |        |      |            |
|ïîñëóã                            |        |      |            |
|----------------------------------+--------+------+------------|
|Ñóáñèä³þ íà ïðèäáàííÿ ñêðàïëåíîãî |        |      |            |
|ãàçó, òâåðäîãî òà ð³äêîãî ï³÷íîãî |        |      |            |
|ïîáóòîâîãî ïàëèâà òà îïëàòó       |        |      |            |
|æèòëîâî-êîìóíàëüíèõ ïîñëóã        |        |      |            |
|----------------------------------+--------+------+------------|
|Äîïîìîãó íà ïîõîâàííÿ             |        |      |            |
|----------------------------------+--------+------+------------|
|----------------------------------+--------+------+------------|
|----------------------------------+--------+------+------------|
|---------------------------------------------------------------|
|I Äîêóìåíòè, ùî äîäàþòüñÿ äî çàÿâè                             |
|---------------------------------------------------------------|
|                 Íàçâà äîêóìåíòà                  | ʳëüê³ñòü  |
|                                                  |  àðêóø³â   |
|--------------------------------------------------+------------|
|Äîâ³äêà ïðî ñêëàä ñ³ì'¿                           |            |
|--------------------------------------------------+------------|
|Äîâ³äêè ïðî õàðàêòåðèñòèêó æèòëà òà ðîçì³ð ïëàòè  |            |
|çà æèòëîâî-êîìóíàëüí³ ïîñëóãè                     |            |
|--------------------------------------------------+------------|
|Äåêëàðàö³ÿ ïðî äîõîäè òà ìàéíîâèé ñòàí            |            |
|--------------------------------------------------+------------|
|Äîâ³äêè ïðî äîõîäè êîæíîãî ÷ëåíà ñ³ì'¿            |            |
|--------------------------------------------------+------------|
|Âèñíîâîê ë³êàðñüêî¿ êîì³ñ³¿ ìåäè÷íîãî çàêëàäó     |            |
|ùîäî íåîáõ³äíîñò³ ïîñò³éíîãî ñòîðîííüîãî          |            |
|äîãëÿäó çà ³íâàë³äîì I ÷è II ãðóïè âíàñë³äîê      |            |
|ïñèõ³÷íîãî ðîçëàäó                                |            |
|--------------------------------------------------+------------|
|Äîâ³äêà ç ì³ñöÿ íàâ÷àííÿ (ñëóæáè)                 |            |
|--------------------------------------------------+------------|
|Äîâ³äêè ïðî íàÿâí³ñòü òà ðîçì³ð çåìåëüíèõ ä³ëÿíîê,|            |
|ÿê³ âèä³ëåíî äëÿ âåäåííÿ îñîáèñòîãî ï³äñîáíîãî    |            |
|ãîñïîäàðñòâà, ãîðîäíèöòâà, ñ³íîêîñ³ííÿ,           |            |
|âèïàñàííÿ õóäîáè, òà çåìåëüíî¿ ÷àñòêè (ïàþ),      |            |
|âèä³ëåíî¿ âíàñë³äîê ðîçïàþâàííÿ çåìë³             |            |
|--------------------------------------------------+------------|
|Äîâ³äêà îðãàí³â ïîäàòêîâî¿ àäì³í³ñòðàö³¿          |            |
|--------------------------------------------------+------------|
|Äîâ³äêà ë³êâ³äàö³éíî¿ êîì³ñ³¿ äëÿ îñ³á,           |            |
|çâ³ëüíåíèõ ç ðîáîòè ó çâ'ÿçêó ç ë³êâ³äàö³ºþ       |            |
|ï³äïðèºìñòâà, óñòàíîâè, îðãàí³çàö³¿               |            |
|--------------------------------------------------+------------|
|Äîâ³äêà äåðæàâíî¿ ñëóæáè çàéíÿòîñò³ äëÿ îñ³á,     |            |
|çàðåºñòðîâàíèõ ó äåðæàâí³é ñëóæá³ çàéíÿòîñò³      |            |
|ÿê áåçðîá³òí³                                     |            |
|--------------------------------------------------+------------|
|Êîï³ÿ ñâ³äîöòâà ïðî íàðîäæåííÿ äèòèíè             |            |
|--------------------------------------------------+------------|
|Êîï³ÿ òðóäîâî¿ êíèæêè                             |            |
|--------------------------------------------------+------------|
|Êîï³ÿ ð³øåííÿ ïðî óñèíîâëåííÿ àáî âñòàíîâëåííÿ    |            |
|îï³êè                                             |            |
|--------------------------------------------------+------------|
|Äîâ³äêà äåðæàâíîãî îðãàíó ðåºñòðàö³¿ àêò³â        |            |
|öèâ³ëüíîãî ñòàíó ïðî ï³äñòàâè âíåñåííÿ äî êíèãè   |            |
|çàïèñ³â íàðîäæåííÿ â³äîìîñòåé ïðî áàòüêà äèòèíè   |            |
|--------------------------------------------------+------------|
|Âèòÿã ç àêòà îãëÿäó ìåäèêî-ñîö³àëüíî¿ åêñïåðòíî¿  |            |
|êîì³ñ³¿ ³ç çàçíà÷åííÿì ãðóïè ³íâàë³äíîñò³ (äëÿ    |            |
|³íâàë³ä³â ç äèòèíñòâà)                            |            |
|--------------------------------------------------+------------|
|Äîâ³äêà ë³êàðñüêî-êîíñóëüòàòèâíî¿ êîì³ñ³¿ äèòÿ÷èõ |            |
|ë³êóâàëüíî-ïðîô³ëàêòè÷íèõ çàêëàä³â (äëÿ ä³òåé     |            |
|³íâàë³ä³â)                                        |            |
|--------------------------------------------------+------------|
|²íø³ äîêóìåíòè, ÿê³ ïåðåäáà÷åí³ â³äïîâ³äíèìè      |            |
|íîðìàòèâíî-ïðàâîâèìè òà çàêîíîäàâ÷èìè àêòàìè      |            |
|--------------------------------------------------+------------|
|ÓÑÜÎÃÎ                                            |            |
-----------------------------------------------------------------
 
