CNG HO X HI CH NGHA VIT NAM

c lp - T do - Hnh phc

Mu s: 22/XN-TNCN
(Ban hnh km theo Thng t
s 62 /2009/TT-BTC ngy
27/3/2009 ca B Ti chnh)

BN K KHAI
V NGI TN TT KHNG C KH NNG LAO NG

Knh gi: UBND x (phng) ..

H v tn ngi np thu: ......................................................................
M s thu (nu c):............................................................................................................................................
S CMND/H chiu: ...... Ngy cp: .......
Ni cp: .........
Ch hin nay: ............................................................................................................................................
Cn c qui nh v h s chng minh ngi ph thuc nu ti khon 3, Mc I. Phn
B Thng t s 84/2008/TT-BTC ngy 30/9/2008 ca B Ti chnh hng dn thi hnh
mt s iu ca Lut thu TNCN v Ngh nh s 100/2008/N-CP ngy 8/9/2008 ca
Chnh ph qui nh chi tit mt s iu ca Lut thu Thu nhp c nhn v vic chnh
quyn x phng xc nhn ngi ph thuc b tn tt khng c kh nng lao ng.
Ti k khai ngi sau y l ngi tn tt, khng c kh nng lao ng c tnh
gim tr gia cnh vo thu nhp ca ti theo qui nh ca Lut thu TNCN.
Stt

H v tn
ngi ph thuc

Nm
sinh

S
CMND
/H chiu

Quan h vi
ngi lm n

a ch thng tr
ca ngi ph thuc

Biu hin
tn tt (*)

1
2

Ti cam oan nhng li khai trn l ng s tht, nu sai ti xin chu hon ton trch
nhim./.
..

, ngy . thng . nm 20
NGI LM N

(K tn)
XC NHN CA UBND X, PHNG:

UBND ... xc nhn ng (b)

thng tr ti ............ b tn tt ng nh k khai./.
..

, ngy . thng . nm 20

TM. UBND..

(k tn, ng du)

(*) Ghi ch - Biu hin tn tt c khai theo nguyn tc sau: khai r ngi
ph thuc b khim khuyt b phn no trn c th (nh thiu tay, chn, mt,) hoc
cn bnh him ngho mc phi (nh bnh down, di chng cht c mu gia cam,...)

Ghi ch:
- (*) Biu hin tn tt c khai theo nguyn tc sau: khai r ngi ph thuc b
khim khuyt b phn no trn c th (nh thiu tay, chn, mt,) hoc cn bnh him
ngho mc phi (nh bnh down, di chng cht c mu gia cam,...)
- Xc nhn ca UBND phng, x: trng hp i tng np thu c nhiu

ngi ph thuc nhiu a im khc nhau th ti mi a phng c ngi ph

thuc sng, i tng np thu phi lp t khai v ngh UBND phng, x ni
xc nhn.
V d: ng A c 3 ngi ph thuc b tn tt khng c kh nng lao ng
sng ti 3 a im khc; trong c 2 ngi x X, 1 ngi x Y. ng A s
phi lp 02 bn khai theo mu 22/XN-TNCN; 01 bn ngh UBND x X xc
nhn cho 02 ngi ph thuc sng x X, 01 bn ngh UBND x Y xc nhn
cho 01 ngi sng x Y.

CNG HO X HI CH NGHA VIT NAM

c lp - T do - Hnh phc
BN K KHAI
V NGI PHI TRC TIP NUI DNG

Mu s: 21a /XN -TNCN

(Ban hnh km theo Thng t
s 62 /2009/TT-BTC ngy
27/3/2009 ca B Ti chnh)

Knh gi: UBND x (phng) ..

H v tn ngi np thu: ......................................................................
M s thu (nu c):............................................................................................................................................
S CMND/H chiu: ...... Ngy cp: .......
Ni cp: .........
Ch hin nay:

............................................................................................................................................

