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

Заявление о выдаче документа, подтверждающего регистрацию

в системе индивидуального (персонифицированного) учета

Заполняется печатными буквами

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

│(персонифицированного) учета │

│ │

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

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

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

│ │

│Пол ._. (м/ж) │

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

│Место рождения: │

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

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

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

│ 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 вид документа, удостоверяющего личность, в соответствии с│

│ законодательством Российской Федерации) │

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

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

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

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

│Номер актовой записи при рождении ._._._._._._._._._._._._._._._._._._._._._._._._._. │

│(заполняется при предъявлении в качестве документа, удостоверяющего личность,│

│свидетельства о рождении) │

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

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Дата заполнения Подпись

"._._." ._._._._._._._._. ._._._._. года зарегистрированного лица _______

(представителя)

Заполняется страхователем (работодателем)

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│Заверяю, что зарегистрированное лицо имеет открытый индивидуальный │

│лицевой счет со страховым номером ._._._. - ._._._. - ._._._. ._._., │

│на основании которого сведения о его стаже и заработке │

│представлялись/будут представлены в ПФР. │

│ (ненужное зачеркнуть) │

│ │

│Наименование должности руководителя Подпись Расшифровка подписи│

│ │

│Дата │

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