Заявление о выдаче дубликата страхового свидетельства (Форма АДВ-3)

Заявление о выдаче дубликата страхового свидетельства:

Заполняется застрахованным лицом печатными буквами:

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│Данные, указанные в страховом свидетельстве │

│ И В А Н О В А │

│Фамилия ._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._. │

│ М А Р И Н А │

│Имя ._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._. │

│ Л Ь В О В Н А │

│Отчество ._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._. │

│ Ж │

│Пол ._. (м/ж) │

│ 1 0 М А Р Т А 1 9 6 1 │

│Дата рождения "._._." ._._._._._._._._._. ._._._._. года │

│Место рождения: │

│ У С Т Ь - Н Е Р А │

│ город (село, дер., ...) ._._._._._._._._._._._._._._._._._._._._._._._._._. │

│ О Й М Я К О Н С К И Й │

│ район ._._._._._._._._._._._._._._._._._._._._._._._._._. │

│ Я К У Т С К А Я А С С Р │

│ область (край, респ., ...) ._._._._._._._._._._._._._._._._._._._._._._._._._. │

│ страна ._._._._._._._._._._._._._._._._._._._._._._._._._. │

│ Р О С С И Я │

│Гражданство ._._._._._._._._._._._._._._._._._._._._._. │

│Адрес постоянного места жительства │

│ 1 4 4 0 0 7 М О С К О В С К А Я о б л , │

│Адрес индекс ._._._._._._.адрес._._._._._._._._._._._._._._._. │

│регистрации Э Л Е К Т Р О С Т А Л Ь г , М И Р А у л , │

│ ._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._. │

│ д 2 0 , к в 1 2 │

│ ._._._._._._._._._._._._._._._._._._._._._._._._._._._._. │

│Адрес места индекс _._._._._._.адрес._._._._._._._._._._._._._._._._._._. │

│жительства ._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._. │

│фактический ._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._. │

│ (заполнять при отличии от адреса регистрации) │

│ 8 - 9 8 5 - 1 1 1 - 1 3 - 1 2 │

│Телефоны ._._._._._._._._._._._._._._._._._._._._. │

│ (домашний и/или рабочий) │

│Документ, удостоверяющий личность │

│ П А С П О Р Т Р О С С И И │

│Вид документа ._._._._._._._._._._._._._._._._._._._._._._._._._. │

│ (указать название документа: паспорт, удостоверение │

│ личности и другие документы, удостоверяющие личность) │

│ 3 3 9 9 4 5 0 6 0 │

│Серия, номер ._._._._._._._._._. ._._._._._._. │

│ 2 0 И Ю Л Я 2 0 0 0 │

│Дата выдачи "._._." ._._._._._._._._. ._._._._. года │

│ 3 6 О М г М О С К В Ы │

│Кем выдан ._._._._._._._._._._._._._._._._._._._._._._._._._. │

│ ._._._._._._._._._._._._._._._._._._._._._._._._._. │

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Дата заполнения Личная подпись

1 0 А В Г У С Т А 2 0 0 0 ПЕТРЕНКО

"._._." ._._._._._._._._. ._._._._. года застрахованного лица --------

Заполняется страхователем (работодателем).

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│Заверяю, что застрахованное лицо имело страховое свидетельство обязательного пенсионного │

│страхования со страховым номером 1 2 3 - 1 2 3 - 1 2 3 4 4 │

│ ._._._. ._._._. ._._._. ._._., на основании которого │

│сведения о его стаже и заработке │

│представлялись/-б-у-д-у-т- -п-р-е-д-с-т-а-в-л-е-н-ы- -в- -П-Ф-Р-. │

│---------------------------------------------------------------- │

│ (ненужное зачеркнуть) │

│ │

│Наименование должности руководителя ДИРЕКТОР Подпись ГУСЕВ Расшифровка подписи ГУСЕВ В.В.│

│ │

│Дата 10 АВГУСТА 2001 Г. │

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