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[2025]
[]
[null,null,null,null,null,null,null,null,null,null,"  PFC-FER"]
[]
["PROJEKT PLANU FINANSOWEGO FUNDUSZU EMERYTALNO - RENTOWEGO"]
[]
["Część A."]
["Lp.","CHAPTER_CODE","UATTRIBUTE01","Treść",null,"Wstępne wykonanie / wykonanie *)\n……... r.\n(rok N-1)","Ustawa budżetowa na …….. r.\n(rok N)","Przewidywane wykonanie\nw ………. r.\n(rok N)","Projekt planu na ………. r.\n(rok N+1)","Projekt planu na ………. r.\n(rok N+2)","Projekt planu na ………. r.\n(rok N+3)","Projekt planu na ………. r.\n(rok N+4)"]
[null,null,null,null,null,"w tysiącach złotych"]
[1,null,null,2,null,3,4,5,6,7,8,9]
["I","PFCFER.A1_1","PFCFER.A1_1.I","Zadania wynikające z ustawy tworzącej fundusz celowy",null,{"$f":"SUM(F12:F19)","v":0},0,0,0,0,0,0]
[1,"PFCFER.A1_1","PFCFER.A1_1.I.1","Emerytury rolnicze"]
[2,"PFCFER.A1_1","PFCFER.A1_1.I.2","Renty rolnicze"]
[3,"PFCFER.POZ_A_1","PFCFER.POZ_A_1"]
["4","PFCFER.POZ_A_1","PFCFER.POZ_A_1"]
["5","PFCFER.POZ_A_1","PFCFER.POZ_A_1"]
["6","PFCFER.POZ_A_1","PFCFER.POZ_A_1"]
["7","PFCFER.POZ_A_1","PFCFER.POZ_A_1"]
["8","PFCFER.POZ_A_1","PFCFER.POZ_A_1"]
[]
[]
["Część B. Plan finansowy w układzie memoriałowym"]
["Lp.","CHAPTER_CODE","UATTRIBUTE01","Treść","Paragrafy","Wstępne wykonanie / wykonanie *)\n……... r.\n(rok N-1)","Ustawa budżetowa na …….. r.\n(rok N)","Przewidywane wykonanie\nw ………. r.\n(rok N)","Projekt planu na ………. r.\n(rok N+1)","Projekt planu na ………. r.\n(rok N+2)","Projekt planu na ………. r.\n(rok N+3)","Projekt planu na ………. r.\n(rok N+4)"]
[null,null,null,null,null,"w tysiącach złotych"]
[1,null,null,2,3,4,5,6,7,8,9,10]
["I","PFCFER.B1_1","PFCFER.B1_1.I","Stan funduszu na początek roku","x"]
[null,"PFCFER.B1_1","PFCFER.B1_1.I.0","w tym:","x","x","x","x","x","x","x","x"]
["1.","PFCFER.B1_1","PFCFER.B1_1.I.1","-  środki pieniężne","x"]
["2.","PFCFER.B1_1","PFCFER.B1_1.I.2","-  należności","x"]
["3.","PFCFER.B1_1","PFCFER.B1_1.I.3","-  zobowiązania, z tego:","x",{"$f":"SUM(F31:F32)","v":0},{"$f":"SUM(G31:G32)","v":0},0,0,0,0,0]
["3.1","PFCFER.B1_1","PFCFER.B1_1.I.3.1","    - niewymagalne","x"]
["3.2","PFCFER.B1_1","PFCFER.B1_1.I.3.2","    - wymagalne","x"]
["II","PFCFER.B1_1","PFCFER.B1_1.II","Przychody","x","x","x","x","x","x","x","x"]
[null,"PFCFER.B1_1","PFCFER.B1_1.II.0.1","- bez refundacji kosztów wypłaty świadczeń zbiegowych i innych transferów","x",{"$f":"SUM(F36:F38,F41,F44)","v":0},{"$f":"SUM(G36:G38,G41,G44)","v":0},0,0,0,0,0]
[null,"PFCFER.B1_1","PFCFER.B1_1.II.0.2","- z refundacją kosztów wypłaty świadczeń zbiegowych  i innych transferów","x",{"$f":"F34+F42","v":0},{"$f":"G34+G42","v":0},0,0,0,0,0]
["1.","PFCFER.B1_1","PFCFER.B1_1.II.1","Dotacja z budżetu państwa",243]
["2.","PFCFER.B1_1","PFCFER.B1_1.II.2","Składki (przypis)","082"]
["3.","PFCFER.B1_1","PFCFER.B1_1.II.6","Inne wpłaty",null,{"$f":"SUM(F39,F40)","v":0},{"$f":"SUM(G39,G40)","v":0},0,0,0,0,{"$f":"SUM(L39,L40)","v":0}]
