Приложение 2. Заявление об изменении анкетных данных зарегистрированного лица, содержащихся в индивидуальном лицевом счете (Форма АДВ-2)

Заявление об изменении анкетных данных зарегистрированного лица,

содержащихся в индивидуальном лицевом счете

Заполняется зарегистрированным лицом печатными буквами

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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) ._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._. │

│Новые анкетные данные (указать только изменившиеся данные): │

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

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

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

│Пол ._. (м/ж) │

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

│Место рождения: │

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

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

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

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

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

│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 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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Дата заполнения Подпись зарегистрированного лица

(представителя)

"._._." ._._._._._._._._. ._._._._. года ________________________________