cgNG uoa xA HqI CHU NGHIA VIET'NAM

DQc lap -'I'rJ'do - Hgnh phIc

To rcrAr LB PHi TRUOC 84.

(ip dang cliii voi nhit, diit)

[01] K] tinh thu6: Theo tung l6n ph6t sin]r ngriy ... th6ng ... ndm ,..
[,6n c16u:
[02] r,an f]
Oau: Ll t03l BO sung lAn rhir:...
f] ro chirc, cir n]ran ducrc uy quyan khai thay cho ,gr-rdi nQp thu€

thu6:.
[0s] Ma s6 thu6:
(tprong . 0.u,,1 53 . 9 aol,o,t. ..
[07] Dia chi:Jd...N.,, ,lA*.t ,pW. iW
[08] Quan/huyon: .. .fIo...tt$ .. .. !... Lllflr$htl
[10] DiQn thoai: fullf,ltt..l39 itil
Fax:
[13] D:.ri ly thu6; ho4c 16 ch[,c, c6 nhAn rlu.g'c riy Idrai thay (n6u c6):
Ii4] Ma s6 thue:
tlsl Hep ddng dai thu
NHA DAT:

(SO trigu thu'a d6t): ,l i

,,.; 1O Dan Oo s0:
rJAt:

h6m): fUS
1.5. DiQn tich (m2): ..............1.9.,bL..*.
: (dAt dusc Nhd nu6c.giao, cho thu€; d6t nhfn chuyen nhucrrg;
ir;.\t*g::{,l,ul
cho): rye! '*ld" nh6n
thua k6, hoac nhdn tdng
a)'Ien tO chilc, c6 nhdn chuytin giao eSDD:
d-rr.^f ff frrao
- T6n t6 chuclcd nhdn chuy6n giao
eSDE:. .. . ..
- Md sfr thu€:.
SO CMND ICCCDIH. chi6u (truo.ng hop chrra c6 rn6 s6 thue;:
- Dia chi nguoi giao QSDE: ,,.........,......
b) Thdi diOm ldm giay to chr-ry0n giao QSDD ngay ..,,.,..th6ng .,..... ndrn
.,,.....
1.7. Gi6,tri ddt thqc t6 chuy6n giao (ntiu c6):
 2. Nhd:
2' 1' Th6ng tin v6 nha 6, nhd ldm vi6o, nhd sir clung
cho muc clich kh6c:
toi' *u'rl'*$"u ii;4o"rlane,r,a,
ffi;;ll;; u.i,,,
Chir dg dn:.... ".,,
Dfa chi dp 6n, c6ng trinh
vL
Ilet cau:
A
" SO tAng n6i: ,...56 tAng hAm:
Di€n tich su hiru chung (-r),. .. .....
Di€n tfch so hDu ri6ng (m2):
2.2.DiQn tfch nhd (rn2):
DiQn tich xdy dung (-r), . , 6(|, t..nl,
DiQn tich sdn x6y dr,rng
a a ar ,\ I
(m2): &ttrh.nL
2.,3. NguOn g6c nhd:
a) TU x6y dung:
- Ndm hodn c6ng (ho{c ndm b6t
dAu sri.clpng nhd): lglf
b) Mua, thua k6, tdng cho:
- Thdi di6m ldm gi6y to chr.ry6n giao
nird: Ngdy th6ng ........ ndm ....,.,.
2.4. Gi6 tri nha (dong):
Gi6 tl'i nhd, dAt thpc t6 nhQn chuy6n
(ddrgi' nhrrcrng n, nh6n thu,a k6 n, nlifln t4ng cho E

4. Tdi s6n thu6c diQn'dugc mi6n IQ phi tru6c bA (ly do):

T'6n tO chf,c/c6 nh0n 56 CMND/C-CCD7H6

-:. Ma sd thu6
oong so h[i.u chi6u (truo'ng ho. p Tj, lQ sd h[u (%)
chua c6 ma s6 thutll

kirai.i.