["3.1","PFCFER.B1_1","PFCFER.B1_1.II.6.1","Wpłaty od jednostek na państwowy fundusz celowy",230]
["3.2","PFCFER.B1_1","PFCFER.B1_1.II.6.2","Środki z Funduszu Przeciwdziałania COVID-19 na finansowanie\nlub dofinansowanie realizacji zadań związanych z przeciwdziałaniem COVID-19",218]
["4.","PFCFER.B1_1","PFCFER.B1_1.II.3","Pozostałe przychody (przypis)","x"]
["5.","PFCFER.B1_1","PFCFER.B1_1.II.4","Refundacja kosztów wypłaty świadczeń zbiegowych i inne transfery 1)","x"]
["5.1","PFCFER.B1_1","PFCFER.B1_1.II.4.1","w tym z Funduszu Ubezpieczeń Społecznych","x"]
["6.","PFCFER.B1_1","PFCFER.B1_1.II.5","Przelewy redystrybucyjne, w tym:",296]
["6.1","PFCFER.B1_1","PFCFER.B1_1.II.5.1","-  odpis z funduszu składkowego"]
["6.2","PFCFER.POZ_B_1","PFCFER.POZ_B_1"]
["6.3","PFCFER.POZ_B_1","PFCFER.POZ_B_1"]
["6.4","PFCFER.POZ_B_1","PFCFER.POZ_B_1"]
["III","PFCFER.B1_2","PFCFER.B1_2.III","Koszty ","x","x","x","x","x","x","x","x"]
[null,"PFCFER.B1_2","PFCFER.B1_2.III.0.1","- bez świadczeń zbiegowych i innych transferów","x",{"$f":"SUM(F53,F54,F55,F56,F58,F60,F61,F62)","v":0},{"$f":"SUM(G53,G54,G55,G56,G58,G60,G61,G62)","v":0},0,0,0,0,0]
[null,"PFCFER.B1_2","PFCFER.B1_2.III.0.2","- ze świadczeniami zbiegowymi i innymi transferami","x",{"$f":"SUM(F52,F58,F60,F61,F62)","v":0},{"$f":"SUM(G52,G58,G60,G61,G62)","v":0},0,0,0,0,0]
["1.","PFCFER.B1_2","PFCFER.B1_2.III.1","Transfery na rzecz ludności","311, 458",{"$f":"SUM(F53:F57)","v":0},{"$f":"SUM(G53:G57)","v":0},0,0,0,0,0]
["1.1","PFCFER.B1_2","PFCFER.B1_2.III.1.1","- emerytury i renty rolnicze",311]
["1.2","PFCFER.B1_2","PFCFER.B1_2.III.1.2","- zasiłki pogrzebowe",311]
["1.3","PFCFER.B1_2","PFCFER.B1_2.III.1.3","- zasiłki macierzyńskie",311]
["1.4","PFCFER.B1_2","PFCFER.B1_2.III.1.4","- pozostałe świadczenia","311, 458"]
["1.5","PFCFER.B1_2","PFCFER.B1_2.III.1.5","- świadczenia zbiegowe i inne transfery ","x"]
["2.","PFCFER.B1_2","PFCFER.B1_2.III.2","Pozostałe, w tym:","x"]
["2.1","PFCFER.B1_2","PFCFER.B1_2.III.2.1","- odpis na fundusz administracyjny",296]
["3.","PFCFER.B1_2","PFCFER.B1_2.III.3","Składki na ubezpieczenia zdrowotne finansowane                                              z dotacji budżetu",413]
["4.","PFCFER.B1_2","PFCFER.B1_2.III.4","Inne koszty","x"]
["5.","PFCFER.B1_2","PFCFER.B1_2.III.5","Przeciwdziałanie COVID-19",311]
["IV","PFCFER.B1_2","PFCFER.B1_2.IV","Stan funduszu na koniec roku (I + II - III)","x",{"$f":"SUM(F26+F35-F51)","v":0},0,0,0,0,0,0]
[null,"PFCFER.B1_2","PFCFER.B1_2.IV.0","w tym:","x","x","x","x","x","x","x","x"]
["1.","PFCFER.B1_2","PFCFER.B1_2.IV.1","- środki pieniężne","x"]
["2.","PFCFER.B1_2","PFCFER.B1_2.IV.2","- należności","x"]
["3.","PFCFER.B1_2","PFCFER.B1_2.IV.3","- zobowiązania, z tego:","x",{"$f":"SUM(F68:F69)","v":0},{"$f":"SUM(G68:G69)","v":0},0,0,0,0,0]
["3.1","PFCFER.B1_2","PFCFER.B1_2.IV.3.1","    - niewymagalne","x"]
