WNIOSEK O NADANIE OBYWATELSTWA POLSKIEGO

WNIOSEK O NADANIE OBYWATELSTWA POLSKIEGO

Z)*A2?N"$+I!3/"#+21B8/B>A*I$"(3)$&*4
"
9(+!2"2"%!'>"(#J1(/=
O' ( !. &1
!,'+%+'(&,!P)O+*&/.*O+,#!/.1(&Q!
#5>8B,2D48L=78=78A,@95A?<65>6,2=793:?,4593>R,>649>=6S,37R,>,9CM6;=78=76A7,>6A783>I>9=DA7,,
=6,3E5T,NU,7,NV
1
,
"
(A7R,7,=6>273:9,2=793:9B62ID
TTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTT,B=76,TTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTT,5T
98)*B&A$($FN")"%!'!=
..................................................................
[)*B&A*"3!"(47*B*3)*"H$'$I+!H))"9P@Q"A8"R"L@Q"A8="$&G6@"4'G+1AO"%$'1A21"(3)$&*4
P58>DB8=E,
R>8I>D49349<7E8M,#9<3:78M
O=93>R,9,=6B6=78,9CD26E8<3E26,49<3:78F9
W>636B=78=78
2
[)*B&A*"3!"(#)&!3)*"%!7&2*I$"A)>I/"/2!&!%3)*3)!C
.......................................................
"
9#$%#)&"(3)$&4$%!(A1=
3
(T,
%6=8,I?B>9>78AI6,?C78F6MJI8F9,37R,9,=6B6=78,9CD26E8<3E26
0," ]8)?"9)8)$3!=
2. Nazwisko
3. Nazwisko rodowe
P," :!'!"/+$%2*3)!"9%2)*^@"8)*&)>A@"+$4=
/
/
Q," [)*B&A*"/+$%2*3)!"9#!^&'($@"8)*B&A$($FN=
<," ]8)?"$BA!
T," !2()&4$"$BA!
V," ]8)?"8!'4)
9. Nazwisko rodowe matki
05," ZJ*N"9["U"8?XA2123!@"_"U"4$6)*'!=
11. Obywatelstwo
0-," `'!3"A1()731
4
0L,"
/8*+"Za`ab"9B*X*7)"2$&'!J"3!%!31=
((T, +B583,>6A783>:6=76,I?B>9>78AI6
0," Z!^&'($
-," [)*B&A$($FN"9(+!2"2"4$%*8"#$A2'$(18=
L," ;7)A!"93/8*+"%$8/")"3/8*+"8)*&24!3)!=
(((T,,,(=@95A6IM8,9,49376B6=7?,9CD26E8<3E26,49<3:78F9,2,45>83>L9;I7G,M8F9,?E56I78,956>
B6I78,=6CDI76,9CD26E8<3E26,7==8F9,46X3E26
0," c21"A/%2$2)*8)*A"#$&)!%!J"$61(!'*7&'($"#$7&4)*"9(#)&!N"de_"7/6" ]a=
-," f*X*7)"'!4"U"("B!4)AO"7!'!AO
L," E4$7)A23$FA)"/'+!'1"$61(!'*7&'(!"#$7&4)*I$"93#,"2*2($7*3)*"3!"28)!3?@"2+2*A2*3)*=
P," :!'!"3!61A)!"$61(!'*7&'(!")33*I$"#!^&'(!"9%2)*^@"8)*&)>A@"+$4=
/
/
(YT, ,(=@95A6IM8, 9, 59B>7I6IK, I?B>9>78AI6, 7, B6<3>DIK, 23ER4=DIKG, M8Z8<7, 49376B6<7
9CD26E8<3E29,49<3:78
0," EBA)*A"(3)$&4$%!(A1C
!=":!'!"/+$%2*3)!"9%2)*^@"8)*&)>A@"+$4=
/
/
6="[)*B&A*"/+$%2*3)!"9#!^&'($@"8)*B&A$($FN=
Q
A=""E4$7)A23$FA)" /'+!'1" $61(!'*7&'(!" #$7&4)*I$" #+2*2" $BA!" 93#," (" (13)4/" $6$()>21(!3)!"
