En Distrito de Santa Rosa Alto Yanajanca, siendo las_______horas, del
día___/____/____, se hizo presente ante el suscrito, la persona de___________________________________, de ( ) años de edad, natural de________________, estado civil_______________ identificado(a) con DNI_________________, de ocupación___________________________________, con domicilio en el Distrito de Santa Rosa de Alto Yanajanca, Provincia de Marañón, Departamento de Huánuco;____________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________