NHAN vrtN D4r LV rnuE +It W 'sdv;!.T: rhcinslg... ndm.aLll

Hg vd t6n:,..,,.,..,.. 0 Ncuor NOp iHuE hoac
EAI DIEN I.IQ? PHAP.CII; NcubiNqp
Ch['ng chi hdnh ngh€ s0:..,...... THUE

lg cHrrc, cA ivlLrv
(chft ky, ghi rd hQ r€n;
r#8'W euytN KrrAr rrrAy
r1i: ,y-io;;rr nd;iffi;ffi;,
diQn tfi)

l\fr^fr futt" "i q"P

--1lL
N* l..(" f*Y
/.

ceNc Hdlrr )oi rrel cnu Ncsia vIEr NAM

liQcJg_p - trl tto - H?nh phrlc

TO KHAI rt t I ,[ su'I]UNG oAt psl NdNG Nc H l[]p

(,'ip dltng daival hp gia ilinlr. ca nhdn tr.ong trut).ng hqp chuy€n nlurqtng, thru kd,
fing
cho rlt4,€tr s* dgng ddt)

l0ll Ky tinh thu6: Nern .......

[02] Lln rlAu: tr l03l 86 sung lAn thir:. . . ...
f . pHAN NGTIOT NQp rltttti TU'KIrAt
i. Ngtrdl n6o fliudi

;oz1 sd cMNDaro crri6rybciijEffi.q rraffi-o/ */[t.so.a,,(0+

t0Sf Ngay c61t: .Atl.l.[u.u., i0!rl Nof rrip; ......kc ....d"!,,....d,t..............,,......,..,...'
I l0l Oia chi cU trrlr:

,.frui ty thud (,rdu p6):

lf il ren d+i ly thud:..,,,,
it4l tuta s6 thuti:

ilfl H-op d0ng dai ly thuti: Ngdv:

r. Thfra o6t ehlq thu6r
il6l rhOng titi ngusi srl dgng ridt:

CMND/CCCD/
H0 pht6u (trUong hqp rd
rfi0n cllrra c6

llTl oia chl thrta dAt:

[12,t1 S6 nna: .....,^........;..
'.'.'rXl^*^.'"'........ ll7.zlDu&ng/phd: ........
tlz.rl ,affi,0,r, fnl,+, 1rr.nI phrrt^s;rini ,'.i"' ........f* ..y.*
t17.sl Qtr4n/rruy-en, . ifu. Lfn?... [1?,61 Tinh/Thinh phrS: .......&*dry..al$1.........
| !81 Ld thria cl6t duy nh6t: I _ I o I
llgl Dang ky kC khai t6ng irl,rgr iqri (Qurln/l lUypn): .........
 2

t20l Da c6 gi6y chrlng nh4n: m

[20.U s6 ei6v chrmg nhfln:.].{6lmnti.lo..ts,...., lz}.2lNeny cdp: ..03lna/.$t/......

t20.sl Dten ttch, ....hr[2..........120.61 Loai elAt/ Upc dich sit dutrs: e&.{.
lZ 11 T6ng diQn tich thgc t6 srlr dr,rng .,6o muc dich phi nOng nghiQp:

Izl.zlDi0rl tich d6t sft dgrig sai mqc dich/chua sir dgng theo dfing quy dinh:
t21.31 H?rt mtic (niiu c6): ...............

tll.4l DiQn tlch d6t l6n " cdti (irn : ..................,...........

l22l Chuac6 gi6y chtng nhf,rr: n
lzl.llDien tlch: ........ l22.2ll'oai ddtlMpc dich dang sir clpng:
i23l Thdi rli6m Uit diu sti duirg O6t, . . . . i . .,. ...,.. ,

t24l Thdi di6rrr thay d6i th6ng tln ciia thua ddt:
4. D6i vcri tISt 6'nlri nhi6u tfrnS nhi6u h0 &, nhir chutrg cu [ZS1 ftfnh trAn di€n tich sdn
thrc tii stb dyng):
[25.11 Lorli nhd: ...125.21 DiQn tich: t25.31 H0.sO phdn b6: ..........
I
5, Tru'b'ng hg'p rni6n, khi rd tnsdng hqp thuQ,c di€n duc1t: mi6n, gidm thuii
giim thui6 [ZO1
nhu: thu'ong binh, gia dinh thtrotlg binh li)t s!, d6i tuAng ch[nh sdch, ...):

