[Annexed form No.12] <Revision 2005.1.15> (Front page)
		□Death □Confirmation of missing person			Handling period
Immediately
Report of Seal Impression for
□Alteration of report contents
□Cancellation □Reinstatement
※ Please check on □.
Applicant	Name (Chinese characters)	( )	Resident Registration No.		Seal Impression	Seal
Address in Korea
Overseas address
Nationality
Matters to report(apply)
Reason for written report
Supporting evidence (Annexed)
Consent of legal representative	Name		Seal impression	Seal	Resident Registration No.
Address		Relationship
Confirmation of overseas diplomatic and consular missions (consulates)	I hereby confirm the above facts. ...... Day ...... Month .......... Year Overseas diplomatic and consular missions(Consulates) Signature
Remarks
I hereby report(apply) a seal impression for (Death. Confirmation of missing person. Alteration of report contents. Cancellation. Reinstatement) according to Article 8(Article 9, Article 11) of「Law of Seal Impression's Certification」 and Article 11(Article 12) of「Enforcement Ordinance of Law for Seal Impression's Certification」.	Handling charge
Nothing
...... Day ...... Month .......... Year Reporter(Applicant) (Signature or seal) Address (Resident Registration No.: ) Proxy ○○○ (Signature or seal) Address (Resident Registration No.: ) Relationship TO : HEAD OF SI․GU․EUP․MYEON․DONG
210mm×297mm(신문용지 54g/㎡(재활용품))

(Rear page)
1 2. 3. 4.	※ NOTES The proxy who visits at certifying office must certainly submits the identification card. In case of notifying a death or confirmation of missing person, only heir must submit the notification form. But if the heir can't visit at jurisdiction certifying office, can submit with his delegation. In case of an overseas residents, please write passport No. on section of resident registration No. and in case of a foreigner, write alien registration No. and in case of a domestic residence declarer, write domestic residence report No. If you want to submit a report of seal impression, please check ☑ on related items and then submit. ※ This report(application) form is handled like belows.
	Civil affairs person					Reporting(Applying) items 1. Death 2. Confirmation of missing person 3. Alteration of report contents 4. Cancellation 5. Reinstatement
	Report (Apply)		▲		Acceptance of report(apply)
		▼
	Certification office (Eup․Myeon․Dong)					Arrangement of report(apply) facts

Report(Application) of seal impression for

[□Death □Confirmation of missing person □Alteration of report contents □Cancellation □Reinstatement]

인감 신고(신청)서[□사망 □실종신고 □신고사항의 변경 □말소 □부활

※ Please check on □. (□안에 표시를 합니다.)

□ Applicant (대상자)

￭ Please write name with Chinese characters.

(대상자의 이름을 한자와 함께 쓰세요)

￭ Please write resident registration No. (대상자의 주민등록번호를 쓰세요)

￭ Please put seal impression. (대상자의 인감을 날인하세요)

￭ Please write address in Korea. (대상자의 국내주소를 쓰세요)

￭ Please write overseas address. (대상자의 국외주소를 쓰세요)

￭ Please write nationality. (대상자의 국적을 쓰세요)

□ Please write matters to report(apply). (신고사항을 쓰세요)

□ Please write reason for written report. (서면신고 사유를 쓰세요)

□ Please attach supporting evidence as an annexed. (입증자료를 첨부하세요)

□ Consent of legal representative (법정대리인의 동의)

￭ Please write name of legal representative. (법정대리인의 성명을 쓰세요)

￭ Please put seal impression of legal representative.

(법정대리인의 인감을 날인하세요)

￭ Please write resident registration No. of legal representative.

(법정대리인의 주민등록번호를 쓰세요)

￭ Please write address of legal representative.

(법정대리인의 주소를 쓰세요)

￭ Please write relationship with applicant. (신청인과의 관계를 쓰세요)

□ Confirmation of diplomatic establishment abroad(consulate)

(재외공관(영사관)의 확인)

￭ Please receive the signature from diplomatic establishment abroad(consulates).

(재외공관(영사관)의 확인을 받으세요)

※ I hereby report(apply) a seal impression(Death. Confirmation of missing person.

Alteration of report contents. Cancellation. Reinstatement) according to Article 8

(Article 9, Article 11) of the 「Law of seal impression's certification」 and Article 11

(Article 12) of「Enforcement ordinance of the Law for seal impression's certification」.

(「인감증명법」제8조(제9조, 제11조) 및 「인감증명법 시행령」제11조(제12조)에 의하여

인감(사망․실종선고․신고사항의 변경․말소․부활)신고(신청)합니다.)

□ Reporter(applicant) 신고(신청)인

￭ Please write date of report(application). (신고(신청)일을 쓰세요)

￭ Please write name of reporter(applicant) and signature and seal.

(신고(신청)인의 성명을 쓰고 서명날인하세요)

￭ Please write address and resident registration No. of applicant.

(신청인의 주소와 주민등록번호를 쓰세요)

□ Proxy (대리인)

￭ Please write name of proxy and signature and seal.

(대리인의 성명을 쓰고 서명날인하세요)

￭ Please write address and resident registration No. of proxy.

(대리인의 주소와 주민등록번호를 쓰세요)

￭ Please write relationship with applicant. (신청인과의 관계를 쓰세요)

※ NOTES 유의사항

1. The proxy who visits at certifying office must certainly submits the identification card.

(증명청을 방문하는 대리인은 반드시 신분증을 제시하여야 합니다.)

2. In case of notifying a death or confirmation of missing person, only heir must

submit the notification form. But if the heir can't visit at jurisdiction certifying

office, can submit with his delegation.

(사망 또는 실종선고를 신고하는 때에는 상속인이 신고서를 제출하여야 합니다.

다만, 상속인이 소관증명청을 방문할 수 없는 경우에는 위임하여 제출할 수 있습니다.)

3. In case of an overseas residents, please write passport No. on section of resident

registration No. and in case of a foreigner, write alien registration No. and in case

of a domestic residence declarer, write domestic residence report No.

(주민등록번호란에 재외국민의 경우에는 여권번호, 외국인의 경우에는 외국인 등록번

호, 국내거소신고자의 경우에는 국내거소신고번호를 기재하여야합니다.)

4. If you want to submit a report of seal impression, please check ☑ on related

items and then submit.

(인감신고서를 제출하고자 하는 경우에는 해당사항란에 ☑체크표시를 한 후 제출합니다.)