1 wniosek o ustalenie prawa do świadczenia pielęgnacyjnego

1 wniosek o ustalenie prawa do świadczenia pielęgnacyjnego

!"#$$"%&'()*+&
,&-.&,&
Poz. 2284
!"#$%&'()&*)+,
WZÓR
!"#$" %&'()&*+ ,-".)#+/01-2& 3$)"'1#-4)"
,&'#)44-5
6',-75
-./0123)0)415672./2)896-6):0);-/6:< 2./6)8/27=>.6<[email protected]>0
8#93: ;
:!&A)BCBDE)FD'AG!H#$AH)C'I)B)FCJ!KA&'A)L*!M!)NB)OM'!N$%A&'!)L'AKIG&!$EH&AGB
;()9
!"#$)7<&
!+(-, =>?>@AB
C"*" +,&'#-4)"
DEF$"*-.7*$&
G)-/71- #"()-7#<"4)"
H-.-I&4 J4)-&E&$)0#<&$&B
G)-/71&$&3:
K&' %&1#*&$F
L.)1"
!+(-, '&(+ !+(-, ()-7#<"4)"
M4&7#9 & +7*".-4)- %,"$" '& 3$)"'1#-4)" %)-.924"1F/4-2& $ #$)0#<+ # &%)-<0 4"'5
NNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNN
J)()9 ) 4"#$)7<&B
C"*" +,&'#-4)" NNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNN 4+(-, =>?>@AB NNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNN
DEF$"*-.7*$& NNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNN
G)-/71- #"()-7#<"4)" NNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNN
H-.-I&4 J4)-&E&$)0#<&$&B NNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNN
AB
M %,#F%"'<+ 2'F 4)- 4"'"4& 4+(-,+ =>?>@O 4".-PF %&'": 4+(-, '&<+(-4*+ %&*$)-,'#"/01-2& *&P7"(&3:N
!"#$$"%&'()*+&
,&/0&,&
Poz. 2284
!"#$% &&
! "#$%&'()*+%*,-./01(*,/-2&3*+%/,45&$&,'6,#$%&'()*+%&,4%*378+&(9:+*86,
'$()*+,"*-. /01
*2 34(5/6"0 +*70 68 39*(+")(0.
:2 "*34"7*;*-<"*34"7*;0- 6)# " (*9=7>*-) =39*(7)*?8,5-) +4 $()*+,"07)* 3)0@#A7*,5?70A4.
,2 7)0 -*- =6B*@470A4 39*(* +4 0-095B=95. 907B5. 907B5 94+")770? " B5B=;= $-)09,) -*;/47>*
39"5"7*70? ( 39"53*+>= ":)0A= 39*(* +4 907B5 94+")770? ) )770A4 $()*+,"07)* 0-095B*@74C
907B4(0A4. 907B5 64,?*@70?. "*6);>= 6B*;0A4. 7*=,"5,)0@6>)0A4 $()*+,"07)* >4-3076*,5?70A4.
"*6);>= 39"0+0-095B*@70A4 ) $()*+,"07)* 39"0+0-095B*@70A4.
+2 7)0 -*- =6B*@470A4 39*(* +4 $()*+,"07)* 3)0@#A7*,5?70A4. 630,?*@70A4 "*6);>=
43)0>=D,"0A4 ) "*6);>= +@* 43)0>=7*. 4 >BE95- -4(* ( =6B*()0 " +7)* F >()0B7)* GHIF 9J
4 =6B*@07)= ) (53;*,)0 "*6);>E( +@* 43)0>=7E( KL"J MJ 34"J NOP. " 3EQ7J "-J2.
02 464:* (5-*A*?8,* 43)0>)1
7)0 34"46B*?0 ( "()8">= -*;/0D6>)-. @=: (63E;-*;/470> @0A)B5-=?0 6)# 49"0,"07)04 "7*,"75- 6B437)= 7)030;74639*(74$,).
7)0 "46B*;* =-)06","47* ( 94+")7)0 "*6B#3,"0?. " (5?8B>)0- 94+")75 "*6B#3,"0?
634>90(7)470?. 94+")775- +4-= +")0,>* *@:4. ( "()8">= " >47)0,"74$,)8 >6"B*;,07)*.
90(*@)+*,?) @=: 90R*:)@)B*,?). ( 3@*,E(,0 "*30(7)*?8,0? ,*;4+4:4(8 43)0>#. ( B5( 630,?*@75- 4$94+>= 6">4@74C(5,R4(*(,"5-. " (5?8B>)0- 34+-)4B= (5>47=?8,0A4
+")*;*@74$% @0,"7),"8. @=: 7)0 >49"56B* ( 7)0? " ,*;4+4:4(0? 43)0>) 39"0" ()#,0? 7)/ N +7)
( B5A4+7)=.
