_________________________________________________________
(наименование органа (поставщика социальных услуг)
____________________________________________________________________
в который предоставляется заявление)
от __________________________________________________________________
(фамилия, имя, отчество(при наличии) гражданина)
_______________________, ___________________________________________,
(дата рождения (СНИЛС гражданина)гражданина)
___________________________________________________________________,
(реквизиты документа удостоверяющего личность)
___________________________________________________________________
(гражданство, сведения о месте проживания(пребывания)
__________________________________________________________________,
на территории Российской Федерации)
___________________________________________________________________,
(контактный телефон, e-mail (при наличии))
от <1> _____________________________________________________________
(фамилия, имя, отчества (при наличии) представителя, наименование
государственного органа, органа местного самоуправления, общественного
объединения, представляющих интересы гражданина
__________________________________________________________________
реквизиты документа, подтверждающего полномочия
__________________________________________________________________
представителя, реквизиты документа, подтверждающего
__________________________________________________________________
личность представителя, адрес места жительства, адрес нахождения
государственного органа, органа местного самоуправления, общественного объединения)
Заявление
о предоставлении социальных услуг
Прошу предоставить мне социальные услуги в форме (формах) социального обслуживания: (указывается форма (формы) социального обслуживания)
. в форме социального обслуживания на дому;
. в полустационарной форме.
Оказываемые, ______________________________________________________________________
(указывается желаемый (желаемые) поставщик (поставщики) социальных услуг)
Нуждаюсь в социальных услугах: (указываются желаемые социальные услуги
. социально-бытовые, направленные на поддержание жизнедеятельности получателей социальных услуг в быту;
. социально-медицинские, направленные на поддержание и сохранение здоровья получателей социальных услуг путем организации ухода, оказания содействия в проведении оздоровительных мероприятий, систематического наблюдения за получателями социальных услуг для выявления отклонений в состоянии их здоровья;
. социально-психологические, предусматривающие оказание помощи в коррекции психологического состояния получателей социальных услуг для адаптации в социальной среде, в том числе оказание психологической помощи анонимно с использованием телефона доверия;
. социально-правовые, направленные на оказание помощи в получении юридических услуг, в том числе бесплатно, в защите прав и законных интересов получателей социальных услуг;
. срочные социальные услуги.
и периодичность их предоставления)
. _____________________________________________________________________________________
(1, 2, 3, 4, 5 – раз в неделю; 1, 2 раза в месяц, другое)
В предоставлении социальных услуг нуждаюсь по следующим обстоятельствам: <2> (указываются обстоятельства, которые ухудшают или могут ухудшить условия, жизнедеятельности гражданина)
. полная или частичная утрата способности либо возможности осуществлять самообслуживание, самостоятельно передвигаться, обеспечивать основные жизненные потребности в силу заболевания, травмы, возраста или наличия инвалидности;
. наличие в семье инвалида или инвалидов, в том числе ребенка-инвалида или детей-инвалидов, нуждающихся в постоянном постороннем уходе;
. наличие ребенка или детей (в том числе находящихся под опекой, попечительством), испытывающих трудности в социальной адаптации;
. отсутствие возможности обеспечения ухода (в том числе временного) за инвалидом, ребенком, детьми, а также отсутствие попечения над ними;
. наличие внутрисемейного конфликта, в том числе с лицами с наркотической или алкогольной зависимостью, лицами, имеющими пристрастие к азартным играм, лицами, страдающими психическими расстройствами, наличие насилия в семье;
. отсутствие определенного места жительства, в том числе у лица, не достигшего возраста двадцати трех лет и завершившего пребывание в организации для детей-сирот и детей, оставшихся без попечения родителей;
. отсутствие работы и средств к существованию;
. наличие иных обстоятельств, которые нормативными правовыми актами субъекта Российской Федерации признаны ухудшающими или способными ухудшить условия жизнедеятельности граждан.
Условия проживания и состав семьи: (указываются условия проживания)
. частный сектор;
. городской сектор.
и состав семьи)
. одинокий(ая)
. одиноко проживающий(ая)
. проживаю в семье с______________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Сведения о доходе, учитываемые для расчета величины среднедушевого дохода получателя(ей) социальных услуг <3>:
. пенсия____________________________________________________________________________________________
. компенсационная выплата ___________________________________________________________________________
. ЕДВ ______________________________________________________________________________________________
. другие выплаты ____________________________________________________________________________________
______________________________________________________________________________________________________
Достоверность и полноту настоящих сведений подтверждаю.
На обработку персональных данных о себе в соответствии со статьей 9 Федерального закона от 27 июля 2006 г. N 152-ФЗ «О персональных данных» <4> для включения в реестр получателей социальных услуг: ________________________________________________________
(согласен // не согласен)
_________________ (________________________________________) «_________» ________________________ г.
(подпись) (Ф.И.О.) (дата заполнения заявления)
—————————————————————————
<1> Заполняется в случае, если заявление подается лицом или государственным органом, органом местного самоуправления, общественным объединением, представляющим интересы гражданина.
<2> В соответствии со статьей 15 Федерального закона от 28 декабря 2013 г. N 442-ФЗ «Об основах социального обслуживания граждан в Российской Федерации».
<3> Статьи 31 и 32 Федерального закона от 28 декабря 2013 г. N 442-ФЗ «Об основах социального обслуживания граждан в Российской Федерации».
<4> Собрание законодательства Российской Федерации, 2006, N 31, ст. 3451; 2010, N 31, ст. 4196; 2011, N 31, ст. 4701; 2013, N 30, ст. 4038.
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