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						Okręgowa Rada Lekarska
						Bydgoskiej Izby Lekarskiej

WNIOSEK O UDZIELENIE 
POMOCY PIENIĘŻNEJ W ZWIĄZKU Z UTRATĄ ŹRÓDŁA ZAROBKOWANIA

        Zwracam się z prośbą o udzielenie zapomogi pieniężnej w wysokości ................................

CEL PRZEZNACZENIA POMOCY ORAZ UZASADNIENIE: 

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Oświadczam, iż powyższe dane złożyłem/am zgodnie z prawdą.

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(podpis wnioskodawcy) 

OŚWIADCZENIE O SYTUACJI MAJĄTKOWEJ WNIOSKODAWCY

I. Osiągnięty dochód i posiadany majątek:
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II. Obciążenia i zaległości: 
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III. Osoby będące na utrzymaniu wnioskodawcy
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IV. Szczególne okoliczności mające wpływ na sytuację majątkową Wnioskodawcy
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Powyższe oświadczenie składam świadomy(a), iż na podstawie art. 233 § 1 Kodeksu karnego za podanie nieprawdy lub zatajenie prawdy grozi kara pozbawienia wolności. 

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