Утверждена
постановлением Правления
Пенсионного фонда
Российской Федерации
от 11 января 2017 г. № 2п
Анкета застрахованного лица Заполняется застрахованным лицом печатными буквами. ┌────────────────────────────────────────────────────────────────────────────────────────┐
│ П У Ч К О В │
│Фамилия ._._._._._._._._._._._._._._._._._._._._._._._._._._._._. │
│ И В А Н │
│Имя ._._._._._._._._._._._._._._._._._._._._._._._._._._._._. │
│ Р О М А Н О В И Ч │
│Отчество ._._._._._._._._._._._._._._._._._._._._._._._._._._._._. │
│ М │
│Пол ._. (м/ж) │
│ 0 5 М А Я 1 9 8 5 │
│Дата рождения "._._." ._._._._._._._._. ._._._._. года │
│Место рождения: │
│ М О С К В А │
│ город (село, дер., ...) ._._._._._._._._._._._._._._._._._._._._._. │
│ район ._._._._._._._._._._._._._._._._._._._._._. │
│ область (край, респ., ...) ._._._._._._._._._._._._._._._._._._._._._. │
│ страна ._._._._._._._._._._._._._._._._._._._._._. │
│ Р О С С И Я │
│Гражданство ._._._._._._._._._._._._._._._._._._._._._. │
│Адрес постоянного места жительства │
│ 1 2 5 4 3 5 М О С К В А Г . │
│Адрес индекс ._._._._._._. адрес ._._._._._._._._._._._._._. │
│ Д У Б Р А В Н А Я У Л , Д . 3 5 , │
│регистрации ._._._._._._._._._._._._._._._._._._._._._._._. │
│ К В . 97 │
│ ._._._._._._._._._._._._._._._._._._._._._._._. │
│Адрес места индекс ._._._._._._. адрес ._._._._._._._._._._._._._. │
│жительства ._._._._._._._._._._._._._._._._._._._._._._._. │
│фактический ._._._._._._._._._._._._._._._._._._._._._._._. │
│ (заполнять при отличии от адреса регистрации) │
│ 8 ( 4 9 5 ) 7 5 3 4 8 7 7 │
│Телефоны ._._._._._._._._._._._._._._._._._._._._._._._. │
│ (домашний и/или рабочий) │
│Документ, удостоверяющий личность │
│ П А С П О Р Т Р О С С И И │
│Вид документа ._._._._._._._._._._._._._._._._._._._._._._._._._. │
│ (указать название документа: паспорт, удостоверение │
│ личности и другие документы, удостоверяющие личность) │
│ 4 5 0 7 2 1 0 4 5 0 │
│Серия, номер ._._._._._._._._._._._._._._._._._._._. │
│ 1 2 Д Е К А Б Р Я 2 0 0 6 │
│Дата выдачи "._._." ._._._._._._._._. ._._._._. года │
│ О В Д Р – Н А М И Т И Н О Г . │
│Кем выдан ._._._._._._._._._._._._._._._._._._._._._._._._._. │
│ М О С К В Ы │
│ ._._._._._._._._._._._._._._._._._._._._._._._._._. │
└────────────────────────────────────────────────────────────────────────────────────────┘ Дата заполнения Личная подпись
2 7 М А Р Т А 2 0 1 7 ПУЧКОВ
"._._." ._._._._._._._._. ._._._._. года застрахованного лица -------
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