ba De hein: 2405/2023
Fecha de Sollcttud
DECLARACION ‘Afio_| Mes | Dia | Cludad/Municipio
FURAMENTAPA {7073 [09 [29 |Bocaramanga
Identificacién del deciarante: Yon FAH Qvivoga, [mado _senuincado(a)
con documento de Wdentieaiin Cc_X TL__c&___PA__cD__PT__Nimero 1098329 /80_
OTIVO DE LA DECLARACION
‘Warque con una X el motivo dela Gedarein: x
1. Convivencia ydependenda __—_2. Unién marital de 3.Padres ohermancs 4. otros
‘cconsmics ‘necho/Unién Libre hhuérfanos de padces Soe al
‘Detiaro bajo la gravedad de joremento que tode Ia informacin aqui suministiada es VERIDICA. Autoriza Gue por cualquler me
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