4$3(*3AB)@" /21&4!3)!" 2*2($7*3)!" 3!" 28)!3?" 7/6" 2I$%1" 3!" 2+2*A2*3)*" &)?" $61(!'*7&'(!"
polskiego) oraz ewentualnie data utraty
d) Obywatelstwo
*=" /8*+"Za`ab"9B*X*7)"2$&'!J"3!%!31=
-," [!'4!"(3)$&4$%!(A1C
!=":!'!"/+$%2*3)!"9%2)*^@"8)*&)>A@"+$4=
/
/
6="[)*B&A*"/+$%2*3)!"9#!^&'($@"8)*B&A$($FN=
A=""E4$7)A23$FA)" /'+!'1" $61(!'*7&'(!" #$7&4)*I$" #+2*2" 8!'4?" 93#," (" (13)4/" $6$()>21(!3)!"
4$3(*3AB)@" /21&4!3)!" 2*2($7*3)!" 3!" 28)!3?" 7/6" 2I$%1" 3!" 2+2*A2*3)*" &)?" $61(!'*7&'(!"
polskiego) oraz ewentualnie data utraty
d) Obywatelstwo
*=" /8*+"Za`ab"9B*X*7)"2$&'!J"3!%!31=
L," :!7&)"(&'?#3)"9%2)!%4$()*@"#+!%2)!%4$()*="(#)&!N"%!3*"B!4"("##4'"0"7/6"-
6
YT, (, =@95A6IM8,9,[5HBL6IK,?E5>DA6=76,I?B>9>78AI6G,M8F9,937JF=7RI76IK,>629B92DIKG
B>76L6<=9;I7,49<7EDI>=8M,7,349L8I>=8M
0," g+G%J!"/'+218!3)!
!="#+$(!%2*3)*"(J!&3*B"%2)!J!73$FA)"I$&#$%!+A2*B"9#$%!N"+$%2!B=
6="/8$(!"$"#+!A?"9#$%!N"8)*B&A*"#+!A1=
A="/8$(1"27*A*3)!@"$"%2)*J$")'#,
%=")33*"S+G%J!"/'+218!3)!
-," "E&)>I3)?A)!"2!($%$(*"93#,"&'$#3)*")"'1'/J1"3!/4$(*"7/6"2!($%$(*@"#+!A*"'(G+A2*@"#/67)A1&'14!@"
3!I+$%1@"(14$3!3*"#+$B*4'1=
L," "Z+213!7*X3$FN"%$"#!+'))"#$7)'1A231AO"9B*X*7)"'!4"U"%$"B!4)AO")"$%"4)*%1=
7
P," "Y$%2!B"%2)!J!73$FA)"&#$J*A23*B@"#+213!7*X3$FN"%$"$+I!3)2!AB)"&#$J*A231AO"9B*X*7)"'!4"U"%$"B!4)AO"
i od kiedy)
, ,Y(T, ,(=@95A6IM8, 9, >=6M9A9;I7, 45>8>, I?B>9>78AI6, MR>D:6, 49<3:78F9, \28BL?F, 9I8=D
2=793:9B62ID],^,49B:58;<7S,2L6;I728
0,"h+!4"23!B$8$FA)"B?214!"#$7&4)*I$"("8$()*")"#)F8)*,
-,""Z$2)$8" #)*+(&21" U" A/%2$2)*8)*A" +$2/8)*" (1+!X*3)!" )" 3!BA2?FA)*B" /X1(!3*" &J$(3)A'($
%$'1A2>A*"3!B67)X&21AO"8/"%2)*%2)3"X1A)!@"7*A2"3)*"/8)*"#)&!N"("B?214/"#$7&4)8,
L,""Z$2)$8" %+/I)" U" A/%2$2)*8)*A" #$+$2/8)*(!" &)?" (" B?214/" #$7&4)8" $+!2" #$'+!H)" 2!#)&!N" '*"
wypowiedzi.