["3.2","PFCFER.B1_2","PFCFER.B1_2.IV.3.2","    - wymagalne","x"]
[]
[]
["Część C.  Dane w układzie kasowym"]
["Lp.","CHAPTER_CODE","UATTRIBUTE01","Treść","Paragrafy","Wstępne wykonanie / wykonanie *)\n……... r.\n(rok N-1)","Ustawa budżetowa na …….. r.\n(rok N)","Przewidywane wykonanie\nw ………. r.\n(rok N)","Projekt planu na ………. r.\n(rok N+1)","Projekt planu na ………. r.\n(rok N+2)","Projekt planu na ………. r.\n(rok N+3)","Projekt planu na ………. r.\n(rok N+4)"]
[null,null,null,null,null,"w tysiącach złotych"]
[1,null,null,2,3,4,5,6,7,8,9,10]
["I","PFCFER.C1_1","PFCFER.C1_1.I","Dochody","x","x","x","x","x","x","x","x"]
[null,"PFCFER.C1_1","PFCFER.C1_1.I.0.1","- bez refundacji kosztów wypłaty świadczeń zbiegowych i innych transferów","x",{"$f":"SUM(F79,F80,F81,F84,F87)","v":0},{"$f":"SUM(G79,G80,G81,G84,G87)","v":0},0,0,0,0,0]
[null,"PFCFER.C1_1","PFCFER.C1_1.I.0.2","- z refundacją kosztów wypłaty świadczeń zbiegowych i innych transferów","x",{"$f":"F77+F85","v":0},{"$f":"G77+G85","v":0},0,0,0,0,0]
["1.","PFCFER.C1_1","PFCFER.C1_1.I.1","Dotacja z budżetu państwa",243]
["2.","PFCFER.C1_1","PFCFER.C1_1.I.2","Składki","082"]
["3.","PFCFER.C1_1","PFCFER.C1_1.I.6","Inne wpłaty","x",{"$f":"F82+F83","v":0},{"$f":"G82+G83","v":0},0,0,0,0,0]
["3.1","PFCFER.C1_1","PFCFER.C1_1.I.6.1","Wpłaty od jednostek na państwowy fundusz celowy",230]
["3.2","PFCFER.C1_1","PFCFER.C1_1.I.6.2","Środki z Funduszu Przeciwdziałania COVID-19 na finansowanie \nlub dofinansowanie realizacji zadań związanych z przeciwdziałaniem COVID-19",218]
["4.","PFCFER.C1_1","PFCFER.C1_1.I.3","Pozostałe","x"]
["5.","PFCFER.C1_1","PFCFER.C1_1.I.4","Refundacja kosztów wypłaty świadczeń zbiegowych i innych transferów1)","x"]
["5.1","PFCFER.C1_1","PFCFER.C1_1.I.4.1","w tym z Funduszu Ubezpieczeń Społecznych","x"]
["6","PFCFER.C1_1","PFCFER.C1_1.I.5","Przelewy redystrybucyjne, w tym:",296]
["6.1","PFCFER.C1_1","PFCFER.C1_1.I.5.1","-  odpis z funduszu składkowego"]
["6.2","PFCFER.POZ_C_1","PFCFER.POZ_C_1"]
["6.3","PFCFER.POZ_C_1","PFCFER.POZ_C_1"]
["6.4","PFCFER.POZ_C_1","PFCFER.POZ_C_1"]
["II","PFCFER.C1_2","PFCFER.C1_2.II","Wydatki ","x","x","x","x","x","x","x","x"]
[null,"PFCFER.C1_2","PFCFER.C1_2.II.0.1","- bez świadczeń zbiegowych i innych transferów","x",{"$f":"F113+F114+F115+F119+F120+F121+F118","v":0},{"$f":"G113+G114+G115+G119+G120+G121+G118","v":0},0,0,0,0,0]
[null,"PFCFER.C1_2","PFCFER.C1_2.II.0.1.0","  w tym: ","x",{"$f":"SUM(F95,F96,F97,F98,F99,F100,F101,F102)","v":0},{"$f":"SUM(G95,G96,G97,G98,G99,G100,G101,G102)","v":0},0,0,0,0,0]
[null,"PFCFER.C1_2","PFCFER.C1_2.II.0.1.A","             na finansowanie z UE pochodzące z BP 2)","x"]
[null,"PFCFER.C1_2","PFCFER.C1_2.II.0.1.B","             na finansowanie z UE pochodzące z BŚE","x"]
[null,"PFCFER.C1_2","PFCFER.C1_2.II.0.1.C","             na finansowanie z EFTA pochodzące z BP 3)","x"]