Tdi cam rloan s5 liQu khni trOn li ctiing vd chiu tr6ch nhiQrn trtrdc phdp lur1t v6 sO tigu
cfd khai./.
-ru l,tyr4,., ngdy..J.{:, thdng..A0. ndm... 2-.0. L L
NHAN VrtN DA.r Lf THUE I
NGIIOI NQP THI-IE ho{r: -
I{tr vi ten:...................,..,...... DAI DIEN HQ" Pru$ CUA NctIO'I NQP
Chring chi hdnh ngh6 s6:...... THUE
(Chfr tqt, ghi rd hp ftn; ch*c vq vd ddng diiu Qt€u
c6)/Ky diQn tir)

N1^a, dw+W
');l---
T*^V
ryww
 3

I t. PHAN XAC EINH CUN CO QUAN CHI.IC NANC (DON Vi tiiN,' OANg ViQt NAM)
l. Ngrrdi nQp thud
l27l H9 vi t6n:
2sf Ngiy/
f 28] Ngny/.thdt
tli4ng/ n6m sinlr:
izolua s6 thuti:

f
30l So cM{D/fIO cm6ryEcEn
l3 tl Ngey cap: .,....,.....i....r........,..... 132; Noi c6p:
2. Thrla adt chlrr thud

l33f Dia chi:

t33.11 SO ita: l33.ZI Euong/ph6: ............
[33.3] f6/th0n: ..ii....i.................,..i. t33.41 phuorg/x6/thi h6n:
[33,5] Qu&n&uyEh: ........... [33.61 Tlnh/Thdqh plrO: ......r...........i....
l34l Da c6 gi6y chrlrrrg nhfln: n
[34,11 S6 gi6y plling nhf,n: .r..i....?...i.., lF4,ZlNSdy cdpt .,.....,.r....ii.,......,.....,...
[34.31 Tt* ddt s5: ...,..:........., ......... 134.41 To b6n trO s6:
[34.5]DiQnt{cha6tptritr0ngrrglrippghitr6nQCN:
[34.6] Dt0n tfph thgc t6 s}r iltillg; pho iiruo dich phi nCIirB frghiQp: ii.,i,?i!.,i,r..,.....r.r.ir........
Il4,7lLod eAU Muc dlch sf dpng: ......,......,i...i.,....r..i.!.........i.........i,...i.........i.....
[34.81 Hqntnirc (Hsn rnti.c tqi thdi dt*ni ctip GCN): .................. .......................
t3.51 Chua c6 giAy chrhlg nh0rt: n
[35.u Di0rr tich: .. l3s.2l roai dau Muc dich dang sri dlrng: ........................

[sf1 Thoi dicintha,y AOi thoirgtiii oriathfia ddt: ...,......?.i.. ...i...

.!.,....
3. Tru'dng hqp ml6n, giim tlrrrii IsBl @hi rd trudng hqp thuQc diQn duqc mtdrt, gidm thud
nhu: thuong binh, gia dlnh thtxrttg binh li1t sf, dtii tup'ng chlnh sdch ...):
4. Cnri cli tfnll thu$
f
39l DiQn tfctr dAt tlrgc tti srt rlring: .i,.,...,!.....!..,,.... [40] Haii mirc tirrh thtr6:
f {tl
rnong tiu x6o dinh eid dfu:
l4l,1f Loai ddV mgc dich srl dung: ...i...!.r.....|. .,....,.14t.Li ren du0nrg/vtlng: ............
141.31 Dosn duonglkhu vgo: ......... l4t.{1lo4i du&ng: .............
l4l.5l vi rti/hrng: .......... t41.61 Gi6 d6t: I4L.7|FIQ s6 (rlubng/h6m...):

5. Dtgn tich ii6t dnh thu6

5.r. D6t b (lnh cho diit 6, bao g,)m cd trud'ng hqp s* dung diit 6.ae tinn doanh)
'linh t€n (iQn tfch c6 quyAn sri dgng
[43] DiQn tlch vust kh6ng qu6
[42] Dien tich trong han mric . 3 l6n han mirc
(thuii s*it: 0,0i%o)
- -Aue@:UlU--
 \
\

5a5il o rha rht tAng nhi6u h0 d, nhd chung cu (tfnh ffAn di€n tlch sdn thvc
dltng):

[as] DiQn tfclu ......., . t46l I{Q s5 phdn b6: ..........

