Úradný záznam 

Úradný záznam napísaný dňa		..........................................................
							          (uviesť dátum a miesto)

Dostavil sa bez predvolania			..........................................................
		   				         Meno a priezvisko, dátum narodenia,
								adresa trvalého pobytu 

Uvádza sa ................................................................................................................
......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

V Poproči, dňa: ............................			

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