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                                                                                                              Załącznik nr 1 do  Uchwały NR VI/40/15

         RADY MIASTA KOŁOBRZEG

z dnia 2 marca 2015 r.

 

 

 

 

 

 

Oświadczenie o dochodzie na członka rodziny 

 

……………………

data

………………………………………………………..

 

………………………………………………………..

imię i nazwisko rodziców/opiekunów prawnych) kandydata

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

adres zamieszkania

 

 

OŚWIADCZENIE

 

                Na podstawie art. 20 t. ust. 2 pkt 3  ustawy z dnia 7 września 1991 r. o systemie oświaty (Dz. U. z 2004 r. Nr 256, poz. 2572 z późn. zm.) oświadczam, że dochód  na osobę w rodzinie kandydata ……………………………………………………………………………………………………………

(imię i nazwisko kandydata)

wynosi ………………zł (brutto) , słownie…………………………………………………………….

……………………………………………………………………………………………………………co stanowi kwotę niższą, wyższą (właściwe podkreślić) od kwoty  przyjętej, jako kryterium dochodu przy ubieganiu się o przyjęcie do przedszkoli, oddziałów przedszkolnych funkcjonujących w szkołach podstawowych, dla których organem prowadzącym jest Gmina Miasto Kołobrzeg.

 

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

 

 

 ………………………………………

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