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{\f44\fbidi \fswiss\fcharset238\fprq2{\*\panose 00000000000000000000}Arial Narrow CE{\*\falt Arial};}{\flomajor\f31500\fbidi \froman\fcharset238\fprq2{\*\panose 02020603050405020304}Times New Roman;}
{\fdbmajor\f31501\fbidi \froman\fcharset238\fprq2{\*\panose 02020603050405020304}Times New Roman;}{\fhimajor\f31502\fbidi \fswiss\fcharset238\fprq2{\*\panose 020f0302020204030204}Calibri Light;}
{\fbimajor\f31503\fbidi \froman\fcharset238\fprq2{\*\panose 02020603050405020304}Times New Roman;}{\flominor\f31504\fbidi \froman\fcharset238\fprq2{\*\panose 02020603050405020304}Times New Roman;}
{\fdbminor\f31505\fbidi \froman\fcharset238\fprq2{\*\panose 02020603050405020304}Times New Roman;}{\fhiminor\f31506\fbidi \fswiss\fcharset238\fprq2{\*\panose 020f0502020204030204}Calibri;}
{\fbiminor\f31507\fbidi \froman\fcharset238\fprq2{\*\panose 02020603050405020304}Times New Roman;}{\f471\fbidi \froman\fcharset0\fprq2 Times New Roman;}{\f470\fbidi \froman\fcharset204\fprq2 Times New Roman Cyr;}
{\f472\fbidi \froman\fcharset161\fprq2 Times New Roman Greek;}{\f473\fbidi \froman\fcharset162\fprq2 Times New Roman Tur;}{\f474\fbidi \froman\fcharset177\fprq2 Times New Roman (Hebrew);}{\f475\fbidi \froman\fcharset178\fprq2 Times New Roman (Arabic);}
{\f476\fbidi \froman\fcharset186\fprq2 Times New Roman Baltic;}{\f477\fbidi \froman\fcharset163\fprq2 Times New Roman (Vietnamese);}{\f811\fbidi \froman\fcharset0\fprq2 Cambria Math;}{\f810\fbidi \froman\fcharset204\fprq2 Cambria Math Cyr;}
{\f812\fbidi \froman\fcharset161\fprq2 Cambria Math Greek;}{\f813\fbidi \froman\fcharset162\fprq2 Cambria Math Tur;}{\f816\fbidi \froman\fcharset186\fprq2 Cambria Math Baltic;}{\f817\fbidi \froman\fcharset163\fprq2 Cambria Math (Vietnamese);}
{\f841\fbidi \fswiss\fcharset0\fprq2 Calibri;}{\f840\fbidi \fswiss\fcharset204\fprq2 Calibri Cyr;}{\f842\fbidi \fswiss\fcharset161\fprq2 Calibri Greek;}{\f843\fbidi \fswiss\fcharset162\fprq2 Calibri Tur;}
{\f844\fbidi \fswiss\fcharset177\fprq2 Calibri (Hebrew);}{\f845\fbidi \fswiss\fcharset178\fprq2 Calibri (Arabic);}{\f846\fbidi \fswiss\fcharset186\fprq2 Calibri Baltic;}{\f847\fbidi \fswiss\fcharset163\fprq2 Calibri (Vietnamese);}
{\f899\fbidi \fswiss\fcharset238\fprq2 Arial Narrow CE;}{\f900\fbidi \fswiss\fcharset204\fprq2 Arial Narrow Cyr;}{\f902\fbidi \fswiss\fcharset161\fprq2 Arial Narrow Greek;}{\f903\fbidi \fswiss\fcharset162\fprq2 Arial Narrow Tur;}