Cn c qui nh ti im 3.1.7 (), khon 3, Mc I, Phn B Thng t s

84/2008/TT-BTC ngy 30/9/2008 ca B Ti chnh hng dn thi hnh mt s
iu ca Lut thu TNCN v Ngh nh s 100/2008/N-CP ngy 8/9/2008 ca
Chnh ph qui nh chi tit mt s iu ca Lut thu Thu nhp c nhn v vic
chnh quyn x phng xc nhn thc t ang nui dng ngi ph thuc l ng
b ni, ng b ngoi, c, d, ch , bc, cu rut, anh ch em rut, chu rut v cc
c nhn khc c tnh gim tr cho ngi ph thuc.
Ti k khai ngi sau y ang sng cng vi ti.
Stt

H v tn
ngi ph thuc

Ngy
sinh

S
CMND
/H chiu

Quan h vi
ngi khai

a ch thng tr ca
ngi ph thuc

1
2

Ti xin cam oan k khai trn l ng s tht, nu sai ti xin chu hon ton
trch nhim./.
, ngy . thng . nm 20

..

NGI LM N

(K tn)
XC NHN CA UBND X, PHNG (ni ngi np thu c tr):

UBND xc nhn ngi c k khai

trong biu (nu trn) hin ang sng cng ng (b) .
ti a ch ./.
, ngy . thng . nm 20

..

TM. UBND..

(k tn, ng du)

CNG HO X HI CH NGHA VIT NAM

c lp - T do - Hnh phc
BN K KHAI
V NGI PHI TRC TIP NUI DNG

Mu s: 21b /XN -TNCN

(Ban hnh km theo Thng t
s 62 /2009/TT-BTC ngy
27/3/2009 ca B Ti chnh)

Knh gi: UBND x (phng) ..

H v tn ngi np thu: ......................................................................
M s thu (nu c):............................................................................................................................................
S CMND/H chiu: ...... Ngy cp: .......
Ni cp: .........
Ch hin nay:

............................................................................................................................................

Cn c qui nh ti im 3.1.7 (), khon 3, Mc I, Phn B Thng t s

84/2008/TT-BTC ngy 30/9/2008 ca B Ti chnh hng dn thi hnh mt s
iu ca Lut thu TNCN v Ngh nh s 100/2008/N-CP ngy 8/9/2008 ca
Chnh ph qui nh chi tit mt s iu ca Lut thu Thu nhp c nhn v vic
chnh quyn x phng xc nhn thc t ang nui dng ngi ph thuc l ng
b ni, ng b ngoi, c, d, ch, bc, cu rut, anh ch em rut, chu rut v cc
c nhn khc c tnh gim tr cho ngi ph thuc.
Ti k khai ngi sau y khng ni nng ta, ti ang trc tip nui dng:
Stt

H v tn
ngi ph thuc

Ngy
sinh

S
CMND
/H chiu

Quan h vi
ngi lm n

a ch thng tr ca
ngi ph thuc

1
2

Ti xin cam oan nhng li khai trn l ng s tht, nu sai ti xin chu hon
ton trch nhim./.
, ngy . thng . nm 20

..

NGI LM N

(K tn)
XC NHN CA UBND X, PHNG (ni ngi ph thuc c tr):

UBND xc nhn ngi c k khai

trong biu (nu trn) khng ni nng ta, ang sng ti x (phng)
../.
, ngy . thng . nm 20

..

TM. UBND..

(k tn, ng du)

Ghi ch:
Xc nhn ca UBND phng, x: trng hp i tng np thu c nhiu

ngi ph thuc nhiu a im khc nhau th ti mi a phng c ngi ph

thuc sng, i tng np thu phi lp t khai v ngh UBND phng, x ni
xc nhn.
V d: ng B c 3 ngi ph thuc (khng ni nng ta v ng B ang
trc tip nui dng) ang sng ti 3 a im khc; trong c 02 ngi x K,
01 ngi x M. ng A s phi lp 02 bn khai theo mu s 21b/XN-TNCN; 01
bn ngh UBND x K xc nhn cho 02 ngi ph thuc sng x K, 01 bn
ngh UBND x M xc nhn cho 01 ngi sng x M.