(ANEXO I)

SENHOR CHEFE DA DELEGACIA __________________________________________

__________________________________________________________________________________,
REQUERENTE
____________________________________________, ____________________________
NACIONALIDADE CPF/CNPJ
___________________,
_____________________________________________________,
CIDADE
ENDEREO
______________________, ( ____ ) ______________,
____________,
CEP TELEFONE
UF

requer a Vossa Senhoria o reembolso do valor R$_______________

(________________________________________________________________), pago
atravs da(s) guia(s) anexa(s), pelo motivo a seguir relatado:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
____________________________________________________________________________

Solicito que a devoluo seja depositada na CONTA CORRENTE no.

_______________________, Banco no. _____________, Agncia no. ________________,
em nome de ________________________________________________________________,
CPF/MF no. _________________________________________________________, endereo
___________________________________________________________________________,
fone ( _____ ) _______________________.

Nestes termos,

Pede deferimento.

_____________________, _____ de _______________ de ________.

_______________________________________________
Assinatura do Requerente