{\f906\fbidi \fswiss\fcharset186\fprq2 Arial Narrow Baltic;}{\flomajor\f31510\fbidi \froman\fcharset0\fprq2 Times New Roman;}{\flomajor\f31509\fbidi \froman\fcharset204\fprq2 Times New Roman Cyr;}
{\flomajor\f31511\fbidi \froman\fcharset161\fprq2 Times New Roman Greek;}{\flomajor\f31512\fbidi \froman\fcharset162\fprq2 Times New Roman Tur;}{\flomajor\f31513\fbidi \froman\fcharset177\fprq2 Times New Roman (Hebrew);}
{\flomajor\f31514\fbidi \froman\fcharset178\fprq2 Times New Roman (Arabic);}{\flomajor\f31515\fbidi \froman\fcharset186\fprq2 Times New Roman Baltic;}{\flomajor\f31516\fbidi \froman\fcharset163\fprq2 Times New Roman (Vietnamese);}
{\fdbmajor\f31520\fbidi \froman\fcharset0\fprq2 Times New Roman;}{\fdbmajor\f31519\fbidi \froman\fcharset204\fprq2 Times New Roman Cyr;}{\fdbmajor\f31521\fbidi \froman\fcharset161\fprq2 Times New Roman Greek;}
{\fdbmajor\f31522\fbidi \froman\fcharset162\fprq2 Times New Roman Tur;}{\fdbmajor\f31523\fbidi \froman\fcharset177\fprq2 Times New Roman (Hebrew);}{\fdbmajor\f31524\fbidi \froman\fcharset178\fprq2 Times New Roman (Arabic);}
{\fdbmajor\f31525\fbidi \froman\fcharset186\fprq2 Times New Roman Baltic;}{\fdbmajor\f31526\fbidi \froman\fcharset163\fprq2 Times New Roman (Vietnamese);}{\fhimajor\f31530\fbidi \fswiss\fcharset0\fprq2 Calibri Light;}
{\fhimajor\f31529\fbidi \fswiss\fcharset204\fprq2 Calibri Light Cyr;}{\fhimajor\f31531\fbidi \fswiss\fcharset161\fprq2 Calibri Light Greek;}{\fhimajor\f31532\fbidi \fswiss\fcharset162\fprq2 Calibri Light Tur;}
{\fhimajor\f31533\fbidi \fswiss\fcharset177\fprq2 Calibri Light (Hebrew);}{\fhimajor\f31534\fbidi \fswiss\fcharset178\fprq2 Calibri Light (Arabic);}{\fhimajor\f31535\fbidi \fswiss\fcharset186\fprq2 Calibri Light Baltic;}
{\fhimajor\f31536\fbidi \fswiss\fcharset163\fprq2 Calibri Light (Vietnamese);}{\fbimajor\f31540\fbidi \froman\fcharset0\fprq2 Times New Roman;}{\fbimajor\f31539\fbidi \froman\fcharset204\fprq2 Times New Roman Cyr;}
{\fbimajor\f31541\fbidi \froman\fcharset161\fprq2 Times New Roman Greek;}{\fbimajor\f31542\fbidi \froman\fcharset162\fprq2 Times New Roman Tur;}{\fbimajor\f31543\fbidi \froman\fcharset177\fprq2 Times New Roman (Hebrew);}
{\fbimajor\f31544\fbidi \froman\fcharset178\fprq2 Times New Roman (Arabic);}{\fbimajor\f31545\fbidi \froman\fcharset186\fprq2 Times New Roman Baltic;}{\fbimajor\f31546\fbidi \froman\fcharset163\fprq2 Times New Roman (Vietnamese);}
{\flominor\f31550\fbidi \froman\fcharset0\fprq2 Times New Roman;}{\flominor\f31549\fbidi \froman\fcharset204\fprq2 Times New Roman Cyr;}{\flominor\f31551\fbidi \froman\fcharset161\fprq2 Times New Roman Greek;}