..,.,..!..............,..........
5.3. Dien tfch ct6t san xuAt kinh doarrl, - Tirh tr6n diQn tfch sfr dung dtng mr.rc d{ch:

nhd chung cu): ....,...

S.+. O5t sri dgng kh6ng dtng rnuc dich ho{c chua sri dgng theo thing quy dinh:
tagl DiQn tich: ........ . t50] MUc dich thuc t6 dang sri dsng:
15U He s6 phdn AAt 6aAi v6'i nhd nhiiu tdng nhiiu hO d, nhd chung cu): ........
s.S. D6t l6n chitirn:

I54l HQ s6 phdn A6 6Aivdi nhd nhiiu ting nhiitt hQ d, nhd chung cu): ........
...,ngdy....... thdng....... ndm....... ..., ngdy....... thdng....... ndnr.......
cAN Be vAN prroNc nAxc rcf crAM Eoc vAN pHoNG otrxc rcf
EAT DAI EATDAT !

(K! t€n, gh ra h9 ftn) (Ky t1n, ghi rd he ftn, d6ng ddu)

 CONG HOA XA HQI CHU NGHIA VIET NAM
DOc lflP - TW do - H+nh Phtic

TO KHAI THUE THU NHAP CA NUAX

(tip dang dOf vAi cd nhdn cd thu nhQp ti.r chuydn nhag'ng btit dAng sdn;
thu nhQp t* nhdn th*a kd vd nhdn qud tfing ld biit dQng sdn)

t01l Ky tinh thu5: Ldn ph6t sinh: Ngdy ... th6ng " ' n5m "'
t03l BO sung lAn thir:...
[02] L6n dAu: u
I. THONG TIN NGIIOI CHUYEN NHI,qNG, NHA.N THUA KE, QUA TANG
[0a]T0nngudinQpthu6:Dwud,..,..E-,*(6@,-
[ost Masothue(n6uc6): I I lm f-f-[l
c6 nhan qu6c tich viet Nam):
106l s6 CMND/CCCD/HO chi6u (trudng hqp
t06.U Ngdy c6p:.. . t06.21 Noi cAP:.

l07l Hn chitlu (trudng ho. p c6 nhdn kh6ng co qu6c tich ViQt Nam):

t07.11 Ngdy cAp:.. . l07.2lNoi c6P:

[08] Dia chi ch6 cY hiqn t4i: . '

t09l Qufln/huyQn: . t10l TinUThdnh ph6:

[13] TOnt6 chric, c6nhdnt@

U4l Ma s6 thu6 (n6u c6):
[.5] Dia chi:
[16] QuQn/huyQn: .. t17l Tinh/Thdnh ph6:

[20] TGn clai lf thu5 (ni5u c6)

t2U MA sO ttuC (ni5u c6):
I22lEia chi: ..
[23] QuQn/huyQn: ...lz4\TinhlThdnh ph6:
[25] EiQn tho4i: [26] Email: """""""
[27] Hqp d6ng dai ly thu5: t28l 56: [29] NgAv:""""""""
tdi sin gin 1i6n v6i d6t:
t30l GiAy to vd quyen sir dgng d6t, quydn sd htu nhd 6 vd

t30.U 56:... .. t30.21 Do co quan: t30'31 Cdp ngdy:

hinh thdnh trong tuong lai lo-i
[31] HA'p d6ng mua b6n nhd &, cdng trinh xdy dgng
v6i chri dg 6n cfp 1, c1'p 2 ho{c Sdn giao dfch ctra chri dg 6n:

[32]Hqp dOng chuy6n nhugng trao d6i bAt dQng sin:

I32.U 56:... I32.2lNoi 10p'
" ' " 132'31Nedv lflp:''
|32.4|Coquanchringth1rc.....t32.5]Ngdyclrftngthuc:'............:.......'..
 2
II. THONG TIN NGIIfl NHAN CuuvBN NH1IqNG, NHAN tHtIA KE, -
QUA TANG

t34l Ma sO ttru6 (n6u c6):

p chua c6 m5 so thuiS): .0LLLI3.0.0I..,lqV
t35l 56 CMND/CCCD/r{O chit5u (trudng h-o.