S2 7* 464:# (5-*A*?8,8 43)0>) )77* 464:* 7)0 -* =6B*@470A4 39*(* +4 (,"0$7)0?6"0? 0-095B=95.
A2 ,";470> 94+")75 464:5 639*(=?8,0? 43)0># 7)0 -* =6B*@470A4 39*(* +4 +4+*B>= +4 "*6);>=
94+")770A4. 4 >BE95- -4(* ( *9BJ IH =6B*(5 " +7)* GT @)6B43*+* GHHU 9J 4 $()*+,"07)*,R
94+")775,R KL"J MJ " GHIN 9J 34"J IIF. " 3EQ7J "-J2. "(*70? +*@0? V=6B*(8W. 630,?*@70A4
"*6);>= 43)0>=D,"0A4. $()*+,"07)* 3)0@#A7*,5?70A4 ) "*6);>= +@* 43)0>=7*. 4 >BE95- -4(*
( =6B*()0 " +7)* F >()0B7)* GHIF 9J 4 =6B*@07)= ) (53;*,)0 "*6);>E( +@* 43)0>=7E(.
R2 7* 464:# (5-*A*?8,8 43)0>) 7)0 ?06B =6B*@470 39*(4 +4 +4+*B>= +4 "*6);>= 94+")770A4.
4 >BE95- -4(* ( *9BJ IH =6B*(5. 39*(4 +4 630,?*@70A4 "*6);>= 43)0>=D,"0A4. 39*(4 +4
$()*+,"07)* 3)0@#A7*,5?70A4 ) 39*(4 +4 "*6);>= +@* 43)0>=7*. 4 >BE95- -4(* ( =6B*()0
" +7)* F >()0B7)* GHIF 9J 4 =6B*@07)= ) (53;*,)0 "*6);>E( +@* 43)0>=7E(.
!"#$$"%&'()*+&
,&/1&,&
Poz. 2284
!" #$" %&%'(" )*+$,$-./." %0 12 " ##$" %&%'$" # 1" -1&3" 405$)# %#$" 6$" ,5$# /." 7%" 8) $7/61# $" #$"
0%25*/ 1")*7$329)"6) .6$#*/:"6"%0 12.";4'"05610 &*"%"2%%57*#$/- "&*&31+9)"6$'160 1/61# $"
&0%<1/6#1,%";4'"7)4&35%##1"4+%)*"%"6$'160 1/61# 4"&0%<1/6#*+"&3$#%) .=">1"056*&<4,4-./1"
6$" ,5$# /." 8) $7/61# 1" #$" 0%25*/ 1" )*7$329)" 6) .6$#*/:" 6" %0 12." # 1" )*<./6$" 05$)$" 7%"
3$2 1,%"8) $7/61# $"#$"0%7&3$) 1"4&3$)*="
-!" # 1" -1&31+" 6$3547# %#*?6$3547# %#$" $# " # 1" )*2%#4-(" ##1-" 05$/*" 6$5%'2%)1-" @05616"
6$3547# 1# 1" ;4'" )*2%#*)$# 1" ##1-" 05$/*" 6$5%'2%)1-" 5%64+ 1" & (A" )*2%#*)$# 1" 05$/*" #$"
0%7&3$) 1" &3%&4#24" 05$/*=" &3%&4#24" &<4>'%)1,%=" 4+%)*" %" 05$/(" #$2<$7/6." %5$6"
)*2%#*)$# 1"05$/*";4'"8) $7/61# 1"4&<4,"#$"0%7&3$) 1"4+%)*"$,1#/*-#1-="4+%)*"6;1/1# $="
4+%)*"%"76 1<%"$;'%")"%251& 1"/6<%#2%&3)$")"5%;# /61-"&09<76 1;# "05%742/*-#1-="&09<76 1;# "
29<12" 5%;# /6*/:" ;4'" &09<76 1;# " 4&<4," 5%;# /6*/:=" $" 3$2>1" 05%)$761# 1" 0%6$5%;# /61-"
76 $<$;#%8/ ",%&0%7$5/61-!="
2!" 0561'*)$+?# 1" 0561'*)$+B!" 0%6$" ,5$# /$+ " C61/6*0%&0%; 31-" D%;&2 1-BB!" )" 0$E&3) 1=" )"
2395*+"+$-."6$&3%&%)$# 1"05610 &*"%"2%%57*#$/- "&*&31+9)"6$'160 1/61# $"&0%<1/6#1,%BBB!="
;!" /6<%#12" +%-1-" 5%76 #*=" )" 5%64+ 1# 4" $53F" G" 023" HI" 4&3$)*" 6" 7# $" JK" ; &3%0$7$" JLLG" 5F" %"
8) $7/61# $/:" 5%76 ##*/:=" 0561'*)$?# 1" 0561'*)$B!" 0%6$" ,5$# /$+ " C61/6*0%&0%; 31-"
D%;&2 1-BB!" )" 0$E&3) 1=" )" 2395*+" +$-." 6$&3%&%)$# 1" 05610 &*" %" 2%%57*#$/- " &*&31+9)"
6$'160 1/61# $"&0%<1/6#1,%BBB!F"
B!