{\flominor\f31552\fbidi \froman\fcharset162\fprq2 Times New Roman Tur;}{\flominor\f31553\fbidi \froman\fcharset177\fprq2 Times New Roman (Hebrew);}{\flominor\f31554\fbidi \froman\fcharset178\fprq2 Times New Roman (Arabic);}
{\flominor\f31555\fbidi \froman\fcharset186\fprq2 Times New Roman Baltic;}{\flominor\f31556\fbidi \froman\fcharset163\fprq2 Times New Roman (Vietnamese);}{\fdbminor\f31560\fbidi \froman\fcharset0\fprq2 Times New Roman;}
{\fdbminor\f31559\fbidi \froman\fcharset204\fprq2 Times New Roman Cyr;}{\fdbminor\f31561\fbidi \froman\fcharset161\fprq2 Times New Roman Greek;}{\fdbminor\f31562\fbidi \froman\fcharset162\fprq2 Times New Roman Tur;}
{\fdbminor\f31563\fbidi \froman\fcharset177\fprq2 Times New Roman (Hebrew);}{\fdbminor\f31564\fbidi \froman\fcharset178\fprq2 Times New Roman (Arabic);}{\fdbminor\f31565\fbidi \froman\fcharset186\fprq2 Times New Roman Baltic;}
{\fdbminor\f31566\fbidi \froman\fcharset163\fprq2 Times New Roman (Vietnamese);}{\fhiminor\f31570\fbidi \fswiss\fcharset0\fprq2 Calibri;}{\fhiminor\f31569\fbidi \fswiss\fcharset204\fprq2 Calibri Cyr;}
{\fhiminor\f31571\fbidi \fswiss\fcharset161\fprq2 Calibri Greek;}{\fhiminor\f31572\fbidi \fswiss\fcharset162\fprq2 Calibri Tur;}{\fhiminor\f31573\fbidi \fswiss\fcharset177\fprq2 Calibri (Hebrew);}
{\fhiminor\f31574\fbidi \fswiss\fcharset178\fprq2 Calibri (Arabic);}{\fhiminor\f31575\fbidi \fswiss\fcharset186\fprq2 Calibri Baltic;}{\fhiminor\f31576\fbidi \fswiss\fcharset163\fprq2 Calibri (Vietnamese);}
{\fbiminor\f31580\fbidi \froman\fcharset0\fprq2 Times New Roman;}{\fbiminor\f31579\fbidi \froman\fcharset204\fprq2 Times New Roman Cyr;}{\fbiminor\f31581\fbidi \froman\fcharset161\fprq2 Times New Roman Greek;}
{\fbiminor\f31582\fbidi \froman\fcharset162\fprq2 Times New Roman Tur;}{\fbiminor\f31583\fbidi \froman\fcharset177\fprq2 Times New Roman (Hebrew);}{\fbiminor\f31584\fbidi \froman\fcharset178\fprq2 Times New Roman (Arabic);}
{\fbiminor\f31585\fbidi \froman\fcharset186\fprq2 Times New Roman Baltic;}{\fbiminor\f31586\fbidi \froman\fcharset163\fprq2 Times New Roman (Vietnamese);}}{\colortbl;\red0\green0\blue0;\red0\green0\blue255;\red0\green255\blue255;\red0\green255\blue0;
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{\*\pnseclvl3\pndec\pnstart1\pnindent720\pnhang {\pntxta .}}{\*\pnseclvl4\pnlcltr\pnstart1\pnindent720\pnhang {\pntxta )}}{\*\pnseclvl5\pndec\pnstart1\pnindent720\pnhang {\pntxtb (}{\pntxta )}}{\*\pnseclvl6\pnlcltr\pnstart1\pnindent720\pnhang {\pntxtb (}