P,"Z$2)$8"'+2*A)"U"A/%2$2)*8)*A"#$&J/I/B*"&)?"6)*I7*"B?214)*8"#$7&4)8"("8$()*")"#)F8)*,
, Y((T,,%6=8,A6LZ9=:6,I?B>9>78AI6
0," ]8)?"9)8)$3!=
2. Nazwisko
3. Obywatelstwo
Y(((T,,->D,I?B>9>78A78I,?C78F6L,37R,9,=6CDI78,9CD26E8<3E26,2,45>83>L9;I7,\M8Z8<7,E6:,^
4593>R,9,49B6=78,2,M6:7IK,9:9<7I>=9;I76IK,956>,828=E?6<=78,3DF=6E?5R,6:E]
V
(_T, ,(=@95A6IM8, B9EDI>JI8, A6L9<8E=78F9, 9CMRE8F9, 2=793:78A, =6, 49B3E6278, 65ET, `
?3E62D, >, B=76, U, :278E=76, Uaab, 5T, 9, 9CD26E8<3E278, 49<3:7A, \2, 45>D46B:?, FBD
2=7938:, 9C8MA?M8, 27RI8M, =7Z, M8B=8F9, A6L9<8E=78F9G, =6<8ZD, 2D48L=7S, 6=8:3, B9
=7=78M3>8F9,2=793:?]
0,":!3*"8!J$7*'3)*I$
!="]8)?"9)8)$3!=
b) Nazwisko i nazwisko rodowe
A=":!'!"/+$%2*3)!"9%2)*^@"8)*&)>A@"+$4=
/
/
%="[)*B&A*"/+$%2*3)!"9#!^&'($@"8)*B&A$($FN=
*="]8)?")"3!2()&4$"$BA!
H="]8)?")"3!2()&4$"+$%$(*"8!'4)
I="ZJ*N"9["U"8?XA2123!@"_"U"4$6)*'!=
O="E61(!'*7&'($
)="`'!3"A1()731
9
B=" /8*+"Za`ab"9B*X*7)"2$&'!J"3!%!31=
-," c
" 21"%+/I)*"2"+$%2)AG("8!J$7*'3)*I$"2J$X1J$"$F()!%A2*3)*"$"(1+!X*3)/"2I$%1"3!"3!61A)*"#+2*2
8!J$7*'3)*I$" $61(!'*7&'(!" #$7&4)*I$" U" !+'," T" /&'," -" #4'" -" /&'!(1" 2" %3)!" -" 4()*'3)!" -55." +,
$" $61(!'*7&'()*" #$7&4)8" 9(#)&!N" de_" 7/6" ]a" $+!2" (&4!2!N" $+I!3@" #+2*%" 4'G+18" 2J$X$3$
$F()!%A2*3)*@"$+!2"*(*3'/!73)*"&1I3!'/+?"!4'=
L," c
" 21"2$&'!J$"2J$X$3*"$F()!%A2*3)*"8!J$7*'3)*I$@"4'G+1"/4$^A21J"0<"7!'@"$"(1+!X*3)/"2I$%1"3!
