ࡱ> .0+,-_$bjbjA05\5\{""""""""8,#$P#4".#####%%%K.M.M.M.M.M.M.$1V4q."%%@%%%q.""##.O(O(O(%."8#"#K.O(%K.O(O(:-,"-#01 &-7..0.- 4'4-4"-8O(%%%q.q.O(%%%.%%%%4%%%%%%%%%R V!:ANEXO II PORTARIA CONJUNTA N 1 /DIRBEN/DIRAT/INSS, 7 DE AGOSTO DE 2017 (*) DECLARAO DO TRABALHADOR RURAL Nome:________________________________________________________________________________ Apelido:_______________________________DN:______/______/_______CPF:_______________________ Perodo de atividade de segurado especial que deseja comprovar: Data Incio: ____/_____/_____ Data Fim: ____/_____/_____ Forma que exerce/exerceu a atividade de segurado especial: ( ) Individualmente ( ) Em regime de economia familiar Se exerce/exerceu a atividade em regime de economia familiar, informe sua condio no grupo: ( ) Titular ( ) Componente Se componente do grupo familiar, informe o grau de parentesco com o titular: ( ) Cnjuge ( ) Companheiro(a) ( ) Filho(a) maior de 16 anos ( ) Equiparado a filho(a) maior de 16 anos ( )Pai/me Informe a condio de produtor em relao ao imvel rural onde exerce/exerceu a atividade: ( ) Acampado ( ) Assentado ( ) Arrendatrio ( ) Comodatrio ( ) Condmino ( ) Foreiro ( ) Meeiro ( ) Parceiro ( ) Posseiro/possuidor ( ) Proprietrio ( ) Usufruturio Se proprietrio ou assentado, caso tenha havido cesso da terra, informe: Forma de cesso (arrendamento, parceria, meao, etc): ________________ rea cedida (ha):__________ O outorgado (arrendatrio, parceiro, meeiro, etc) exerce atividade como segurado especial? Sim ( ) No ( ) Informe os seguintes dados sobre o imvel onde exerce/exerceu a atividade: Nome e CPF do proprietrio: ___________________________________________ / _____________________ rea total da propriedade, contnua ou descontnua (ha): ______________ rea trabalhada (ha):___________ Nome da propriedade:_______________________________________________________________________ Municpio: ______________________________ UF: ____ Ponto de referncia:_________________________ Informe a atividade agropecuria principal e destinao (produtor de feijo, criador de ovelhas, etc): Atividade: ______________________________________________ ( ) Subsistncia ( ) Comercializao ( ) No desenvolvo atividade agropecuria, somente auxilio nos servios domsticos do grupo familiar. Informe se h/houve processo de beneficiamento/industrializao artesanal com incidncia de Imposto Sobre Produtos Industrializados IPI (produo de queijo, doce, farinha, etc): ( ) No. ( ) Sim. Data Incio: ____/_____/_____ Data Fim: ____/_____/_____ Data Incio: ____/_____/_____ Data Fim: ____/_____/_____ Informe se est/esteve afastado(a) da atividade rural: ( ) No. ( ) Sim. Data Incio: ____/_____/_____ Data Fim: ____/_____/_____ Data Incio: ____/_____/_____ Data Fim: ____/_____/_____ Informe se h/houve utilizao de empregado(s) contratado(s) ou prestador(es) de servio: ( ) No. ( ) Sim. Ano(s):__________ N de dias no ano civil: __________ N de contratados: _____ Ano(s):__________ N de dias no ano civil: __________ N de contratados: _____ Informe se recebe/recebeu outra renda e/ou exerce/exerceu outra atividade, diferente de segurado especial (emprego, prestao de servio, benefcio, atividade turstica, artstica, artesanal, dirigente sindical ou de cooperativa, mandato de vereador, dentre outras): ( ) No. ( ) Sim. Qual:________________________ Incio: ____/_____/_____ Fim: ____/_____/_____ Valor: _____ Qual:________________________ Incio: ____/_____/_____ Fim: ____/_____/_____ Valor: _____ Declaro, sob as penas previstas na legislao, que as informaes prestadas nesta declarao so verdadeiras, estando ciente das penalidades do art. 299 do Cdigo Penal Brasileiro. Local: ______________________________________________ Data: ____/_____/_____   ___________________________________________________________________ Asinatura do segurado/requerente Art. 299 do Cdigo Penal: Omitir, em documento pblico ou particular, declarao que dele devia constar ou nele inserir ou fazer inserir declarao falsa ou diversa da que devia ser escrita, com o fim de prejudicar direito, criar obrigao ou alterar a verdade sobre fato juridicamente relevante. Pena - recluso, de um a cinco anos, e multa, se o documento pblico, e recluso de um a trs anos, e multa, se o documento particular.       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