{\pntxta )}}{\*\pnseclvl7\pnlcrm\pnstart1\pnindent720\pnhang {\pntxtb (}{\pntxta )}}{\*\pnseclvl8\pnlcltr\pnstart1\pnindent720\pnhang {\pntxtb (}{\pntxta )}}{\*\pnseclvl9\pnlcrm\pnstart1\pnindent720\pnhang {\pntxtb (}{\pntxta )}}\pard\plain \ltrpar
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\fs20\lang1045\langfe1045\loch\af0\hich\af0\dbch\af31505\cgrid\langnp1045\langfenp1045 {\rtlch\fcs1 \af44\afs24 \ltrch\fcs0 \f44\fs24\insrsid8207434 \hich\af44\dbch\af31505\loch\f44 \hich\f44 Byto\'f1}{\rtlch\fcs1 \af43\afs24 \ltrch\fcs0 
\f43\fs24\insrsid8208835 \hich\af43\dbch\af31505\loch\f43 , dnia\tab \tab 
\par }\pard \ltrpar\qc \li0\ri0\sb631\sl-318\slmult0\nowidctlpar\wrapdefault\nocwrap\nooverflow\aspalpha\aspnum\faroman\adjustright\rin0\lin0\itap0 {\rtlch\fcs1 \ab\af44\afs28 \ltrch\fcs0 \b\f44\fs28\insrsid8208835 \hich\af44\dbch\af31505\loch\f44 \hich\f44 O
\'8c\loch\f44 WIADCZENIE
\par }\pard \ltrpar\ql \li0\ri0\sb684\sl-240\slmult0\nowidctlpar\tqr\tldot\tx5256\tldot\tx8568\wrapdefault\nocwrap\nooverflow\aspalpha\aspnum\faroman\adjustright\rin0\lin0\itap0 {\rtlch\fcs1 \af0 \ltrch\fcs0 \lang1024\langfe1024\noproof\insrsid9911352 
{\shp{\*\shpinst\shpleft10061\shptop3514\shpright10475\shpbottom3514\shpfhdr0\shpbxpage\shpbxignore\shpbypage\shpbyignore\shpwr2\shpwrk0\shpfblwtxt0\shpz0\shplid1026{\sp{\sn shapeType}{\sv 20}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}
{\sp{\sn shapePath}{\sv 4}}{\sp{\sn fFillOK}{\sv 0}}{\sp{\sn fFilled}{\sv 0}}{\sp{\sn lineWidth}{\sv 12065}}{\sp{\sn lineDashing}{\sv 2}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\sp{\sn dxWrapDistLeft}{\sv 0}}{\sp{\sn dxWrapDistRight}{\sv 0}}
{\sp{\sn posrelh}{\sv 1}}{\sp{\sn posrelv}{\sv 1}}{\sp{\sn dhgt}{\sv 251658240}}{\sp{\sn fLayoutInCell}{\sv 0}}{\sp{\sn fBehindDocument}{\sv 0}}{\sp{\sn fLayoutInCell}{\sv 0}}}{\shprslt{\*\do\dobxpage\dobypage\dodhgt8192
\dpline\dpptx0\dppty0\dpptx414\dppty0\dplinedot\dpx10061\dpy3514\dpxsize414\dpysize0\dplinew19\dplinecor0\dplinecog0\dplinecob0}}}}{\rtlch\fcs1 \af43\afs23 \ltrch\fcs0 \f43\fs23\insrsid8208835 \hich\af43\dbch\af31505\loch\f43 Ja, \tab , PESEL\tab 
\par }\pard \ltrpar\ql \li1512\ri0\sb189\sl-190\slmult0\nowidctlpar\wrapdefault\nocwrap\nooverflow\aspalpha\aspnum\faroman\adjustright\rin0\lin1512\itap0 {\rtlch\fcs1 \af44\afs17 \ltrch\fcs0 \f44\fs17\expnd0\expndtw-3\insrsid8208835 
\hich\af44\dbch\af31505\loch\f44 \hich\f44 (imi\'ea\loch\f44 -imiona, nazwisko)}{\rtlch\fcs1 \af43\afs17 \ltrch\fcs0 \f43\fs17\expnd0\expndtw-3\insrsid8208835 
