Държавен вестник, бр. 70, 2013 г., стр. 135

БРОЙ  70	
Д Ъ Р Ж А В Е Н  В Е С Т Н И К 	
СТР.  135  
III. Кой?
ЛИЦА
 Проверени/задържани лица, представляващи интерес, включително и лицата, пътували с тях. 
 Име, презиме, фамилия; пол; ЕГН/ЛНЧ; дата и място на раждане; извършител/потърпевш
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придружава се от: .....................................................................................................................................................................
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ППС/плавателно средство
Вид; рег. №; марка; модел; цвят; VIN; IMO
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IV. Какво?
ДЕЯНИЕ/ДЕЙСТВИЕ
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АДМИНИСТРАТИВНО НАРУШЕНИЕ
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ПРЕСТЪПЛЕНИЕ
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V. Взето отношение
Проверка
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Установяване
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Акт/фиш; Предупредителен протокол
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Използване на сила, помощни средства или употреба на оръжие
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Задържане/отвеждане
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ДАЛИ ДОКЛАДА: 1. ....................../.............................; 2. ..................................../....................................; 
3. ................................../...................................... (длъжност, подпис, фамилия на служителите от ГПН)
Забележка. Настоящата бланка е приложение към докладната записка за резултатите от служебната 
дейност по чл. 63, ал. 2 или към отчетната карта по чл. 63, ал. 3.