Приложение № 1
к приказу Фонда пенсионного и социального
страхования Российской Федерации
от 30 октября 2023 г. № 2153

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Форма АДВ-1                                                      Код по ОКУД │              │
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                              Анкета зарегистрированного лица

Заполняется зарегистрированным лицом печатными буквами

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│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 ._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._.│
│            (указать название документа: паспорт, удостоверение личности или другие документы,   │
│                                          удостоверяющие личность)                               │
│Серия, номер  ._._._._._._._._._._._._._._._._._._._.                                            │
│Дата выдачи   "._._."._._._._._._._._. ._._._._. года                                            │
│Кем выдан     ._._._._._._._._._._._._._._._._._._._._._._._._._.                                │
│              ._._._._._._._._._._._._._._._._._._._._._._._._._.                                │
│                                                                                                 │
│Реквизиты акта гражданского состояния о рождении:                                                │
│Номер актовой записи о рождении ._._._._._._._._._._._._._._._._._._._._._._._._._.              │
│Дата составления актовой записи о рождении "._._."._._._._._._._._. ._._._._. года               │
│Наименование органа, которым произведена государственная регистрация акта о рождении._._._._._._.│
│._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._._.    │
│Идентификационный номер налогоплательщика (при наличии) ._._._._._._._._._._._._._._._.          │
│                                                                                                 │
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Дата заполнения                               Подпись зарегистрированного лица (представителя)
"._._."._._._._._._._._. ._._._._. года       _________________________________________________