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Załącznik nr  3  -     Oświadczenie   o samotnym wychowywaniu kandydata                                                                                                                                    

 

             …………………….   

data

………………………………………………………..

 imię i nazwisko rodziców(opiekunów prawnych) kandydata

 ……………………................................................

 adres zamieszkania

 

 

 

OŚWIADCZENIE

 

 

                Na podstawie art. 20t. ust. 2 pkt 1 lit. c ustawy  z dnia 7 września 1991 r. o systemie oświaty (Dz. U. z 2004 r. Nr 256, poz. 2572 z późn. zm.) oświadczam, o  samotnym wychowywaniu  dziecka ………………………………………………………………………………………………………

 

oraz nie wychowywaniu żadnego dziecka wspólnie z jego rodzicem.

 

Jednocześnie oświadczam, że jestem świadomy(a) odpowiedzialności karnej za złożenie fałszywego oświadczenia.

 

 Do oświadczenia dołączam:

a)     prawomocny wyrok sądu rodzinnego orzekający rozwód lub separację*

b)        akt zgonu *

--------------------------------

*właściwe zaznaczyć

 

 …………………………………..

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