[null,"PFCFER.C1_2","PFCFER.C1_2.II.0.1.D","             na finansowanie z EFTA pochodzące z BŚE","x"]
[null,"PFCFER.C1_2","PFCFER.C1_2.II.0.1.E","             na finansowanie zadań w ramach KPO – część grantowa","x"]
[null,"PFCFER.C1_2","PFCFER.C1_2.II.0.1.F","             na współfinansowanie krajowe z BP w ramach projektów UE 4)","x"]
[null,"PFCFER.C1_2","PFCFER.C1_2.II.0.1.G","             na współfinansowanie krajowe z BP w ramach projektów EFTA 5)","x"]
[null,"PFCFER.C1_2","PFCFER.C1_2.II.0.1.H","             na współfinansowanie krajowe z innych źródeł w ramach projektów UE 4)","x"]
[null,"PFCFER.C1_2","PFCFER.C1_2.II.0.2","- ze świadczeniami zbiegowymi i innymi transferami","x",{"$f":"F93+F117","v":0},{"$f":"G93+G117","v":0},0,0,0,0,0]
[null,"PFCFER.C1_2","PFCFER.C1_2.II.0.2.0","  w tym: ","x",{"$f":"SUM(F105,F106,F107,F108,F109,F110,F111,F112)","v":0},{"$f":"SUM(G105,G106,G107,G108,G109,G110,G111,G112)","v":0},0,0,0,0,0]
[null,"PFCFER.C1_2","PFCFER.C1_2.II.0.2.A","             na finansowanie z UE pochodzące z BP 2)","x"]
[null,"PFCFER.C1_2","PFCFER.C1_2.II.0.2.B","             na finansowanie z UE pochodzące z BŚE","x"]
[null,"PFCFER.C1_2","PFCFER.C1_2.II.0.2.C","             na finansowanie z EFTA pochodzące z BP 3)","x"]
[null,"PFCFER.C1_2","PFCFER.C1_2.II.0.2.D","             na finansowanie z EFTA pochodzące z BŚE","x"]
[null,"PFCFER.C1_2","PFCFER.C1_2.II.0.2.E","             na finansowanie zadań w ramach KPO – część grantowa","x"]
[null,"PFCFER.C1_2","PFCFER.C1_2.II.0.2.F","             na współfinansowanie krajowe z BP w ramach projektów UE 4)","x"]
[null,"PFCFER.C1_2","PFCFER.C1_2.II.0.2.G","             na współfinansowanie krajowe z BP w ramach projektów EFTA 5)","x"]
[null,"PFCFER.C1_2","PFCFER.C1_2.II.0.2.H","             na współfinansowanie krajowe z innych źródeł w ramach projektów UE 4)","x"]
["1.","PFCFER.C1_2","PFCFER.C1_2.II.1","Emerytury i renty",311]
["2.","PFCFER.C1_2","PFCFER.C1_2.II.2","Zasiłki pogrzebowe",311]
["3.","PFCFER.C1_2","PFCFER.C1_2.II.3","Pozostałe świadczenia, w tym:","311, 458"]
["3.1","PFCFER.C1_2","PFCFER.C1_2.II.3.1","odsetki",458]
["4.","PFCFER.C1_2","PFCFER.C1_2.II.4","Świadczenia zbiegowe i inne transfery ","x"]
["5.","PFCFER.C1_2","PFCFER.C1_2.II.8","Przeciwdziałanie COVID-19",311]
["6.","PFCFER.C1_2","PFCFER.C1_2.II.5","Odpis na fundusz administracyjny",296]
["7.","PFCFER.C1_2","PFCFER.C1_2.II.6","Składki na ubezpieczenie zdrowotne finansowane z dotacji budżetu",413]
["8.","PFCFER.C1_2","PFCFER.C1_2.II.7","Zasiłki macierzyńskie",311]
[]
[null,null,null,"1) w tym z Funduszu Ubezpieczeń Społecznych …………………….  tys. zł."]
[null,null,null,"2) W tej pozycji należy wykazać środki w paragrafach z czwartą cyfrą 1, 8."]
[null,null,null,"3) W tej pozycji należy wykazać środki w paragrafach z czwartą cyfrą 5."]
[null,null,null,"4) W tej pozycji należy wykazać środki w paragrafach z czwartą cyfrą 2 i 9."]