"
M 10%3561'#1"&2518; NF"
BB!
"
M 1" 7%3*/6*" )*-$674" ;4'" 0%'*34" 345*&3*/6#1,%=" ;1/6# /61,%" ;4'" 6) .6$#1,%" 6" 0%7-(/ 1+" 05616" 76 1/2%"
2&63$</1# $"0%6$",5$# /$+ "C61/6*0%&0%; 31-"D%;&2 1-F"
BBB!
"
D5610 &*"%"2%%57*#$/- "&*&31+9)"6$'160 1/61# $"&0%<1/6#1,%"+$-."6$&3%&%)$# 1"#$"3151# 1A"O4&35 ="P1;, ="
Q$# =" R #;$#7 =" R5$#/- =" S51/- =" T &60$# =" T%;$#7 =" U5;$#7 =" V42&1+'45,$=" M 1+ 1/=" D%534,$; =" W6)1/- ="
X<%/:="X 1;2 1-" P5*3$# ="Y*054="Y61/:="Z&3%# =" V 3)*=" [%3)*="\$;3*="D%;&2 ="W<%)$/- ="W<%)1# ="X(, 15="
P4<,$5 ="C4+4# "M%5)1, ="U&;$#7 ="V 1/:31#&31 #4="W6)$-/$5 "%5$6"%7"H"; 0/$"JLHG"5F"Y:%5)$/- F"
"
"
"""""""""FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF"
""""""""""""""""@7$3$="0%70 &"%&%'*"4' 1,$-./1-"& (!"
!
"#! $%&'()*+,-',! )./0*+1*,! 23/(4,-'(! 56(&(! ).! %&'()*+,-'(! 5',478-(*09-,8.! )4(! .3.:0;"
-(! </=6,9! +8.)-',! +! 56+,5'3(>'! 23/(&0! +! )-'(! "?! 42/,8.! @ABC! 6 ! ! D.),<3! 6.)+'--0!!!!!!!
'" .5',<2E*+0! FG+ ! H ! +! "I@?! 6 ! 5.+ ! "IJ"#! *'1K0! .:.&'1+,<! (4'>,-/(*09-0;! '--,9! -'K"
!"#$$"%&'()*+&
,&/2&,&
Poz. 2284
! "#$ !% &'()*+ *#$ )$ %+(')!,-.$ !/ %*+01$ %+(&0*$ 2#&/-3,*-$ 4,+(3&#$ 50"$ ! "#
"6473#$ ' 4,+*7$ ,#!/6%3,7$ !% &'()*+ *71$ )$ ' ,0.+(*+0$ 0!/#)-$ ,$ 4*+#$ 8$ 3,(')3#$
9:;;$'< $ )!%+('#*+0$ ' 4,+*-$ +$ !-!/(.+($ %+(3,-$ ,#!/6%3,(=$ >?,<$ @<$ ,$ 9:;A$ '<$ % ,<$ BB91$
,$%CD*<$,.<E<$
!"#$%&'(%)* +,./&($', /0/12 #2)%3%45',4 /6$,7$ 8$, +245* (/09%:$ 6/(1%#$,8$ 6.%# ./&($'$,:07$';* 05
)%</:,98$ :=1 :,3$92)=45 0$> /.(,'(,8$,) / (8%'(82) 09/68$= 8$,6,<8/06.%#8/"'$*
8$, )% $882'; /0?1 06/7.,#8$/82'; # 6$,.#0(2) 09/68$= ( /0/15 #2)%3%45'5 /6$,7$* 05
)%</:,98$, :=1 :,3$92)=45 0$> /.(,'(,8$,) / (8%'(82) 09/68$= 8$,6,<8/06.%#8/"'$ /.%(
8$, )% /6$,7=8% @%792'(8,3/ &($,'7% #2)%3%45',3/ /6$,7$ %8$ /0/12 1>&5',4 ./&($85
(%09>6'(5 06/7.,#8$/85* &:% &($,'7% #2)%3%45',3/ /6$,7$ # ./(=)$,8$= =09%#2 ( &8$%
A '(,.#'% BCDD .E / #06$,.%8$= ./&($82 $ 0209,)$, 6$,'(2 (%09>6'(,4* :=1 :,3$92)=45 0$>
/.(,'(,8$,) / (8%'(82) 09/68$= 8$,6,<8/06.%#8/"'$E
EEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEE
F&%9%* 6/&6$0 /0/12 =1$,3%45',4 0$>G
H(>"I JJJ
FG)+#43,(*+($ $,#%',(!/#*+0$%' )#4,(*+#$H !% 4#'!/)#$' 5*(H $50"$)-& *-)#*+#$%'#3-$)$
H !% 4#'!/)+($' 5*-.$%',(,$' 5*+&#1$.#IJ *&#$' 5*+&#$50"$4 . )*+&#K$
$
FG)+#43,#.1$J(K$
;<$$$$L(!/(.$' 5*+&+(.$+$$,#%',(!/#I#.M,#%',(!/#I(.$%' )#4,(*+#$H !% 4#'!/)#$' 5*(H $ 4$
4*+#$NNNNNNOE$
9<$ L(!/(.$ .#IJ *&+(.$ ' 5*+&#$ #5" $ 4 . )*+&+(.OOE$ +$ ,#%',(!/#I#.M,#%',(!/#I(.$
%' )#4,(*+#$H !% 4#'!/)#$' 5*(H $#5" $)-& *-)#*+#$%'#3-$)$H !% 4#'!/)+($' 5*-.$OOE$ 4$
4*+#$NNNNNNOE$
$
!"#$%&'(%)* +, 4,09,) "#$%&/)2K"#$%&/)% /&6/#$,&($%:8/"'$ 7%.8,4 (% (</+,8$, @%<0(2#,3/
/"#$%&'(,8$%E
LG
M%:,+2 #6$0%I &%9>* /& 7$,&2 (%6.(,09%8/ 6./#%&(,8$% 3/06/&%.09#% ./:8,3/ %:1/ #27/82#%8$% 6.%'2
# 3/06/&%.09#$, ./:82)E
LLG
M$,6/9.(,18, 07.,":$IE
EEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEE
F&%9%* 6/&6$0 /0/12 =1$,3%45',4 0$>G
!"#$$"%&'()*+&
,&/3&,&
Poz. 2284
! "#$%"&'() $*+&, *&-./%/0 1"2%1 ,& "#&13 '3 41+&'/$5,+& "+5678,&/%-,5839
! "#$#%&'()*+$,! #-,".),%),-! */*(,$#)*+$,! 01,%),*)0$2! 3* 04%56 *"*7-! 87,%&-59$-! ",:! 5%".!
*7* ,9#-)-! ),%# ;*$#),%! 3* ,-<*1,=! *! .0$2! #1,-)-$2! 3*<1,*. >%-(,#859$0! + ,-<$#%),-!
>*<#,))%?!
@,%3*,)A*>1* -),%! *>&-)8! ;-+$, %&*! 3>* -<#9$%&*! 3*".:3* -),%! ! "3>- ,%! + ,-<$#%B
>*<#,))0$2!*!#1,-)-$26!*!/.'>0$2!1* -!3* 04%56!1*4%!"/8./* -=!3* ".-),%1!),%)-(%4),%
3*7>-)0$2! + ,-<$#%B! >*<#,))0$26! -! ! /*)"%/ %)$5,! ! /*),%$#)*+$,9! ,$2! # >*.8! >-#! #!
*<"%./-1,!8".- * 01,!#-!*3'C),%),%?
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
"#$%$& '(#')* (*(+, -+)./$012.0 *)34
5( 67)(*8- #(912:$; 7$*%3'-012. #(8-;.7%,<
=4
!!!!!!!!!!!!!!!!!!!!!!!!!!!
>4
!!!!!!!!!!!!!!!!!!!!!!!!!!!
?4
!!!!!!!!!!!!!!!!!!!!!!!!!!!
@4
!!!!!!!!!!!!!!!!!!!!!!!!!!!
AB6)$#2:$;& C. 0.*%.; B6)$#(;,DB6)$#(;$ (#'(6).#:)$E7(B2) 8$F7.0 :$ :9(C.7). G$9*:,6./(
(B6)$#2:.7)$!
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
";).0*2(6(BH& #$%$4
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
"'(#')* (*(+, -+)./$012.0 *)3 *89$#$012.0 (B6)$#2:.7).4
!
!