     Ïðîøó â    ðàç³    ïðèçíà÷åííÿ    äîïîìîãè   êîøòè   ãîò³âêîþ
ïåðåðàõîâóâàòè
---
| | ÷åðåç äåðæàâíå ï³äïðèºìñòâî çâ'ÿçêó N ________________________
---
---
| | íà îñîáîâèé ðàõóíîê N ________ ÌÔÎ ___________ êîä ___________
---
áàíê _____________________________________________________________
 
     ϳäòâåðäæóþ â³äñóòí³ñòü    çàáîðãîâàíîñò³   ç   ïëàòåæ³â   çà
æèòëîâî-êîìóíàëüí³ ïîñëóãè,   çì³í   ó   ñêëàä³   ñ³ì'¿    òà    â
õàðàêòåðèñòèö³ æèòëà (ïðè ïîâòîðíîìó çâåðíåíí³).
     ß òà ÷ëåíè ì ñ³ì'¿ äàºìî  çãîäó  íà  çá³ð  ³íôîðìàö³¿  ïðî
ñ³ì'þ, äîõîäè, âëàñí³ñòü òà ìàéíî, ùî íåîáõ³äíà äëÿ îòðèìàííÿ âñ³õ
âèä³â ñîö³àëüíî¿ äîïîìîãè, çàçíà÷åíèõ ìíîþ ó çàÿâ³.
     ß óñâ³äîìëþþ, ùî íàâåäåí³ ìíîþ â³äîìîñò³ ïðî äîõîäè òà ìàéíî,
ùî âïëèíóëè àáî ìîãëè âïëèíóòè íà âñòàíîâëåííÿ ïðàâà íà  ñîö³àëüíó
äîïîìîãó  òà íà âèçíà÷åííÿ ¿¿ ðîçì³ðó,  áóäóòü ïåðåâ³ðåí³ çã³äíî ç
÷èííèì çàêîíîäàâñòâîì Óêðà¿íè.
     Ïðî â³äìîâó  â ïðèçíà÷åíí³ àáî ïðèïèíåííÿ âèïëàòè ïðèçíà÷åíî¿
ñîö³àëüíî¿ äîïîìîãè (ïîâåðíåííÿ íàäì³ðó íàðàõîâàíèõ êîøò³â) ó ðàç³
ïîäàííÿ   íåïîâíèõ  ÷è  íåäîñòîâ³ðíèõ  â³äîìîñòåé  ïðî  äîõîäè  òà
ìàéíîâèé ñòàí ñ³ì'¿ ìåíå ïîïåðåäæåíî.
     Ó äàíèé  ÷àñ  ÿ íå ïðàöþþ,  íå íàâ÷àþñü,  íå ñëóæó (íåîáõ³äíå
ï³äêðåñëèòè).
     Ó çâ'ÿçêó ç öèì ìåíå ïîâ³äîìëåíî,  ùî â ðàç³ ïðàöåâëàøòóâàííÿ
âïðîäîâæ  òåðì³íó  ïðèçíà÷åííÿ  äîïîìîãè  â³äïîâ³äíî  äî   Çàêîí³â
Óêðà¿íè  "Ïðî  äåðæàâíó äîïîìîãó ñ³ì'ÿì ç ä³òüìè" òà "Ïðî äåðæàâíó
ñîö³àëüíó äîïîìîãó ³íâàë³äàì ç äèòèíñòâà  òà  ä³òÿì  ³íâàë³äàì"  ÿ
çîáîâ'ÿçóþñü   ïîâ³äîìèòè  îðãàíè  ïðàö³  òà  ñîö³àëüíîãî  çàõèñòó
íàñåëåííÿ.
 
