Edition May 2018

FORM 27
INYANDIKO ISABA GUHINDURA IMIKORESHEREZE Y’UBUTAKA

Umwirondoro
Njyewe/Twebwe: .....…………………………………………………………………………………………………………………...........
Irangamimerere: …………………………….…………………………………………………………………..........................................
Indangamuntu/Pasiporo: …………………..………………………………………………………………………………………..........
Aderesi: Akarere ka…………………….…. Umurenge wa ……………………………Akagari ka ……………………............
Umudugudu wa ………………................
Telefoni : ………………………………………... E-mail: ……................…………………………………………………………….........

Cyangwa
Isosiyete/ONG/Ishyirahamwe ry’umwuga/Idini/Koperative/Ibindi………………………………………………......
Njyewe (Uhagarariye mu buryo bwemewe n'amategeko):………………………………….............................................
Indangamuntu/Pasiporo: ……......………………………………………………………………………………………………………..
Aderesi: Akarere ka…………………….…. Umurenge wa ……………………………Akagari ka ……………………............
Umudugudu wa ………………................
Telefoni: ……………………………………….. E-mail: …………………………………………………….............................................

Ndasaba guhindura guhindura imikoreshereze y’ubutaka

Amakuru ku kibanza/Isambu
Nimero y'ikibanza/isambu (UPI): …………………………..................................
Umujyi wa Kigali/Intara: ………………………………………................
Akarere: …………………………………………………...
Umurenge: …………………………………….……………..
Akagari: …………………………………….……………..

Ibisobanuro k'ubusabe………………………………………………………………………………………….....................................
……………………………………………………………………………………………………………………………….....................................
……………………………………………………………………………………………………………………………….....................................

Ibisabwa
Ibyangombwa by'ubutaka1
Uruhushya rwo guhindura guhindura imikoreshereze y’ubutaka rutangwa
n’Umuyobozi bw’Akarere cyangwa undi mukozi w'Akarere yabihereye ububasha
hakurikijwe igishushanyo mbonera

…………………………….. ………………………………………………………………………………
Itariki y'ubusabe Umukono w'usaba (w'abasaba)

Byakiriwe kandi bisuzumwa na: ……………………………….............................................................

Icyo ashinzwe: ...........................................................................................

Itariki: ………………………………………………………
Kashe
Umukono: …………………………………………………

1
Bitewe n’imitungire y’ubutaka, ibyangombwa by’ubutaka bishobora kuba kimwe muri ibi bikurikira:
 Amasezerano y’ubukode burambye, icyemezo cy’iyandikisha ry’ubukode bw’igihe kirekire n’ igishushanyo cyerekana ingano y’ubutaka
 Icyemezo cy’inkondabutaka
 Icyemezo cy’Iyandikisha ry’Impapurompamo ngenankomyi,
 Icyemezo cy’iyandikisha ry’ibice by’isangiramutungo ku nyubako