\par }\pard \ltrpar\ql \li0\ri0\sb167\sl-276\slmult0\nowidctlpar\wrapdefault\nocwrap\nooverflow\aspalpha\aspnum\faroman\adjustright\rin0\lin0\itap0 {\rtlch\fcs1 \af0 \ltrch\fcs0 \lang1024\langfe1024\noproof\insrsid9911352 
{\shp{\*\shpinst\shpleft2774\shptop4320\shpright10455\shpbottom4320\shpfhdr0\shpbxpage\shpbxignore\shpbypage\shpbyignore\shpwr2\shpwrk0\shpfblwtxt0\shpz1\shplid1027{\sp{\sn shapeType}{\sv 20}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}
{\sp{\sn shapePath}{\sv 4}}{\sp{\sn fFillOK}{\sv 0}}{\sp{\sn fFilled}{\sv 0}}{\sp{\sn lineWidth}{\sv 12065}}{\sp{\sn lineDashing}{\sv 2}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\sp{\sn dxWrapDistLeft}{\sv 0}}{\sp{\sn dxWrapDistRight}{\sv 0}}
{\sp{\sn posrelh}{\sv 1}}{\sp{\sn posrelv}{\sv 1}}{\sp{\sn dhgt}{\sv 251659264}}{\sp{\sn fLayoutInCell}{\sv 0}}{\sp{\sn fBehindDocument}{\sv 0}}{\sp{\sn fLayoutInCell}{\sv 0}}}{\shprslt{\*\do\dobxpage\dobypage\dodhgt8193
\dpline\dpptx0\dppty0\dpptx7681\dppty0\dplinedot\dpx2774\dpy4320\dpxsize7681\dpysize0\dplinew19\dplinecor0\dplinecog0\dplinecob0}}}}{\rtlch\fcs1 \af44\afs24 \ltrch\fcs0 \f44\fs24\insrsid8208835 \hich\af44\dbch\af31505\loch\f44 \hich\f44 zamieszka\'b3
\loch\f44 y/a
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\hich\af43\dbch\af31505\loch\f43                                          }{\rtlch\fcs1 \af43\afs17 \ltrch\fcs0 \f43\fs17\expnd0\expndtw-3\insrsid8208835 \hich\af43\dbch\af31505\loch\f43 (adres zamieszkania)
\par }\pard \ltrpar\ql \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0\pararsid6116788 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid6116788 
\par 
\par }\pard \ltrpar\qc \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0\pararsid6116788 {\rtlch\fcs1 \ab\af31506\afs24 \ltrch\fcs0 \b\f31506\fs24\insrsid6116788\charrsid6116788 \hich\af31506\dbch\af31505\loch\f31506 \hich\f31506 o\'9c\loch\f31506 
\hich\f31506 wiadczam, \'bf\loch\f31506 \hich\f31506 e nie jest prowadzone przeciwko mojej osobie post\'ea\loch\f31506 powanie }{\rtlch\fcs1 \ab\af31506\afs24 \ltrch\fcs0 \b\f31506\fs24\insrsid6116788 \hich\af31506\dbch\af31505\loch\f31506 
                                       }{\rtlch\fcs1 \ab\af31506\afs24 \ltrch\fcs0 \b\f31506\fs24\insrsid6116788\charrsid6116788 \hich\af31506\dbch\af31505\loch\f31506 \hich\f31506 o przest\'ea\loch\f31506 \hich\f31506 pstwo \'9c\loch\f31506 \hich\f31506 
cigane z oskar\'bf\loch\f31506 \hich\f31506 enia publicznego lub przest\'ea\loch\f31506 pstwo skarbowe.}{\rtlch\fcs1 \ab\af31506\afs24 \ltrch\fcs0 \b\f31506\fs24\insrsid8208835\charrsid6116788 