3!61A)*" $61(!'*7&'(!" #$7&4)*I$@" $" 4'G+18" 8$(!" (" !+'," V" /&'!(1" 2" %3)!" -" 4()*'3)!" -55." +,
$" $61(!'*7&'()*" #$7&4)8" 9(#)&!N" de_" 7/6" ]a" $+!2" (&4!2!N" $+I!3@" #+2*%" 4'G+18" 2J$X$3$
$F()!%A2*3)*@"$+!2"*(*3'/!73)*"&1I3!'/+?"!4'=
,_T, (, A7R, 7, =6>273:9, 956>, 6B583, >6A783>:6=76, 45>8B3E627I78<6, ?3E62928F9
A6L9<8E=78F9,\2D48L=7S,M8BD=78,2,45>D46B:?G,FBD,2=7938:,9,=6B6=78,9CD26E8<3E26,
49<3:78F9,B9EDI>D,2DLJI>=78,A6L9<8E=78F9]
_(T, c78M3I8,=6,?>?48L=78=78,9B49278B>7,=6,4DE6=76,7,7=@95A6IM8,>6265E8,2,@95A?<65>?
10
Z+!(%2)($FN"%!31AO"2!(!+'1AO"(*"(3)$&4/"#$'()*+%2!8"(J!&3$+?A2318"#$%#)&*8,
.............................................................
"
9#$%#)&"(3)$&4$%!(A1=
[)*B&A*"3!"/+2?%$(*"#$F()!%A2*3)*"#$%#)&/"(3)$&4$%!(A1@"("#+21#!%4/"I%1"(3)$&*4"&4J!%!31"B*&'"4$+*&#$3%*3A1B3)*,
11
_((T,,!>=6I>8=78,95F6=?,45>DMA?MJI8F9,2=7938:,\29M829B6G,:9=3?<]
O=7938:,45>DMJLd
..................................................................
"
..................................................................
%!'!"9%2)*^@"8)*&)>A@"+$4="
9#$%#)&")"#)*A2?N"$&$61"#+21B8/B>A*B"(3)$&*4=
!C M6 ; = 7 8 = 7 6
B<6,93HC,2D48L=76MJIDIK,2=7938:
0,""Z+2*%"/%2)*7*3)*8"$%#$()*%2)"3!7*X1"/(!X3)*"2!#$23!N"&)?"2"'+*FA)>"#$&2A2*IG731AO"+/6+14"(3)$&4/@"!"("#+21#!%4/"
(>'#7)($FA)"2!#$23!N"&)?"2"'+*FA)>"/&'!(1"2"%3)!"-"4()*'3)!"-55."+,"$"$61(!'*7&'()*"#$7&4)8"9:2,";,"2"-50-"+,"#$2,"0<0=,
-," !7*X1"(1#*J3)N"(&21&'4)*"(18!I!3*"+/6+14),
L,"f*X*7)"#1'!3)*"3)*"%$'1A21"$&$61"(1#*J3)!B>A*B"(3)$&*4@"("$%#$()*%2)"3!7*X1"(#)&!N"(1+!21"i ]a":Edjc\jk,
P,"l3)$&*4"3!7*X1"(1#*J3)N"A21'*73)*"U"("B?214/"#$7&4)8"U"%+/4$(!318)"7)'*+!8),
Q,""c/%2$2)*8)*A" &#+!(/B>A1" (J!%2?" +$%2)A)*7&4>" 3!%" 8!J$7*'3)8" A/%2$2)*8A*8" /8)*&2A2!" (*" (3)$&4/" )3H$+8!AB*"
%$'1A2>A*" 8!J$7*'3)*I$" $6B?'*I$" (3)$&4)*8" 3!" #$%&'!()*" !+'," T" /&'!(1" 2" %3)!" -" 4()*'3)!" -55." +," $" $61(!'*7&'()*"