        Äîäàòêîâà ³íôîðìàö³ÿ, ÿêà ïîâ³äîìëÿºòüñÿ îäèíîêîþ
                 ìàò³ð'þ (ï³äêðåñëèòè íåîáõ³äíå)
 
 
---------------------------------------------------------------
|1. Ó øëþá³                |Ïåðåáóâàëà|      Íå     |Ïåðåáóâàþ|
|                          |          |ïåðåáóâàëà(þ)|         |
|--------------------------+----------+-------------+---------|
|2. Ç îñîáîþ, â³ä ÿêî¿ ìàþ | Ïðîæèâàþ | Íå ïðîæèâàþ |         |
|äèòèíó                    |          |             |         |
|--------------------------+----------+-------------+---------|
|3. Ïåíñ³þ â ðàç³ âòðàòè   | Îòðèìóþ  | Íå îòðèìóþ  |         |
|ãîäóâàëüíèêà àáî ñîö³àëüíó|          |             |         |
|ïåíñ³þ (çàïîâíþþòü ëèøå   |          |             |         |
|âäîâè, âä³âö³)            |          |             |         |
---------------------------------------------------------------
 
     Ó ðàç³  çì³í  ó  ñêëàä³  ñ³ì'¿ (óêëàäåííÿ øëþáó,  óñèíîâëåííÿ
äèòèíè òîùî) ó ïåð³îä ïðèçíà÷åííÿ  òà  âèïëàòè  äîïîìîãè,  ó  òîìó
÷èñë³   â³äïîâ³äíî  äî  Çàêîíó  Óêðà¿íè  "Ïðî  äåðæàâíó  ñîö³àëüíó
äîïîìîãó ³íâàë³äàì ç äèòèíñòâà òà ä³òÿì ³íâàë³äàì", ÿ çîáîâ'ÿçóþñü
ïîâ³äîìèòè îðãàíè ïðàö³ òà ñîö³àëüíîãî çàõèñòó íàñåëåííÿ
_________________________________________________________   ______
   (ï³äïèñ çàÿâíèêà, óïîâíîâàæåíîãî ïðåäñòàâíèêà ñ³ì'¿      (äàòà)
         (âëàñíèêà, ñï³ââëàñíèêà (íàéìà÷à) æèòëà)
 