[36] Van bin PhAn chia di s6n thira ki5,

qui tang td B6t dQng sin

t36.U Noi tap hdi so nhfln thira kti, qud t{ng:

. (?.g&.4 il^rlrrq lla. L/,'g"""
t36.ztNedy ,ir, i1 if ..a.t* . .. I .. ..{.. "1
t36.31 co qrun chri'ng thucl.....Vp' :e'fl eilV fu W
t36.41 Nedy chring thvc: l[l.l.tr n2.t-...'Y"""""""
III. LOAI BAT EQNG SAN CHIIYEN MilrQT'{G, 1g1 .1AN Til-IA rn, qUa' T'!I\G
d6t
t37l Quy0n sri dqng dAt va tdi sin gan li6n tr6n
t38l Quy0n sd hfru hoflc sir dgng nhi o
t39l QuyOn thu6 dAt, thu0 m{t nudc
t40l B6t dQng sin khdc
rv. Dac DIIM sAr DQNG SAN CUUYEN NHUqNG, NHA.N THUA KE,
QUA TANG
[41] Th6ng tin v0 dAt:
t41.U Thri'a A6t sO (SO hieu thua dAt).. . . . .; Td bin 1s6 dO s6 hiQu):

l4t.2l Dia chi:'... ....:"""""'

Thdn/x Onl6p:N.V7,fu,t t
t4t.3l 56 nhd. . .. Tod nhd.. . Ng6/h6m. ..... duln e1ph6......
l4l .4)Phudng/xa:..........Go .....Y^ag "
t41.sl Quflr/huYQr'.......#-? l*Y
: N'rt,( "
t4 1 .61 Tinh/thanh pho : ...... fu*alyd "'

l4l.7l Loai dAt, vi tri thtra d t (1,2,3,4. . ')

+ Lopi O6t t:............... Vitri 1:. ...' DiQntich:' """"m2
+ Lo4i d6t t:............... Vi tri2:. ..'. Dien tich:' """"rn2

+ Loai d6tz:............... Vitri 1:.......'.... DiQntich:' """"m2

+Lo4i ddtz:...........'... Vi tti2:. ."' DiQntich:' """"m2

t41.81 Hq sO (ntiu c6):

t41.91 Ngu6n g6c d6t: (EAt duqc
nhd nu6c giao, cho thu6; EAt nhan chuy6n
nhugng; nh4n thira k6, hopc nh6n t4ng, cho...): ..
,b*
htdu. rLd ..rktf"..4;*+.
[41.10]Gi6trid6tth1rct6chuy6ngiao(ntiuc6):.:......
[42] Thdng tin v€ nha 6, c6ng tiinh x6y
dgng
 3

l42.ll Nha d ri0ng 16:

142.21l.o4i 1:......... CAp nhd O.$r.Oign tich sdn xdy dr,rng: ..6kr1.....m2
l42.3lLoqi2:.........Cap nhd cr.....DiQn tich sdn x6y dpng: .....m2
142.41Gi6 tri nhd thgc t6 chuy6n giao (n6u c6):. . .. . . . ..d6ng

142.51Nha 0 chung cu:

142.61Chri dU 6n:............ l42.71Dia chi dg 6n, c6ng trinhr......
142.81DiQn tich x6y dgng:............142.91DiQn tich sdn xAy dirng:.........m2
142.10) DiQn tich s& ht'u chung:....ln2l42.Il1Di0n tich s& htu ri0ng:.. ....m2
142.r21K6t c6u:... 142.r3) 56 tAng n6i:.......... ..142.141 SO tAng hArn:

142.15) NIm hodn c6ng:. . ... .