D*8$#%),%
I6)$#2:.7). ').E3/7$2,07. : %,%-9- F.:,/7$20) : :$%F-#7).7)$ E-+ )77.0 'F$2, :$F(+8(6.0
'F:,*9-/-0.<
=4 ;$%2. $E+( (02-&
>4 (').8-7(6) G$8%,2:7.;- #:).28$&
?4 (*(+). +3#12.0 F(#:)71 :$*%3'2:1 *'(8F.67)(71 6 F(:-;).7)- -*%$6, : #7)$ J 2:.F62$
>K== F! ( 6*').F$7)- F(#:)7, ) *,*%.;). ').2:, :$*%3'2:.0&
@4 )77,; (*(+(;& 7$ 8%LF,2M :/(#7). : 'F:.')*$;) -*%$6, : #7)$ >N E-%./( =JO@ F! P Q(#.8*
!"#$$"%&'()*+&
,&-.&,&
Poz. 2284
!"#$%%&'$'!($)*+,-#&'-$./&'!0!1$.#)*'23$4)%52-&6%&7'#'1&6.5*$)4'!890'!'#%2-#%&4'85!(%$+'
%$)():%!8( 21%!;-$'
' 6)/)3$' %$)' (!")64+6.' 3+0' )#&<%+6.' #' #25 +"%$)%$2' 3+0' $%%)6' ( 2-&' #2 !0*!1)6' 1' -)3+'
8( 21!12%$2' !($)*$' %2"' !8!0.' 3)<$5&4+6.-.' 8$=' ! #)-#)%$)4' !' #%2-#%&4' 85!(%$+'
%$)():%!8( 21%!;-$' 230!' ! #)-#)%$)4' !' %$)():%!8( 21%!;-$' :.-#%$)' #)' 18*2#2%$24$>'
*!%$)-#%!;-$' 852:)6' 3+0' ":+<!5 12:)6' !($)*$' 3+0' (!4!-&' $%%)6' !8!0&' 1' #1$.#*+' #)' #%2-#%$)'
!< 2%$-#!%.'4!/3$1!;-$.'824!"#$)3%$)6')<#&85)%-6$'' ! 2#' *!%$)-#%!;-$'852:)<!'18(9:+"#$2:+'%2'
-!'"#$),'!($)*+%2'"#$)-*2'1'( !-)8$)'6)<!'3)-#)%$27' )?20$3$52-6$'$')"+*2-6$@'
'
A8!0!47' !' *59 &-?' 4!12' 1' (*5' B7' $%%&4' %$/' 8(!* )1%$!%)' 1' ($) 18#&4' 85!(%$+' #' !8!0.'
1&42<26.-.' !($)*$7' ;1$2"-#)%$)' ($)3=<%2-&6%)' ( #&8:+<+6)7' 1' ( #&(2"*+' <"&' 8():%$!%)' 8.'
:.-#%$)'%285=(+6.-)'12 +%*$>'
CD' !"#$-)' !8!0&' 1&42<26.-)6' !($)*$' %$)' /&6.7' #!8523$' (!#021$)%$' ( 21' !"#$-$)38*$-?7' 8.'
42:!3)5%$'3+0'3)<$5&4+6.'8$='! #)-#)%$)4'!'#%2-#%&4'85!(%$+'%$)():%!8( 21%!;-$E'
FD' %$)' 42' $%%&-?' !890' 8(!* )1%$!%&-?' 1' ($) 18#&4' 85!(%$+7' 8.' 42:!3)5%$)' 3+0' 3)<$5&4+6.' 8$='
! #)-#)%$)4'!'#%2-#%&4'85!(%$+'%$)():%!8( 21%!;-$E'
GD'%$)'42'!8907'!'*59 &-?'4!12'1'(*5'F'$'G7'3+0'3)<$5&4+6.'8$='! #)-#)%$)4'!'#%2-#%&4'85!(%$+'
%$)():%!8( 21%!;-$@'
'
H1$2"-#)%$)'($)3=<%2-&6%)'( #&8:+<+6)>'
CD'!0&125)3!4'(!38*$47'
FD'-+"#!#$)4-!4>'
2D "!'*59 &-?'85!8+6)'8$='( #)($8&'!'*!! "&%2-6$'8&85)491'#20)#($)-#)%$2'8(!:)-#%)<!7'
0D '6)/)3$' 1&%$*2' 5!' #' 1$./.-&-?' I#)-#(!8(!3$5.' J!38*.' +491' "1+85 !%%&-?''''''''''''''''''''''''
!'#20)#($)-#)%$+'8(!:)-#%&47'
-D ( #)0&126.-&4' %2' 5) &5! $+4' I#)-#&(!8(!3$5)6' J!38*$)6' %2' (!"8521$)' #)#1!3)%$2' %2'
(!0&5' 852:&7' #)#1!3)%$2' %2' (!0&5' )#&")%52' ":+<!5) 4$%!1)<!' K%$$' L+ !()68*$)67'
#)#1!3)%$2'%2'(!0&5'-#28!1&'+"#$)3!%)<!'1'#1$.#*+'#'!*!3$-#%!;-$24$7'!'*59 &-?'4!12'
1' 2 5@' CFM' 3+0' 2 5@' CNO' +85@' C' (*5' G' +8521&' #' "%$2' CF' < +"%$2' FPCG' @' !' -+"#!#$)4-2-?''
