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

Приложение N 3
к приказу Фонда пенсионного и социального
страхования Российской Федерации
от 30 октября 2023 г. N 2153

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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:                                                                                  |

|      населенный пункт ._._._._._._._._._._._._._._._._._._._._._._._._._._._.                   |

|      район            ._._._._._._._._._._._._._._._._._._._._._._._._._._._.                   |

|      регион (область, край,       ._._._._._._._._._._._._._._._._._._._._._.                   |

|      республика,...)                                                                            |

|      страна           ._._._._._._._._._._._._._._._._._._._._._._._.                           |

|Гражданство            ._._._._._._._._._._._._._._._._._._._._._._._.                           |

|Адрес           индекс ._._._._._._.адрес ._._._._._._._._._._._._._._.                          |

|постоянного            ._._._._._._._._._._._._._._._._._._._._._._._.                           |

|места жительства       ._._._._._._._._._._._._._._._._._._._._._._._.                           |

|Адрес           индекс ._._._._._._.адрес ._._._._._._._._._._._._._._.                          |

|места                  ._._._._._._._._._._._._._._._._._._._._._._._.                           |

|пребывания             ._._._._._._._._._._._._._._._._._._._._._._._.                           |

|                (заполнять при отличии от адреса постоянного места жительства)                   |

|Телефоны               ._._._._._._._._._._._._._._._._._._._._._._._._._._.                     |

|                                      (домашний и/или рабочий)                                   |

|Документ, удостоверяющий личность:                                                               |

|Вид документа ._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._.|

|            (указ