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Translated from Russian into English
COPY
***
CONSENT
The Russian Federation. The city of Nizhny Novgorod.
The twenty ninth of May of the year two thousand thirteen.
I, ***, citizen of the Russian Federation, born on ***, the place of birth: the city of Gorky,
gender: male, passport *** issued by the Department of Internal Affairs of *** District of the
city of Nizhny Novgorod on ***, subdivision code ***, registered at the place of residence at
the following address: ***, the city of Nizhny Novgorod,
hereby give my consent to travel of my underage daughter, ***, born on ***, citizen of the
Russian Federation, certificate of birth II-TH No. *** issued on *** by the Civil Status
Registry Office of the Administration of *** District of the city of Nizhny Novgorod,
from the Russian Federation to the Swiss Confederation and other countries of the Shengen
Agreement and back to the Russian Federation, the city of Nizhny Novgorod, escorted by
***, citizen of the Russian Federation, born on ***, the place of birth: the city of Gorky,
gender female, passport of the citizen of the Russian Federation *** issued by the Division of
the Department of the Federal Migration Service of Russia for Nizhny Novgorod Region
in *** District of the city of Nizhny Novgorod on ***, subdivision code ***, registered at the
place of residence at the following address: ***, the city of Nizhny Novgorod, Nizhny
Novgorod Region,
for a period from the eighth of June of the year two thousand thirteen to the sixteenth of
June of the year two thousand thirteen. The purpose of travel is tourism.
In accordance with article 22 of the Federal Law of the Russian Federation "Concerning the
Procedure for Exit from the Russian Federation and Entry into the Russian Federation" I
hereby consent that *** undertake responsibility for the life and health of the child, take
urgent decisions to protect rights and legal interests of the child, including on issues of
medical interference, if required, and also submit any applications and receive any documents,
including a visa.
Adoption and (or) delay of *** outside the territory of the Russian Federation is not
envisaged.
*** has signed this consent after its reading aloud.
This consent is certified in duplicate, one of which is to be stored in the files of notary public
of the city of Nizhny Novgorod *** at the following address: ***, the city of Nizhny
Novgorod, (telephone ***).
This consent is issued on uniform blank form No. ***.
The signature:
/***/ /Signature/
The Russian Federation. The city of Nizhny Novgorod.
The ***.
This consent has been certified by me, ***, acting notary public for ***, the notary public of
Nizhny Novgorod, the city of region subordinance.
This consent has been signed by citizen *** in my presence. His personality has been
identified. His legal capacity has been verified.
Fixed in the register under No. ***.
Charged 1,500 rubles.
Acting notary public /Signature/
Seal: /Notary Public ***, location: the city of Nizhny Novgorod, notary circuit: the city of
region subordinance Nizhny Novgorod, individual taxpayer number (INN) ***, ***, No. ***/
The city of Nizhny Novgorod.
The ***.
I, ***, acting notary public for ***, the notary public of Nizhny Novgorod, the city of region
subordinance, certify authenticity of this copy with the original. The latter has no erasures,
additions, crossed out words or other non-stipulated amendments or any particularities.
Fixed in the register under No. ***.
Charged 50 rubles.
Acting notary public /Signature/
Seal: /Notary Public ***, location: the city of Nizhny Novgorod, notary circuit: the city of
region subordinance Nizhny Novgorod, individual taxpayer number (INN) ***, May ***, No.
***/
1/--страниц
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