da produrre alla pubblica amministrazione

 

DICHIARAZIONE SOSTITUTIVA

DELLA CERTIFICAZIONE DI STATO DI FAMIGLIA

(Art. 2 Legge 4 gennaio 1968 n. 15)

 

 

 

Il sottoscritto __________________________________________________________________

 

(cognome)                                                          (nome)

 

 

nato a _______________________________________ (_______) il ______________________

 

(luogo)                                                 (prov.)

 

 

DICHIARA

 

che la famiglia convivente si compone di:

 

 

1)      il dichiarante

 

2)      __________________________________________________________________________

 

(cognome)                                           (nome)                                  (rapporto con dichiarante)

 

____________________________________________________________________________

 

(nato a)                                                                                              (il)

 

3)      ___________________________________________________________________________

 

___________________________________________________________________________

 

4)      ___________________________________________________________________________

 

___________________________________________________________________________

 

5)      ___________________________________________________________________________

 

___________________________________________________________________________

 

6)      ___________________________________________________________________________

 

___________________________________________________________________________

 

 

 

 

__________________________                                          ______________________________

 

                               (data)                                                                                                           (firma da apporre)