\par }\pard \ltrpar\ql \li0\ri0\sb222\sl-193\slmult0\nowidctlpar\wrapdefault\nocwrap\nooverflow\aspalpha\aspnum\faroman\adjustright\rin0\lin0\itap0\pararsid8207434 {\rtlch\fcs1 \af43\afs17 \ltrch\fcs0 \f43\fs17\expnd0\expndtw-3\insrsid8208835 
\par }\pard \ltrpar\ql \li0\ri0\sb518\sl-192\slmult0\nowidctlpar\wrapdefault\nocwrap\nooverflow\aspalpha\aspnum\faroman\adjustright\rin0\lin0\itap0 {\rtlch\fcs1 \af0 \ltrch\fcs0 \lang1024\langfe1024\noproof\insrsid9911352 
{\shp{\*\shpinst\shpleft7090\shptop7346\shpright10472\shpbottom7346\shpfhdr0\shpbxpage\shpbxignore\shpbypage\shpbyignore\shpwr2\shpwrk0\shpfblwtxt0\shpz2\shplid1028{\sp{\sn shapeType}{\sv 20}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}
{\sp{\sn shapePath}{\sv 4}}{\sp{\sn fFillOK}{\sv 0}}{\sp{\sn fFilled}{\sv 0}}{\sp{\sn lineWidth}{\sv 12065}}{\sp{\sn lineDashing}{\sv 2}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\sp{\sn dxWrapDistLeft}{\sv 0}}{\sp{\sn dxWrapDistRight}{\sv 0}}
{\sp{\sn posrelh}{\sv 1}}{\sp{\sn posrelv}{\sv 1}}{\sp{\sn dhgt}{\sv 251660288}}{\sp{\sn fLayoutInCell}{\sv 0}}{\sp{\sn fBehindDocument}{\sv 0}}{\sp{\sn fLayoutInCell}{\sv 0}}}{\shprslt{\*\do\dobxpage\dobypage\dodhgt8194
\dpline\dpptx0\dppty0\dpptx3382\dppty0\dplinedot\dpx7090\dpy7346\dpxsize3382\dpysize0\dplinew19\dplinecor0\dplinecog0\dplinecob0}}}}{\rtlch\fcs1 \af43\afs17 \ltrch\fcs0 \f43\fs17\expnd0\expndtw-3\insrsid8207434 \tab \tab \tab \tab \tab \tab \tab \tab 
\tab 
\par }\pard \ltrpar\ql \fi720\li6480\ri0\sb518\sl-192\slmult0\nowidctlpar\wrapdefault\nocwrap\nooverflow\aspalpha\aspnum\faroman\adjustright\rin0\lin6480\itap0\pararsid6116788 {\rtlch\fcs1 \af43\afs17 \ltrch\fcs0 \f43\fs17\expnd0\expndtw-3\insrsid6116788 
\hich\af43\dbch\af31505\loch\f43 (czytelny podpis)}{\rtlch\fcs1 \af44\afs17 \ltrch\fcs0 \f44\fs17\expnd0\expndtw-3\insrsid6116788 
\par }\pard \ltrpar\ql \li0\ri0\sb518\sl-192\slmult0\nowidctlpar\wrapdefault\nocwrap\nooverflow\aspalpha\aspnum\faroman\adjustright\rin0\lin0\itap0 {\rtlch\fcs1 \af44\afs17 \ltrch\fcs0 \f44\fs17\expnd0\expndtw-3\insrsid8208835 \hich\af44\dbch\af31505\loch\f44 
\hich\f44 Uwaga! Dokument nie mo\'bf\loch\f44 \hich\f44 e by\'e6\loch\f44 \hich\f44  wystawiony wcze\'9c\loch\f44 \hich\f44 niej, ni\'bf\loch\f44 \hich\f44  30 dni przed dniem z\'b3\loch\f44 \hich\f44 o\'bf\loch\f44 \hich\f44 enia zg\'b3\loch\f44 oszenia.
}{\rtlch\fcs1 \af43\afs17 \ltrch\fcs0 \f43\fs17\expnd0\expndtw-3\insrsid8208835 
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