M u s 44/BB-XMẫ ố
Ban hành kèm theo Thông t s 07/2019/TT-BCAư ố
ngày 20/3/2019
....................(1)
....................(2)
S :ố............/BB-XM
C NG HOÀ XÃ H I CH NGHĨA VI T NAMỘ Ộ Ủ Ệ
Đc l p - T do - H nh phúcộ ậ ự ạ
BIÊN B N Ả
Xác minh tình ti t c a v vi c vi ph m hành chínhế ủ ụ ệ ạ
H iồ...........giờ...........phút,
ngày...........tháng............năm...................................................................................................................................................
T i:ạ....................................................................................................................................................................................................................................................
.
- Chúng tôi g m:ồ
1.................................................................C p b c, ch cấ ậ ứ
v :ụ.................................................................................................................................................
Đnơ
v :ị.............................................................................................................................................................................................................................................
2.................................................................C p b c, ch cấ ậ ứ
v :ụ.................................................................................................................................................
Đnơ
v :ị.............................................................................................................................................................................................................................................
- Có s ch ng ki n c a Ông/Bà (n uự ứ ế ủ ế
có):................................................................................................................................................................
Sinh ngày:............/.........../.................Qu c t ch:ố ị ............................................... Nghề
nghi p:ệ...............................................................................
CMND/CCCD ho c h chi u s :ặ ộ ế ố ...........................Ngày c p:ấ.............................N iơ
c p:ấ................................................................................
N i ĐKTT ho c n i hi nơ ặ ơ ở ệ
t i:ạ.......................................................................................................................................................................................
.................................................................................................................Đi nệ
tho i:ạ........................................................................................................................................
- Ti n hành l p biên b n xác minh đi v i:ế ậ ả ố ớ
Ông(Bà)/T ch c(Tên t ch c, ng i đi di n theo phápổ ứ ổ ứ ườ ạ ệ
lu t)ậ:................................................................................................................
...................................................................................................................................................................................................................................................................................
Sinh ngày:..................../....................../...........................Qu c t ch:ố ị .....................................................................................................................................
Ngh nghi p/Lĩnh v c ho t đng ho c Mã s doanhề ệ ự ạ ộ ặ ố
nghi p:ệ.....................................................................................................................
N i hi n t i/Đa ch trơ ở ệ ạ ị ỉ ụ
s :ở...........................................................................................................................................................................................
CMND ho c CCCD ho c h chi u/GCN đăng ký ho c GP thành l pặ ặ ộ ế ặ ậ
s :ố..........................................................................................
Ngày c p:ấ...........................................................................N iơ
c p:ấ.......................................................................................................................................
Đi nệ
tho i:ạ.....................................................................................................................................................................................................................................
N I DUNG XÁC MINHỘ
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Biên b n l p xong h iả ậ ồ ...........giờ...........phút cùng ngày, đã đc l i cho nh ng ng i có tên nêu trên cùng ngheọ ạ ữ ườ
công nh n đúng và cùng ký tên d i đây./.ậ ướ
NG I ĐC XÁC MINHƯỜ ƯỢ
(Ký, ghi rõ h tên)ọ
NG I CH NG KI NƯỜ Ứ Ế
(Ký, ghi rõ h tên)(n u có)ọ ế
NG I L P BIÊN B NƯỜ Ậ Ả
(Ký, ghi rõ h tên)ọ
(1) Tên c quan ch qu n; (2) ơ ủ ả Tên đn v c a ng i có th m quy n l p biên b nơ ị ủ ườ ẩ ề ậ ả . Chú ý: N i dung biên b n ph i ghi c th gi , ngày, tháng, năm, đa đi m x y ra vi ph m; mô t hành vi viộ ả ả ụ ể ờ ị ể ả ạ ả
ph m. Yêu c u nh ng ng i có m t cùng ký xác nh n vào t ng trang. Tr ng h p ng i khai không ký biên b n thì ng i l p biên b n ph i ghi rõ lý do ạ ầ ữ ườ ặ ậ ừ ườ ợ ườ ả ườ ậ ả ả