Nr.............................../....................................Decl. 5.

DECLARATIE,

Subsenmatul (a) ______________________________________, posesor al ____, seria _____, nr. __________, eliberat (a) la data de __________, de politia _________, domiciliat (a) in localitatea ________________________, str. _______________________, bl. ____, sc. ____, ap. ___, judetul ___________, cunoscand prevederile art. 292 cod penal, privind declaratii false, declar pe propria raspundere ca membrii familiei monoparentaleNume............................................................../CNP....................................................Nume............................................................../CNP....................................................Nume............................................................../CNP....................................................Nume............................................................../CNP....................................................al carui unic intretinator sunt, locuiesc impreuna cu subsemnatul.

DATA, SEMNATURA,

F85.5,Ed.1,Rev.1