DICHIARAZIONE SOSTITUTIVA DELLA CERTIFICAZIONE DI 
STATO DI FAMIGLIA

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

 

Il/La sottoscritto/a_____________________________________________________

nato a _____________________________________________________ (_______)

il ____________________

 

DICHIARA

che la famiglia convivente si compone di:

1) il dichiarante

2) ____________________________________________________________________________
    (cognome)                             (nome)                                                           (rapporto con dichiarante)

______________________________________________________________________________
(nato a)                                                                                                                (il)

3) ____________________________________________________________________________

______________________________________________________________________________

4) ____________________________________________________________________________

______________________________________________________________________________

5) ____________________________________________________________________________

______________________________________________________________________________

6) ____________________________________________________________________________

______________________________________________________________________________

7) ____________________________________________________________________________

______________________________________________________________________________

 

 

          _____________________                            __________________________
                               (data)                                                                    (firma)