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S : ố(2) /TLKT
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
………, ngày….…tháng ……năm ………
TRICH LUC KHAI T Ư
H , ch đm, tênọ ữ ệ : ..........................................................................................................................................................................................
Ngày, tháng, năm sinh: ..................................................................................................................................................................................
Gi i tính: ớ……….…… Dân t c: ộ………..……………… Qu c t ch: ố ị .......................................................................................
S đnh danh cá nhân:ố ị (3)..................................................................................................................................................................................
Gi y t tùy thân: ấ ờ .................................................................................................................................................................................................
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Đã ch t vào lúcế................................giờ.................................phút, ngày............................................................... ghi b ng ằ
ch :ữ
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N i ch t:ơ ế .................................................................................................................................
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Gi y báo t /Gi y t thay th Gi y báo t s ấ ử ấ ờ ế ấ ử ố ......................................................................do..........................................
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........................................................................................................................ c p ngày ấ….........................................................................................
H , ch đm, tên ng i đi khai t :ọ ữ ệ ườ ử .........................................................................................................................................
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1() Ghi tên c quan c p Trích l c khai t (ghi đ các c p hành chính).ơ ấ ụ ử ủ ấ
2() Ghi theo S trong S đăng ký khai t .ố ổ ử
(3) Ch ghi trong tr ng h p đã đc c p S đnh danh cá nhân.ỉ ườ ợ ượ ấ ố ị
