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 │

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

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

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

│Пол ._. (м/ж) │

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

│Место рождения: │

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

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

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

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

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

│Адрес постоянного места жительства │

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

│регистрации ._._._._._._._._._._._._._._._._._._._._._._._._._. │

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

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

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

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

│ (заполнять при отличии от адреса регистрации) │

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

│ (домашний и/или рабочий) │

│Документ, удостоверяющий личность │

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

│ (указать название документа: паспорт, удостоверение │

│ личности и другие документы, удостоверяющие личность) │

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

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

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

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

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Дата заполнения Личная подпись

"._._." ._._._._._._._._. ._._._._. года застрахованного лица ___________

Заполняется страхователем (работодателем).

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│Заверяю, что застрахованное лицо имело страховое свидетельство │

│обязательного пенсионного страхования со страховым номером │

│._._._. - ._._._. - ._._._. ._._., на основании которого сведения о его │

│ представлялись/будут представлены в ПФР. │

│стаже и заработке ----------------------------------------- │

│ (ненужное зачеркнуть) │

│ │

│Наименование должности руководителя Подпись Расшифровка подписи│

│ │

│Дата │

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