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

Приложение 3
к постановлению Правления
Пенсионного фонда
Российской Федерации
от 31 октября 2022 г. N 243п

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Форма АДВ-3                                                           Код по ОКУД  |          |

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Заявление о выдаче документа, подтверждающего регистрацию в системе индивидуального
(персонифицированного) учета

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)._._._._._._._._._._._._._._._._._._._._ ._._._._._._._._._._._._._._._.    |

|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)

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