     II. Êîìóíàëüí³ ïîñëóãè,  ÿêèìè êîðèñòóºòüñÿ ñ³ì'ÿ  (äàí³  ïðî
ôàêòè÷íå âèêîðèñòàííÿ æèòëîâî-êîìóíàëüíèõ ïîñëóã *)
 
 
-----------------------------------------------------------------------------------------------
| N îñîáîâîãî   |Ãàçîïîñòà÷àííÿ|   Õîëîäíå    |   Ãàðÿ÷å     |Îïàëåííÿ|Åëåêòðîåíåðã³ÿ|Ïðèì³òêè|
|   ðàõóíêó     |              |âîäîïîñòà÷àííÿ|âîäîïîñòà÷àííÿ|        |              |        |
|               |--------------+--------------+--------------+--------+--------------+--------|
|               |N_____________|N_____________|N_____________|N_______|N_____________|        |
|---------------+--------------+--------------+--------------+--------+--------------+--------|
|Íàçâà òà àäðåñà|              |              |              |        |              |        |
|æèòëîâî-       |              |              |              |        |              |        |
|åêñïëóàòàö³éíî¿|              |              |              |        |              |        |
|îðãàí³çàö³¿    |              |              |              |        |              |        |
|---------------+--------------+--------------+--------------+--------+--------------+--------|
|ñ³÷åíü         |              |              |              |        |              |        |
|---------------+--------------+--------------+--------------+--------+--------------+--------|
|ëþòèé          |              |              |              |        |              |        |
|---------------+--------------+--------------+--------------+--------+--------------+--------|
|áåðåçåíü       |              |              |              |        |              |        |
|---------------+--------------+--------------+--------------+--------+--------------+--------|
|êâ³òåíü        |              |              |              |        |              |        |
|---------------+--------------+--------------+--------------+--------+--------------+--------|
|òðàâåíü        |              |              |              |        |              |        |
|---------------+--------------+--------------+--------------+--------+--------------+--------|
|÷åðâåíü        |              |              |              |        |              |        |
|---------------+--------------+--------------+--------------+--------+--------------+--------|
|ëèïåíü         |              |              |              |        |              |        |
|---------------+--------------+--------------+--------------+--------+--------------+--------|
|ñåðïåíü        |              |              |              |        |              |        |
|---------------+--------------+--------------+--------------+--------+--------------+--------|
|âåðåñåíü       |              |              |              |        |              |        |
|---------------+--------------+--------------+--------------+--------+--------------+--------|
|æîâòåíü        |              |              |              |        |              |        |
|---------------+--------------+--------------+--------------+--------+--------------+--------|
|ëèñòîïàä       |              |              |              |        |              |        |
|---------------+--------------+--------------+--------------+--------+--------------+--------|
|ãðóäåíü        |              |              |              |        |              |        |
|---------------+--------------+--------------+--------------+--------+--------------+--------|
|---------------+--------------+--------------+--------------+--------+--------------+--------|
|---------------------------------------------+-----------------------------------------------|
|Ïëèòà: ãàçîâà                                |       |Íàÿâí³ñòü çàáîðãîâàíîñò³ ç ïëàòåæ³â çà |
|                                             |       |æèòëîâî-êîìóíàëüí³ ïîñëóãè             |
|---------------------------------------------+-------+---------------------------------------|
|åëåêòðè÷íà                                   |       |Ìàþ çàáîðãîâàí³ñòü ó ñóì³ ________ ãðí.|
|---------------------------------------------+-------|                                       |
|êîëîíêà                                      |       |Óãîäó ïðî ïîãàøåííÿ çàáîðãîâàíîñò³     |
|---------------------------------------------+-------|N _____________ â³ä ___________________|
|Âèâåçåííÿ ïîáóòîâîãî ñì³òòÿ òà ð³äêèõ        |       |óêëàäåíî äî _______________ òåðì³íîì íà|
|íå÷èñòîò                                     |       |____________ ì³ñÿö³â                   |
|---------------------------------------------+-------|ç _____________________________________|
|Ñêðàïëåíèé ãàç                               |       |_______________________________________|
|---------------------------------------------+-------|_______________________________________|
|гäêå ï³÷íå ïîáóòîâå ïàëèâî                  |       |_______________________________________|
|---------------------------------------------+-------|          (íàçâà â³äïîâ³äíèõ           |
|Òâåðäå ï³÷íå ïîáóòîâå ïàëèâî                 |       |  æèòëîâî-åêñïëóàòàö³éíèõ îðãàí³çàö³é) |
|---------------------------------------------+-------|                                       |
|Ïðèðîäíèé ãàç (åëåêòðîåíåðã³ÿ) äëÿ îïàëåííÿ  |       |                                       |
|-----------------------------------------------------|                                       |
|* Çàçíà÷àºòüñÿ ó ðàç³ íàÿâíîñò³ çàñîá³â îáë³êó íà    |_______________________________________|
|ï³äñòàâ³ ïðåä'ÿâëåíèõ ðîçðàõóíêîâèõ êíèæîê,          |       (ï³äïèñ çàÿâíèêà, âëàñíèêà,     |
|êâèòàíö³é àáî àíàëîã³÷íèõ äîêóìåíò³â ïðî ôàêòè÷íó    |      ñï³ââëàñíèêà (íàéìà÷à) æèòëà)    |
|îïëàòó æèòëîâî-êîìóíàëüíèõ ïîñëóã çà ïîïåðåäí³é      |                                       |
|ïåð³îä.                                              |                                       |
-----------------------------------------------------------------------------------------------
 
------------------------------------------------------------------
 
     Çàïîâíþºòüñÿ â³äïîâ³äàëüíîþ   îñîáîþ   óïðàâë³ííÿ   ïðàö³  òà
ñîö³àëüíîãî çàõèñòó íàñåëåííÿ
     ³äîìîñò³ ç ïàñïîðòà òà ïîäàíèõ äîêóìåíò³â çâ³ðåí³.
 