QR#@' K@' (!#@' COSP7' #' (9T%@' #4@D7' 3+0' 1' #1$.#*+' #' +#&8*2%$)4' 1' I#)-#&(!8(!3$5)6'
J!38*$)6' 8525+8+' +-?!"T-&' 3+0' !-? !%&' +#+():%$26.-)67' 6)/)3$' #24$)8#*+6.' #' -#:!%*24$'
!"#$%'%2'5) &5! $+4'I#)-#&(!8(!3$5)6'J!38*$)67'
!"#$$"%&'()*+&
,&-/&,&
Poz. 2284
! "#$%& &'()*+, -&./0, "#1*/2, 3, & 4#/&)'(, 5 #$/0", #, .*4-2, ".&)*67, 3, 8*9()3:4%:+,
#1*8&/:;%, "&<$/8, /.3:)%)=7, -/>.3*, 23*$-&;%, 3:38#;:4%:, 4&, ".&)0, 4&, /:.*/#.%2+, "&<$/8&,
)39#4-#8$-%:?#,4&,#-.:$,4%:".3:-.&)3&'()*,$3:@)%2,+%:$%0)*7,#1*8&/:;%,"&<$/8,/.3:)%)=,
".3*'0/*)=,8,):;2,"# '0)%&,$/2 %>8,#.&3,#1*8&/:;%,"&<$/8,/.3:)%)=7,-/>.3*,+&'(,".&8#, #,
8*-#4*8&4%&,".&)*,4&,"# $/&8%:,8%3*,
, ':A:;%, 3&+%:$3-2'(, 4&, /:.*/#.%2+, B3:)3*"#$"#;%/:', C#;$-%:', ".3:3, #-.:$, 3&$%9-#8*7, 8, -/>.*+,
#/.3*+2'(, @8%& )3:4%&, .# 3%44:7, )=*1&, A:, ".3:"%$*, #, -##. *4&)'%, $*$/:+>8, 3&1:3"%:)3:4%&,
$"#9:)34:?#, ;21, 82$/.#44:, 2+#8*, +%0 3*4&.# #8:, #, 3&1:3"%:)3:4%2, $"#9:)34*+, $/&4#8%(,
%4&)3:', D&./E, F, 2$/E, G, %, H, 2$/&8*, 3, 4%&, GI, ;%$/#"& &, GJJH, .E, #, @8%& )3:4%&)=, .# 3%44*)=,,
DK3E,LE,3,GJFM,.E,"#3E,FFN7,3,">O4E,3+E!7,38&4:', &;:',52$/&8(6!E,
P8%& )3:4%:, "%:;0?4&)*'4:, ".3*$92?2':7, ':A:;%, 4%:":94#$".&84#@Q, #$#1*, 8*+&?&'():',
#"%:-%,"#8$/&9&R,
F!, 4%:,">O4%:',4%A, #,2-#<)3:4%&,FIE,.#-2,A*)%&,;21,
G!, 8,/.&-)%:,4&2-%,8,$3-#;:,;21,$3-#;:,8*A$3:'7,': 4&-,4%:,">O4%:',4%A, #,2-#<)3:4%&,GME,.#-2,
,A*)%&E,
P8%& )3:4%:,"%:;0?4&)*'4:,4%:,".3*$92?2':7,':A:;%R,
F!,#$#1&,$".&82'()&,#"%:-0R,
&!, +&, 2$/&;#4:, ".&8#, #, :+:.*/2.*7, .:4/*7, .:4/*, .# 3%44:', 3, /*/292, @+%:.)%, +&9A#4-&,
".3*34&4:', 8, ".3*"& -2, 31%:?2, ".&8&, #, .:4/*, .# 3%44:', %, %44:?#, @8%& )3:4%&,
:+:.*/&;4#S.:4/#8:?#7, .:4/*, $#)'&;4:'7, 3&$%9-2, $/&9:?#7, 4&2)3*)%:;$-%:?#, @8%& )3:4%&,
-#+":4$&)*'4:?#7,3&$%9-2,".3: :+:.*/&;4:?#,;21,@8%& )3:4%&,".3: :+:.*/&;4:?#7,
1!,+&, 2$/&;#4:, ".&8#, #, $":)'&;4:?#, 3&$%9-2, #"%:-2<)3:?#7, @8%& )3:4%&, "%:;0?4&)*'4:?#,
;21,3&$%9-2, ;&,#"%:-24&7,#,-/>.*+,+#8&,8,2$/&8%:,3, 4%&,N,-8%:/4%&,GJFN,.E,#,2$/&;:4%2,,,
