BAN Kt !CHM TAI SAN, THU NI1411 (Ban hanh kern theo Nght clinh 78/2013/ND-CF ngay 17 thing 7 neim 2013

caa Chinh pita)

NAM: 2017

I. THONG TIN CHUNG

1. Nguai ke khai tai san, thu nhap

HQ va ten: NGUYEN TI-IT TUYET MAT Nam sinh: 07/8/1964

ChIrc vu/chic danh ding tac: Tnreing pheng Quanl5r chat lucmg

Ca quan/dcm vi cong tac: Benh vin Da khoa tinh Quang Ninh

HO khau thiremg tra: Ta 78 Khu 5, phuong Bach Dang, TP Ha Long

Chi) 6. hien tai: T6 14 Khu 3, phueng Hang Gai, TP Ha Long

2. V9, hoc chang cüa ngued k'e khai tai san, thu nit: Da ly hon ham 2013

HQ va ten : Nam sinh•

Chfre vg/chirc danh ding tac.

Ca quan/dcm vi cling tac-

HO khau thuemg tru.

Chit)& hi'en tai.

3. Con chut thanh nien (con de, con nuoi theo quy dinh cüa phap luat)

a) Con thir nhat:

H9 va ten: NGUYEN MAT CHI

- Ngay, thang, ham sinh: 16/11/2000

HO khau thueng Ta 78 Khu 5, phuemg Bach Dang, TP Ha Long

Ch ra er hien tai: Ta 14 Khu 3, phuang Hang Gai, TP Ha Long

b) Con thus hai (trees len): Ke khai thu con thu nhat.

H9 va ten.

Ngay, thang, Mm sinh.

- HO khau thueng trir

- Ch b' 6. hien tai.

II. THONG TIN MO TA Vt TAI SAN

1. NM 6, cong trinh xay Ming:

a) Nha

Nha thir nhat: Nha mugn cüa b6 mc a 6

Dia chi: Te 14 Thu 3, phuemg Heng Gai, IT Ha Long

Loai nha: Chung cu 12 tang Cap cong trinh: Chung cu cAp II

Dien tich xay dung: 69,12 m2

Gia tri: Thong xac dinh dugc vi a nhOr

Giay chimg nhan quyen s6 hcru: Mang ten be mc de.

+ Thong tin khac (nu c6):

- Nh'a thir hai (tr6 len): Khong

b) Cong trinh xay dkmg khac: Khong

Cong trinh thir nhat:

Dia chi:

Loai cling trinh Cap c8ng trinh

+ Dien tich:

Gia tn.

Giay chimg nhan quyen s&

Thong tin khac (nen c6):

- Cong trinh thu hai (Tr& len): KO khai tuorng tkr nhu ding trinh thir nhat

2. Quyen sir dung tat:

a) Dat a:

Manh thir nhat: Dat trong thai kSf h8n nhan chin giai quyet

Dia chi: Thira tat se 2, to Ban d sib' 40, tai 0 se 19, KTX can 1 duamg vao Thanh C8ng, phuang Cao xanh, TP Ha Long, Quang Ninh

+ Dien tich: 54,6 m2

Gia tri: 480.480.000 d (Dinh gia cña TAND TP Ha Long)

Giay chang nhan quyen sir dung: AB 145240 do UBND TP Ha Long cap ngay 18/01/2005

Thong tin khac (nu c6): Thong

Manh thir 2: Kh8ng

b) Cac loai dat lchac: Khong

Manh thir nhat:

Dia chi:

+ Dien tich:

+Gjátrj

GiAy chimg than quyan sir dung:

Thong tin khac (nu c6):

Manh thir hai: (MO tã nhu math thir nhAt).

Tian (tin Viet Nam, ngoai te) gam flan mat, tian cho vay, tian gfri ca nhan, tã chat trong nu6c, th chuc nuot ngoai tai Viet Nam ma tong gia tri quy d6i tit 50 tri'eu dang tr6 18n: 01 sa fiat kiem 310 trieu &kg, 01 so Wet lciem 50 trieu tang

O to, mo to, xe gn may, xe may (may id, may the, cac xe may khac), tau thay, tau bay, thuyon va nhang (tong san khk ma Nha nu6c quan ly (theo quy dinh eüa phap luat phai clang lcY stir dung va dugc cap giay clang lcY) c6 tong gia tn m& loai tir 50 trieu dong to( len.

- O to: Thang 5/2015 mua 01 xe oto Mazda 2, tri gia: 574.000.000 d - MO to

Xe gan may - Xe may (may iti, may 'clic, cac loai xe may khac) - Tau thity

Tau bay Thuyen Nhang dOng san khac ma Nha mthe quan 11T (theo quy dinh cüa phap luat

phai clang k)2 sir dung va duge cap giay clang kY/):

5. Kim loai quY, di quY, ca phik, van g6p vao cac co sec, kinh doanh, cac loai giay CO gia tri chuyen nhtrgng lchac co tong gia tri quy deli m& loai tir 50 trieu d'ang tr618n.