142.16l cie tri nhd thpc ti5 chuytin giao (n6u c6):.. ....ddng
l42.l7lNgu6n g6c nha
Tp xdydUng l) 142.181 NAm hodn thdnh (ho4c n[rn bdt dAu sri dung nhd):.....
Chuy6n nhusng I l4z.lglThoi diOm ldm gi6y to chuytin giao nhd:..

142.201C6ng trinh xdy dung (tru nhd 6)

142.21) Chri du 6n:........................142.22)Dia chi dq 5n, c6ng trinh.
142.231lo4i cdng trinh:............... Hang muc c6ng trinh......Cap c6ng trinh.... ..

142.241DiQn tich x6y dgng: ........ 142.251 Diqn tfch sin x6y dung: . . .......m2;
142.261H0 sO (nOu c6):..
142.271Don gi6:..
142.281Gi6 tri c6ng trinh thpc t6 chuyiSn giao (nt5u c6):.. ..d6ng

t43l Tei sin gin li6n v6i d5t

t43.U Lo4i tdi sin gfn 1i0n vdi d6t:...........
143.21Gi6 trf tdi sin gin lien v6'i dAt thpc ti5 chuy6n giao (n6u c6):.... ..c16ng
v. THU NHAP rrICHUYEN NHTIqNG rAr DQNG SAN; rrl NU4N
THUA KE, QUA TANG LA BAT DQNG SAN
[44] Lopi thu nh4p
l44.ll Thu nh4p tir chuy€n nhuong bdt dQng s6n tr
144.21Thu nhQp tu nh4n thila k6, qud tflng T
l45l Gi6 tri chuy€n nhuo. ng U6t dqng s6n vd tdi s6n kh6c gin li6n v6'i d6t ho{c gi6 tri
U6t Agng sin nh6n thii'a k6, qud t{ng: ... tt6ng
*::
rrourj?flrffi::::'u::: :::l ::i ::l ::: :::::::::::::*:::'#;
[a7] Thu nh4p miSn thu6:........ d6ng

[a8l Thuti thu nh4p c6 nhdn dugc mien ([a8]

:147)x2%) -t
dong

t4gl Thu6 thu nhflp cd nhdn phdi nQp OOi v6i chuy6n nhugng bil dQng
 \
4
[50] ThuC thu nhflp c6 nhdn phdi nQp OOi vO'i nhdn thira k6, qud tflng ld b6t dQng s6n:

{[s0]:([4s]-t471-10.000.000) xI0%]:...... .............d6ng

l5U SO thutl phii nQp, dugc miSn cria chri s0 hfru (chi khai trong trudng h-o. p c6
d6ng s& htu hoflc chir s& htu, d6ng so hfru dugc miSn thutl theo quy dinh):
Do'n vi tiin: D6ng Yigt Nam
Ly do c6 nhin
.i
Mn s6
Tf lQ se
Sii ttru6
sii ttru6 -
ouoc mren v(rt Lf do
STT Hg vh t6n
thuii
hiru
phii nQp tluqc nhi 0, quy6n mlen
(%) mten sir dgng alat fr khdc
duy nh6t
l-5 1.1 1sl.21 ls 1.3l 15l.4l ls 1.5l Is 1.6l 1sl.71 ls 1.8l
1 n
2 tr
tr
VII. HO SO I(EM THEO GOM:
...t)d" qh. .FcN. ;. :t b.c.T..?.c.0.
.. . ..L.y.).............
.. ..
5. ..... ... ..............;
tt /
- ...Ccc.n;..[rl.t t...CrLt.............. ..................;
T6i cam doan nhfrng nQi dung kC khai ld dfing vd chiu tr6ch nhiqm tru6c ph6p lu4t
;. ,-
vC nhftng nQi dung d5 khai./.
+lAW ' ndm-La z 2
NHAN vrEN EA.r Lv
t0n:..........
rHUE ifIj{;#JLT#ii
He vd DAr DrEN Hqp pHAp cua Ncuor NQp THUE
Chring chi hdnh ngh6 s6:...... (Chil W, ghi rd ho tdn; chtlc v4 vd d6ng dAu @ei cd)/K!, diQn ttlr)
| -
t\n
Nf^''/^ "Mt "t 1ryoo
'-)/>
y@, rtu rm"ft'