%,8*"9&)%:,3&$%9->8, ;&,#"%:-24>8T,
G!,#$#1&,8*+&?&'()&,#"%:-%R,
&!, "#3#$/&':, 8, 38%(3-2, +&9A:<$-%+7, )=*1&, A:, 8$">9+&9A#4:-, ;:?%/*+2':, $%0, #.3:)3:4%:+,,,,,,,,,,,,,,,,
#,34&)34*+,$/#"4%2,4%:":94#$".&84#@)%7,
1!,3#$/&9&, 2+%:$3)3#4&, 8, .# 3%4%:, 3&$/0")3:'7, 3, 8*'(/-%:+, .# 3%4*, 3&$/0")3:',
$"#-.:84%#4:'7, .# 3%44*+, #+2, 3%:)-&, &;1#7, 8, 38%(3-2, 3, -#4%:)34#@)%(, -$3/&9):4%&7,
.:8&;% &)'%, ;21, .:=&1%;%/&)'%7, 8, ";&)>8):, 3&":84%&'():', )&9# #1#8(, #"%:-07, 8, /*+,,,,,,,,,,,,,,
8, $":)'&;4*+, #@.# -2, $3-#;4#S8*)=#8&8)3*+7, 3, 8*'(/-%:+, "# +%#/2, 8*-#42'():?#,
3%&9&;4#@Q, ;:)34%)3(7, %, -#.3*$/&, 8, 4%:', 3, )&9# #1#8:', #"%:-%, ".3:3, 8%0):', 4%A, M, 4%,,,,,,,,,,,,,,,,,
!"#$$"%&'()*+&
,&--&,&
Poz. 2284
!"#$%&'()*!
+,! '-!%.%/0! #1-$-2343!%5(67(!(''-!%.%/-!1-!)."-8%'6!59- %!&%! 4:6;'(62.:62!6169#")9#*!
<,! 4:=%'67! 9%&:('#! %.%/#! .59- )23462! %5(670! 1-! )."-8%'6! 59- %! &%! &%&-"7)! &%! :-.(=7)!
9%&:(''6$%>! %! 7"?9#1! 1% -! ! -9"@! AB! )."- #>! 59- %! &%! .5642-8'6$%! :-.(=7)! %5(67)C4:6$%>!
59- %! &%! ; (-&4:6'(-! 5(680$'-4#2'6$%! 8)/! 59- %! &%! :-.(=7)! &8-! %5(67)'->! %! 7"?9#1! 1% -!!!!!!!!!!!!!!!!!
!)."- (6!:!&'(-!<!7 (6"'(-!DBA<!9@!%!)."-86'()!(! #5=-4(6!:-.(=7? !&8-!%5(67)'? *!
E,! '-!%.%/0! #1-$-2343!%5(67(!26."!)."-8%'6!59- %!&%!&%&-"7)!&%!:-.(=7)!9%&:(''6$%>!%!7"?9#1!
1% -!
! -9"@! AB! )."- #>! 59- %! &%! .5642-8'6$%! :-.(=7)! %5(67)C4:6$%>! ; (-&4:6'(-!
5(680$'-4#2'6$%!8)/!:-.(=7)!&8-!%5(67)'->!%!7"?9#1!1% -! !)."- (6!:!&'(-!<!7 (6"'(-!DBA<!9@!
%!)."-86'()!(! #5=-4(6!:-.(=7? !&8-!%5(67)'? *!
F,! '-! %.%/0!
5%79#4(6!
#1-$-2343! %5(67(! (''-! %.%/-! 26."! )59- '(%'-! :-! $9-'(43! &%! ; (-&4:6'(-! '-!
#&-"7? ! : (3:-'#4G! :! %5(673>! 4G#/-! H6! 59:65(.#! %! 7%%9&#'-42(! .#."61? !
:-/6:5(64:6'(-! .5%=64:'6$%! 8)/! & )."9%''6! )1% #! %! :-/6:5(64:6'()! .5%=64:'#1! ."-'% (3!
('-4:62@!
! !
I!59:#5-&7)!$&#!%!; (-&4:6'(6!5(680$'-4#2'6!)/(6$-!.(0!9%8'(7>!1-=H%'67!9%8'(7-!/3&J!
&%1% '(7>!; (-&4:6'(6!"%!59:#.=)$)26!%&5% (6&'(%K!!
