PREVIDÊNCIA SOCIAL

1 - NOME : ______________________________________________________________________2 - ENDEREÇO : _________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________3 - PROFISSÃO : _________________________________________________________________4 - DATA NASCIMENTO : ______________________________________________5 - ESTADO CIVIL : _____________________________________________________6 - C.P.F. : _______________________________ R.G. : __________________________________7 - CTPS : ___________________________________________ 8 - CONTRIBUINTE DO INSS : ( ) SIM ( ) NÃO9 - NÚMERO DO NIT, PIS OU PASEP : ______________________________________________10 - DEFICIENTE : ( ) SIM ( ) NÃO TIPO DE DEFICIÊNCIA : ___________________ ________________________________________________________________________________11 - O QUE REQUEREU AO INSS : _________________________________________________ ________________________________________________________________________________12 - FEZ PERÍCIA ? ( ) SIM ( ) NÃO 13 - A PERÍCIA FOI DEFERIDA ? ( ) SIM ( ) NÃO14 - VALOR TOTAL DO SALÁRIO DA FAMÍLIA : _____________________________________15 - TEM FILHOS? ( ) SIM ( ) NÃO QUANTOS ? ( )16 – TELEFONES : ( _____ ) ____________________ , ______________________17 – COM QUEM MORA? _________________________________________________________

OBSERVAÇÕES :

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