     Çàÿâó òà äîêóìåíòè íà ______________________ àðêóøàõ ïðèéíÿòî
"____"____________ 200_ ð. òà çàðåºñòðîâàíî ï³ä N _______.
 
     Äëÿ ðîçãëÿäó      çàÿâè       íåîáõ³äíî       äîäàòè       äî
"____"____________ 200_ ð. òàê³ äîêóìåíòè:
__________________________________________________________________
 
_____________________"Îçíàéîìèâñÿ"________________________________
 (ïð³çâèùå òà ï³äïèñ              (ï³äïèñ çàÿâíèêà, óïîâíîâàæåíîãî
â³äïîâ³äàëüíî¿ îñîáè)               ïðåäñòàâíèêà ñ³ì'¿/âëàñíèêà,
                                    ñï³ââëàñíèêà/íàéìà÷à/æèòëà,
                                             êîîïåðàòèâó)
 
__________________________________________________________________
 
 
     Çàïîâíþºòüñÿ â³äïîâ³äàëüíîþ  îñîáîþ   óïðàâë³ííÿ   ïðàö³   òà
ñîö³àëüíîãî çàõèñòó íàñåëåííÿ
 
 
-------------------------------------------------------------
| III. Ïîòðåáóº ð³øåííÿ ì³ñöåâèõ îðãàí³â âèêîíàâ÷î¿ âëàäè/  |
|   ì³ñöåâîãî ñàìîâðÿäóâàííÿ àáî óòâîðåíî¿ íèìè êîì³ñ³¿     |
|-----------------------------------------------------------|
|              ϳäñòàâà äëÿ ðîçãëÿäó               |Ïðèì³òêà|
|--------------------------------------------------+--------|
|Ïðèçíà÷åííÿ ñóáñè䳿 íåçàëåæíî â³ä çàãàëüíî¿ ïëîù³|        |
|æèòëà                                             |        |
|--------------------------------------------------+--------|
|ßêùî ïðàöåçäàòí³ ãðîìàäÿíè ïðàöåçäàòíîãî â³êó íå  |        |
|ïðàöþâàëè, íå ñëóæèëè, íå íàâ÷àëèñÿ ïðîòÿãîì òðüîõ|        |
|ì³ñÿö³â, ùî ïåðåäóþòü ì³ñÿöþ çâåðíåííÿ            |        |
|--------------------------------------------------+--------|
|Ïðèçíà÷åííÿ ñóáñè䳿 îñîá³, ÿêà íå º âëàñíèêîì    |        |
|(íàéìà÷åì) æèòëà                                  |        |
|--------------------------------------------------+--------|
|Ïîâòîðíå çâåðíåííÿ çà ïðèçíà÷åííÿì ñóáñè䳿,      |        |
|äåðæàâíî¿ ñîö³àëüíî¿ äîïîìîãè ïðè â³äñóòíîñò³     |        |
|äîõîä³â, çà íàÿâíîñò³ äîõîä³â ìåíøå í³æ ì³í³ìàëüíà|        |
|çàðîá³òíà ïëàòà (äëÿ ñîö³àëüíî¿ äîïîìîãè) òà çà   |        |
|íàÿâíîñò³ äîõîä³â ìåíøå í³æ íåîïîäàòêîâàíèé       |        |
|ì³í³ìóì äîõîäó ãðîìàäÿí (äëÿ ñóáñèä³é)            |        |
|--------------------------------------------------+--------|
|Ïîäîâæåííÿ òåðì³íó ïîãàøåííÿ çàáîðãîâàíîñò³ ç     |        |
|ïëàòåæ³â çà æèòëîâî-êîìóíàëüí³ ïîñëóãè            |        |
|--------------------------------------------------+--------|
|Ó ðàç³ íàÿâíîñò³ óìîâ, çàçíà÷åíèõ ó ïóíêò³ 5      |        |
|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 ð.  |        |
|N 848 (ó ðåäàêö³¿ ïîñòàíîâè Êàá³íåòó ̳í³ñòð³â    |        |
|Óêðà¿íè â³ä 22 âåðåñíÿ 1997 ð. N 1050, äàë³ -     |        |
|Ïîëîæåííÿ)                                        |        |
|--------------------------------------------------+--------|
|Ó ðàç³ íàÿâíîñò³ óìîâ, çàçíà÷åíèõ ó ïóíêò³ 10     |        |
|Ïîðÿäêó ïðèçíà÷åííÿ òà âèïëàòè äåðæàâíî¿          |        |
|ñîö³àëüíî¿ äîïîìîãè ìàëîçàáåçïå÷åíèì ñ³ì'ÿì,      |        |
|çàòâåðäæåíîãî ïîñòàíîâîþ Êàá³íåòó ̳í³ñòð³â       |        |
|Óêðà¿íè â³ä 24 ëþòîãî 2003 ð. N 250               |        |
|--------------------------------------------------+--------|
|--------------------------------------------------+--------|
-------------------------------------------------------------
 