A, 9%8'(7%1! !59:#5-&7)!:-59:6."-'(-!59% -&:6'(-!59:6:!'(4G!$%.5%&-9." -!9%8'6$%*!!
D, 1-=H%'7%1! 9%8'(7? ! 8)/! &%1% '(7%1! ! 59:#5-&7)! :-59:6."-'(-! 59% -&:6'(-! 59:6:!
'(4G!$%.5%&-9." -!9%8'6$%!-8/%! #7%'# -'(-!59:6:!'(4G!59-4#! !$%.5%&-9." (6!9%8'#1@!!
! !
L-59:6."-'(6! 59% -&:6'(-! $%.5%&-9." -! 9%8'6$%! 8)/! :-59:6."-'(6! #7%'# -'(-! 59-4#!!!!!!!!!!!!!!!!!!!!
! $%.5%&-9." (6! 9%8'#1! 5%" (69&:-! .(0! ."%.% '#1! %; (-&4:6'(61! :=%H%'#1! 5%&! 9#$%961!
%&5% (6&:(-8'%;4(! 7-9'62! :-! .7=-&-'(6! M-=.:# #4G! :6:'-C@! N7=-&-234#! %; (-&4:6'(6! 26."!
%/% (3:-'#! &%! :- -94(-!
! '(1! 78-):)8(! '-."05)23462! "96;4(K! OP6."61! ; (-&%1#!
%&5% (6&:(-8'%;4(! 7-9'62! :-! :=%H6'(6! M-=.:# 6$%! %; (-&4:6'(-@Q@! R8-):)8-! "-! :-."05)26!
5%)4:6'(6!%9$-')!%!%&5% (6&:(-8'%;4(!7-9'62!:-!.7=-&-'(6!M-=.:# #4G!:6:'-C!S-9"@!AT/!)."- #,@!
!
I!59:#5-&7)!:/(6$)!)59- '(6C!&%!'-."05)234#4G!; (-&4:6CK!
A,
; (-&4:6'(-!9%&:(4(68.7(6$%!8)/!
D,
; (-&4:6'(-!5(680$'-4#2'6$%>!8)/!
+,
.5642-8'6$%!:-.(=7)!%5(67)C4:6$%>!8)/!
<,
&%&-"7)!&%!:-.(=7)!9%&:(''6$%!:!"#")=)!%5(67(!'-&! &:(647(61! !%796.(6! 7%9:#."-'(-!!!!!!!!!!!!!!
:!)98%5)! #4G% - 4:6$%>!8)/!
!"#$$"%&'()*+&
!
,&-0&,&
Poz. 2284
"#$%&'()*+#),-%.'(/#0),)'12345)5,6#)6)($1#6%.)")*/%#)7)'6%.1/%#)89:7)3;),)($1#+./%()
%)64-&#<%.)"#$%&'26)*+#),-%.'(/26)
=)-3"4$&(>(?.)?.*/,)")14<@)A6%#*<".B)64C3#/.)-3"."),$,CD)(-3#6/%,/E)F#31;)8G)($1;) )($1#64!;)
!"#$% &$'()%*+,% "'- *(". #$#/'+0%1% 1'(0/2#,01'( 3#/'%4#5'6 3#45'#. /732%,%*+,7)
8/'%4,0(1'( 3'(9-)1%,7*1( # :%;4(* 05'%1'( 5%*+,(* /327/ 1% 3<%/# 4# 8/'%4,0(1'%)
3'(9-)1%,7*1()#= / .75 <>/1'(; # 3<073%4:& /7*%04& #"#$7 &3<%/1'#1(* 9&$ ,02#1:%
<#40'17 .(* #"#$7 3#0% )<%1',-)?0(,073#"3#9'.(* @#9":'(*A)
B'(3#'1C#<5#/%1'( #<)%1& /2%8,'/()# 3<#/%40+,()# 3#".-3#/%1'( / "3<%/'( 8/'%4,0(D)
<#40'117,E # 05'%1%,E= # :.><7,E 5#/% 3#/7;(*= 5#;( ":&.:#/%6 3#/".%1'(5 1'(1%9(;1'()
3#$<%17,E 8/'%4,0(D <#40'117,E= % / :#1"(:/(1,*'
:#1'(,01#8,'+ ',E 0/<#.& /<%0 0
#4"(.:%5' &".%/#/75' 0% #3>F1'(1'(A)
HA6%#*<"#50)I.)"#-,"/#&#5J"#-,"/#&.5)$%D)")-,64I$"45)-,(<"./%.5!)
)
)
;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;)
))))))))F5%.?$<,6,AK0)*#1#)%)-,*-%$),$,C4)$'&#*#?E<.?),A6%#*<"./%.!)