STATE STATISTICAL REPORTING

                                                               CONFIDENTIALITY IS GUARANTEED BY THE RECEIVER OF INFORMATION

Submission of the distorted data of the state statistical reporting, untimely submission or non-presentation of such reporting attract application of measures of administrative or criminal liability according to the procedure, established by the legislation of the Republic of Belarus

Respondents represent

Representation term

Form to the 4th

legal entities, the separate divisions of legal entities having separate balance according to Instructions on filling of this form:

23rd after the accounting period,

Form code on OKUD

0624001

in the form of the electronic document – with use of the specialized software posted on the website http://www.belstat.gov.by

for January-December – on March 19

on paper:

Quarter

To the main statistical city department of Minsk; to department of statistics in the area (city) of the head statistical department of area *

Full name of the legal entity ________________________________________________________

______________________________________________________________________________________________

Full name of separate division of the legal entity ____________________________

______________________________________________________________________________________________

Postal address _______________________________________________________________________________

E-mail address (www, e-mail) ______________________________________________________________

Territory of finding of structural division _____________________________________________

                                                          (name of the area,

______________________________________________________________________________________________

                        cities of regional subordination, city of Minsk)

Registration number of the respondent in the statistical register (RCBO)

Accounting Number of the Payer (ANP)

1

2

Name of type of economic activity

Code of line

Code on OKRB 005-2011

The volume of production (works, services) less the taxes and fees estimated from revenue *

Cost it is processed -
leg (ispol-
zovanny) customer's material **

The volume of production (works, services) less the taxes and fees estimated from revenue for the last quarter of the accounting period *

for from -
even period

for soot-
vetstvu-
yushchy period of last year

for from -
even period

for soot-
vetstvu-
yushchy period of last year

And

B

In

1

2

3

4

5

In total (amount of lines 11) …. …............

10

X