 
--------------------------------------------------------
|               IV. Ïîòðåáóº îáñòåæåííÿ                |
|         (ìàòåð³àëüíî-ïîáóòîâèõ óìîâ) ñ³ì'¿           |
|------------------------------------------------------|
|            ϳäñòàâè           |гøåííÿ ïðî|   Äàòà   |
|                               | ïðîâåäåííÿ|ïðîâåäåííÿ|
|-------------------------------+-----------+----------|
|Ó ðàç³ íàÿâíîñò³ óìîâ,         |           |          |
|çàçíà÷åíèõ ó ïóíêòàõ 4, 10, 11 |           |          |
|Ïîðÿäêó ïðèçíà÷åííÿ òà âèïëàòè |           |          |
|äåðæàâíî¿ ñîö³àëüíî¿ äîïîìîãè  |           |          |
|ìàëîçàáåçïå÷åíèì ñ³ì'ÿì        |           |          |
|-------------------------------+-----------+----------|
|Äëÿ ï³äòâåðäæåííÿ ôàêòó äîãëÿäó|           |          |
|çà ³íâàë³äîì I àáî II ãðóïè    |           |          |
|âíàñë³äîê ïñèõ³÷íîãî ðîçëàäó   |           |          |
|-------------------------------+-----------+----------|
|Äëÿ ïðèçíà÷åííÿ ñóáñèä³é ó     |           |          |
|âèïàäêàõ, ïåðåäáà÷åíèõ         |           |          |
|Ïîëîæåííÿì                     |           |          |
|-------------------------------+-----------+----------|
|-------------------------------+-----------+----------|
|-------------------------------+-----------+----------|
--------------------------------------------------------
 
_____________________"Îçíàéîìèâñÿ"________________________________
 (ïð³çâèùå òà ï³äïèñ              (ï³äïèñ çàÿâíèêà, óïîâíîâàæåíîãî
â³äïîâ³äàëüíî¿ îñîáè)               ïðåäñòàâíèêà ñ³ì'¿/âëàñíèêà,
                                    ñï³ââëàñíèêà/íàéìà÷à/æèòëà,
                                             êîîïåðàòèâó)
 
 Íà÷àëüíèê Óïðàâë³ííÿ
 ïîë³òèêè àäðåñíî¿ äîïîìîãè                            ².Ã.Ïîë³ùóê
 
------------------------------------------------------------------
 
     Çàïîâíþºòüñÿ â³äïîâ³äàëüíîþ   îñîáîþ   óïðàâë³ííÿ   ïðàö³  òà
ñîö³àëüíîãî çàõèñòó íàñåëåííÿ
     ³äîìîñò³ ç ïàñïîðòà òà ïîäàíèõ äîêóìåíò³â çâ³ðåí³.
 
     Çàÿâó òà äîêóìåíòè íà ______________________ àðêóøàõ ïðèéíÿòî
"____"____________ 200_ ð. òà çàðåºñòðîâàíî ï³ä N _______.
 
     Äëÿ ðîçãëÿäó      çàÿâè       íåîáõ³äíî       äîäàòè       äî
"____"____________ 200_ ð. òàê³ äîêóìåíòè:
__________________________________________________________________
 
_____________________"Îçíàéîìèâñÿ"________________________________
 (ïð³çâèùå òà ï³äïèñ              (ï³äïèñ çàÿâíèêà, óïîâíîâàæåíîãî
â³äïîâ³äàëüíî¿ îñîáè)               ïðåäñòàâíèêà ñ³ì'¿/âëàñíèêà,
                                    ñï³ââëàñíèêà/íàéìà÷à/æèòëà,
                                             êîîïåðàòèâó)