#$7&4)8" (" #4'" ]m" (3)$&4/," l" #+21#!%4/" I%1" (3)$&*4" $6*B8/B*" ()?A*B" 3)X" B*%3*I$" 8!J$7*'3)*I$@" 3!7*X1" (1#*J3)N"
!3*4&"%$"#4'"]m"(3)$&4/,":7!"4!X%*I$"4$7*B3*I$"8!J$7*'3)*I$"3!7*X1"(1#*J3)N"$%%2)*731"*I2*8#7!+2"!3*4&/,
<,""l"#+21#!%4/"I%1"(3)$&*4"%$'1A21"(1J>A23)*"8!J$7*'3)*I$"A/%2$2)*8A!@"#+2*%&'!()A)*7"/&'!($(1"/2!&!%3)!"(3)$&*4"
$+!2"(1#*J3)!"#4'"]@"]]]@"]n@"n@"n]@"n]]]@"]m"##4'"-")"L"$+!2"m"(3)$&4/,
T,":$"(3)$&4/"%$J>A2!"&)?"%$4/8*3'1"#$'()*+%2!B>A*"%!3*")")3H$+8!AB*"2!(!+'*"("#4'"]@"n@"n]]"7/6"("#4'"]m"(3)$&4/,
12
V,":$"(3)$&4/"%$J>A2!"&)?"#$&)!%!3*"%$4/8*3'1"#$'()*+%2!B>A*")3H$+8!AB*"2!(!+'*"("#4'"]]]")"]n"(3)$&4/,
.,":$4/8*3'!8)"#$'()*+%2!B>A18)"%!3*")")3H$+8!AB*@"$"4'G+1AO"8$(!"#$(1X*B@"8$I>"61N"("&2A2*IG73$FA)"%$4/8*3'11)C
" 0="&'()*+%2!B>A*"'$X&!8$FN")"$61(!'*7&'($K
" -="/#+!(3)!B>A*"%$"2!8)*&24!3)!"7/6"#$61'/"3!"'*+1'$+)/8"Y2*A21#$&#$7)'*B"Z$7&4)*BK
" L="$%#)&1"!4'G("/+$%2*3)!2)K
" P="$%#)&1"!4'G("8!JX*^&'(!"7/6")33*"%$4/8*3'1"$4+*F7!B>A*"&'!3"A1()7313)K
" Q="&'()*+%2!B>A*"'$X&!8$FN")"$61(!'*7&'($"8!JX$34!K
" <="&'()*+%2!B>A*"'$X&!8$FN"8!J$7*'3)*I$o8!J$7*'3)AOK
" T="/#+!(3)!B>A*"8!J$7*'3)*I$o8!J$7*'3)AO"%$"2!8)*&24!3)!"7/6"#$61'/"3!"'*+1'$+)/8"Y2*A21#$&#$7)'*B"Z$7&4)*BK
" V="#$'()*+%2!B>A*"#$&)!%!3)*"$61(!'*7&'(!"#$7&4)*I$"#+2*2"+$%2)AG("7/6"%!7&21AO"(&'?#31AOK
" .="#$'()*+%2!B>A*"/'+!'?"#+2*2"A/%2$2)*8A!@"B*I$"%2)*A4$o%2)*A)"$+!2"B*I$"(&'?#31AO"$61(!'*7&'(!"#$7&4)*I$K
05=""&'()*+%2!B>A*"3!61A)*"$61(!'*7&'(!"$6A*I$"#+2*2"A/%2$2)*8A!"7/6"B*I$"%2)*A4$o%2)*A)@"("#+21#!%4/"I%1"("#+2*&2J$FA)"
#$&)!%!7)"$61(!'*7&'($"#$7&4)*K
00="#$'()*+%2!B>A*"S+G%J$"/'+218!3)!K
0-="#$'()*+%2!B>A*"$&)>I3)?A)!"2!($%$(*@"%2)!J!73$FN"#$7)'1A23>")"&#$J*A23>,
"":$4/8*3'"(1%!31"("B?214/"$6A18"&4J!%!"&)?"(+!2"2"B*I$"'J/8!A2*3)*8"3!"B?214"#$7&4)"&#$+2>%2$318"#+2*2"'J/8!A2!"#+21&)?IJ*I$"
