Приложение N 3. Заявление о выдаче документа, подтверждающего регистрацию в системе индивидуального (персонифицированного) учета (Форма АДВ-3)

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│Страховой номер индивидуального лицевого счета ._._._.-._._._.-._._._. ._._. │

│Данные, указанные в документе, подтверждающем регистрацию в системе индивидуального│

│(персонифицированного) учета: │

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

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

│Отчество (при наличии) ._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._. │

│Пол ._. (м/ж) │

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

│Место рождения: │

│ населенный пункт ._._._._._._._._._._._._._._._._._._._._._._._._._._._. │

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

│ регион (область, край, республика, ...) ._._._._._._._._._._._._._._._._._._. │

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

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

│ │

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

│постоянного ._._._._._._._._._._._._._._._._._._._._._._._._._. │

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

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

│пребывания ._._._._._._._._._._._._._._._._._._._._._._._._._. │

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

│ (заполнять при отличии от адреса постоянного │

│ места жительства) │

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

│ (домашний и/или рабочий) │

│Документ, удостоверяющий личность: │

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

│ (указать название документа: паспорт, удостоверение личности или другие │

│ документы, удостоверяющие личность) │

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

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

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

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

│Реквизиты акта гражданского состояния о рождении: │

│Номер актовой записи о рождении ._._._._._._._._._._._._._._._._._._._._._._._._._. │

│Дата составления актовой записи о рождении "._._." ._._._._._._._._. ._._._._. года │

│Наименование органа, которым произведена государственная регистрация акта о рождении ._._._._._._._._._.│

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

│Идентификационный номер налогоплательщика (при наличии) ._._._._._._._._._._._._._. │

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