Kim loai quy

DA quy

_ C phial'

Van gop vao ck co sä kinh doanh

cac loai giAy t6 CO gia tri chuyan nhugng khac

Cac logi tai san khac ma gia tri quy di m& loai tir 50 trieu clang fro len (nhtc thy ccinh, b0 ban ghe, tranh, anh, dâ mji ngh0 va cac logi tc'zi san khac).

Tai san, tai khoan 6 nu6c ngoai gam tat ca tai san quy dinh tir Khoan 1 clan Khoan 6 noi ten nam ngoai lath tho Vi'et Nam.

8: Ck khoan ng gam: cac khoan phai tra, gia tri cac tai san quanlY hO, gilt hi) ca tOng gia tri quy di tilt 50 trieu dong tr618n.

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9. T6ng thu nhap trong nam quy d6i thanh tin Via Nam gm cac khoan lucmg, ph u cap, trg cap, throng, thit lao, cho, tang, Neu, thira ke, thu nhap huong lgi tir cac khoan Mu tu, phat minh, sang che, cac khoan thu nhap khac: Tinh den thang 11/2017 iling thu nhap la 278.000.000 dang, ngutm gac thu nhap tir teen lucmg, thuemg va cac lchoan thu nhap khac theo quy dinh cüa nganh (dc thü, dOc truc...)

GIAI TRINH S1 BIEN HONG CiJA TAI SAN, THU NHAP (Bien dng v tai san, thu nh , giãi trinh n utm gc tai sin tang them

Loii tai sin, thu nhep Tang/ gum

Nei dung giii trinh ngulin gtic titi san, thu nhep tang them

1. Nha 6., ding trinh xay dung (tang, giam ve s6 lugng, Khong din tich hoac thay (lei ve cap nha, ding trinh so voi ky ke khai trudec d6):

Nha a: Cong trinh xay dung khac:

2. Quyen su dung Mt (tAng, giam ve s6 lugng, dien tich, KhOng thay di loai dAt so vai ky ke khai trok do):

flat er: CS loai dat khac:

3. Tier! (tin Viet Nam, ngoai te) gem tien mat, ten oho vay, tien gun ca nhan, t6 chirc trong nu6c7 to chfrc nu& noai tai Viet Nam ma tong gia tri quy doi tir 50 trieu dong tref len.

Gitlin Hien ad có: 01 sd tilt kiem 2 .i la...,

310 tridu clOng, 01 so tiet gm 50 trieu clang (Nguan goc tit cac so tilt kiem nom 2016 chuyin sang) - Lfi do giam: Chi phi chfra benh cho be, de (02 dot didu tri)

4. CS loai deng san: Khong

- 6 to - MO t6 - Xe gan may - Xe may (may Ai, may xec, cac loai xe may lchac) - Tau thtly - Tau bay - Thuyen - Nhfmg dong san lchac ma Nha nu& quan lY (thee quy dinh cila phap luat phai ding lcY sa dung va dugc cap giay dang ky)

5. CS loai tai san: Khong

—

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Khong

Khong

Khong

278 trieu clang (11 thang)

Ngudn gdc thu nhap tie twang, thtrang va ccic khoetn thu nhap khcic theo quy dinh cita nganh ((Ilk thit, dac had, true...)

- Kim loai quy

- Da quY

C6 phieu

Vein g6p vao the ca s& kinh doanh

- Cac loai gidy tä cO gia tri chuyen nhtrgng khac co t6ng

gia tri quy den mOi logi tir 50 trieu clang tra

Cac loai tai sari kit& (nhu cay canh, ba ban ga,

tranh, anh, ad my nghe va cac loqi tai san khcic) ma gid

tri quy aM nied loai tit 50 trieu Sing tit len.

Tai san, tai khoan a nu& ngoai gm tAt ea tai san quy

dinh tit Khoan 1 d'en Khoan 6 noi teen nam ngoai lath

th6 Viet Nam.

Caz khoan ng gOm: cac khoan phai tra, gia tri cac Mi

san quart ly hO, gilt h0 co tong gia tri quy dt)i ta 50 trieu

diing to. len.

Tang thu nhap trong nam quy den thanh tin Via Nam

(Ngieffi ke khai tu xtic dinh cac loci tea san tang, giam trong 19)ke khai va giai trinh ngudn

gdc tai san tang them). Ngay nhan Ban ke khai tai san, thu nhap

Ha Long, ngay...01...thang. .102 Warn 2017 Nguiri nh4n Ban ké khai

(4, ghi ro ho ten, chav 11y/chi/iv danh)

Ng:cry hoan thanh Ban ke khai tat san, thu nhap Ha Long, ngay 20 thang 11 nam 2017

Ngweri ke khai tai san (K,35, ghi rô ha ten)

Nguygn Thi Tuyet Mai

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