!76$"#+2*2"4$3&/7!"Y2*A21#$&#$7)'*B"Z$7&4)*B@"!"4$#)*"%$4/8*3'G("U"(+!2"2")AO"/+2?%$(18"#$F()!%A2*3)*8"2!"2I$%3$FN"2"$+1I)3!J*8,
2)
""c/%2$2)*8A1"&4J!%!B>A1"(3)$&*4"2!"#$F+*%3)A'(*8"($B*($%1"%$J>A2!B>"$%#)&1"!4'G("&'!3/"A1()73*I$"(1%!3*"3!"#$%&'!()*"#$7&4)AO"
4&)>I"&'!3/"A1()73*I$,
3)
"Z!'+2"U"$%3$F3)4"3+"-,
1)
13
+=8:3,B9,4:E,(_1)
2=793:?,9,=6B6=78,9CD26E8<3E26,49<3:78F9
"
[)*B&A*"3!"(47*B*3)*"H$'$I+!H))"9P@Q"A8"R"L@Q"A8="$&$61@"4'G+*B"%$'1A21"
wniosek
(_T,,,(=@95A6IM8, B9EDI>JI8, A6L9<8E=78F9, 9CMRE8F9, 2=793:78A, =6, 49B3E6278, 65ET, `
?3E62D,>,B=76,U,:278E=76,Uaab,5T,9,9CD26E8<3E278,49<3:7A
0,":!3*"8!J$7*'3)*I$
!="]8)?"9)8)$3!=
b) Nazwisko i nazwisko rodowe
A=":!'!"/+$%2*3)!"9%2)*^@"8)*&)>A@"+$4=
/
/
%="[)*B&A*"/+$%2*3)!"9#!^&'($@"8)*B&A$($FN=
*="]8)?")"3!2()&4$"$BA!
1)
""e3*4&"8!"2!&'$&$(!3)*"("#+21#!%4/"$6B?A)!"(3)$&4)*8"()?A*B"3)X"B*%3*I$"8!J$7*'3)*I$,":7!"4!X%*I$"4$7*B3*I$"8!J$7*'3)*I$"3!7*X1"
(1#*J3)N"$%%2)*731"*I2*8#7!+2"!3*4&/,
14
H="]8)?")"3!2()&4$"+$%$(*"8!'4)
I="ZJ*N"9["U"8?XA2123!@"_"U"4$6)*'!=
O="E61(!'*7&'($
)="`'!3"A1()731
B=" /8*+"Za`ab"9B*X*7)"2$&'!J"3!%!31=
-,""c21"%+/I)*"2"+$%2)AG("8!J$7*'3)*I$"2J$X1J$"$F()!%A2*3)*"$"(1+!X*3)/"2I$%1"3!"3!61A)*"#+2*2"
8!J$7*'3)*I$" $61(!'*7&'(!" #$7&4)*I$" U" !+'," T" /&'," -" #4'" -" /&'!(1" 2" %3)!" -" 4()*'3)!" -55." +,"
$" $61(!'*7&'()*" #$7&4)8" 9(#)&!N" de_" 7/6" ]a" $+!2" (&4!2!N" $+I!3@" #+2*%" 4'G+18" 2J$X$3$"
$F()!%A2*3)*@"$+!2"*(*3'/!73)*"&1I3!'/+?"!4'=
L,""c21"2$&'!J$"2J$X$3*"$F()!%A2*3)*"8!J$7*'3)*I$@"4'G+1"/4$^A21J"0<"7!'@"$"(1+!X*3)/"2I$%1"3!"
3!61A)*" $61(!'*7&'(!" #$7&4)*I$@" $" 4'G+18" 8$(!" (" !+'," V" /&'!(1" 2" %3)!" -" 4()*'3)!" -55." +,"
$" $61(!'*7&'()*" #$7&4)8" 9(#)&!N" de_" 7/6" ]a" $+!2" (&4!2!N" $+I!3@" #+2*%" 4'G+18" 2J$X$3$"
$F()!%A2*3)*@"$+!2"*(*3'/!73)*"&1I3!'/+?"!4'=
0Q