CENTRO DE CONCILIACIÓN EXTRAJUDICIAL “………………………….

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Autorizado su funcionamiento por Resolución Directoral Nº 2585-2011-JUS/DNJ-DCMA
Dirección: ………………………………………………………………………
Correo Electrónico: …………………………………………………………..
Teléfono Fijo: ……………………… Celular: ……………………………….

EXP. Nº……………….……….

SOLICITUD PARA CONCILIAR

I. DATOS:

1. Fecha: _______________________________________________________________________________________________________

2. Nombre del solicitante:

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3. Documento de identidad solicitante:

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4. Domicilio del solicitante:

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5. Correo electrónico:
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6. Número telefónico:
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7. Nombre del invitado:

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8. Domicilio del invitado:

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9. Correo electrónico:
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10. Número telefónico:

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II. HECHOS QUE DIERON LUGAR AL CONFLICTO:

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III. OTRAS PERSONAS CON DERECHO ALIMENTARIO:

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IV. PRETENSIÓN A CONCILIAR:

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V. FIRMA DEL SOLICITANTE:

VI. DOCUMENTOS ANEXOS:

1. Copia de D.N.I.

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