[null,null,null,"5) W tej pozycji należy wykazać środki w paragrafach z czwartą cyfrą 6."]
[]
[]
["Część D. Dane uzupełniające"]
["Lp.","CHAPTER_CODE","UATTRIBUTE01","Treść","Jednostki","Wstępne wykonanie / wykonanie *)\n……... r.\n(rok N-1)","Ustawa budżetowa na …….. r.\n(rok N)","Przewidywane wykonanie\nw ………. r.\n(rok N)","Projekt planu na ………. r.\n(rok N+1)","Projekt planu na ………. r.\n(rok N+2)","Projekt planu na ………. r.\n(rok N+3)","Projekt planu na ………. r.\n(rok N+4)"]
[1,null,null,2,3,4,5,6,7,8,9,10]
[1,"PFCFER.D1_1","PFCFER.D1_1.1","Ściągalność składek","%"]
[2,"PFCFER.D1_1","PFCFER.D1_1.2","Przeciętna emerytura (finansowana z FER) bez dodatków","zł"]
[3,"PFCFER.D1_1","PFCFER.D1_1.3","Przeciętna emerytura (finansowana z FER) łącznie z dodatkami","zł"]
[4,"PFCFER.D1_1","PFCFER.D1_1.4","Przeciętna renta (finansowana z FER) bez dodatków","zł"]
[5,"PFCFER.D1_1","PFCFER.D1_1.5","Przeciętna renta (finansowana z FER) łącznie z dodatkami","zł"]
[6,"PFCFER.D1_1","PFCFER.D1_1.6","Liczba emerytur ","tys."]
[7,"PFCFER.D1_1","PFCFER.D1_1.7","Liczba rent","tys."]
[]
[]
["Część E. Dane analityczne"]
["Lp.",null,null,"Treść","Jednostki","Wstępne wykonanie / wykonanie *)\n……... r.\n(rok N-1)","Ustawa budżetowa na …….. r.\n(rok N)","Przewidywane wykonanie\nw ………. r.\n(rok N)","Projekt planu na ………. r.\n(rok N+1)","Projekt planu na ………. r.\n(rok N+2)","Projekt planu na ………. r.\n(rok N+3)","Projekt planu na ………. r.\n(rok N+4)"]
[1,null,null,2,3,4,5,6,7,8,9,10]
[1,"PFCFER.E1_1","PFCFER.E1_1.1","Dodatki do emerytur: pielęgnacyjne","tys. zł"]
[2,"PFCFER.E1_1","PFCFER.E1_1.2","Dodatki do rent, w tym:","tys. zł"]
["2.1","PFCFER.E1_1","PFCFER.E1_1.2.1","  - dodatki pielęgnacyjne ","tys. zł"]
["2.2","PFCFER.E1_1","PFCFER.E1_1.2.2","  - dodatki dla sierot zupełnych","tys. zł"]
[3,"PFCFER.E1_1","PFCFER.E1_1.3","Dodatki do emerytur i rent: za tajne nauczanie","tys. zł"]
[null,null,null,"*) niepotrzebne skreślić"]
[]
[]
[]
[]
[null,null,null,"sporządził ...................................................."]
[null,null,null,"(imię i nazwisko, stanowisko służbowe)"]
[]
[null,null,null,"nr telefonu ......................     adres e-mail ........................"]
[null,null,null,"data .............................       podpis ..............................."]

{"sheet":"PFC-FER F","index":1,"n_rows":23,"n_cols":44,"rows_kept":23,"cut":false,"hidden":true,"merged":[[5,33,6,33],[5,16,6,16],[5,24,6,24],[5,25,6,25],[5,18,5,21],[5,22,5,23],[5,26,6,26],[5,27,5,30],[5,31,5,32],[5,17,6,17],[2,0,6,0],[2,1,6,1],[5,2,6,2],[5,3,6,3],[5,15,6,15],[2,2,4,7],[2,8,2,43],[3,8,3,16],[3,17,3,25],[3,26,3,34],[3,35,3,43],[4,8,4,43],[5,4,5,7],[5,8,6,8],[5,9,5,12],[5,13,5,14],[5,43,6,43],[5,34,6,34],[5,35,6,35],[5,36,5,39],[5,40,5,41],[5,42,6,42]]}
[]
["Część F  Plan finansowy w układzie zadaniowym"]
["Kod klasyfikacji zadaniowej","Cel","Miernik",null,null,null,null,null,"Wydatki według źródeł finansowania / Koszty"]
[null,null,null,null,null,null,null,null,"2017 r.",null,null,null,null,null,null,null,null,"2018 r.",null,null,null,null,null,null,null,null,"2019 r.",null,null,null,null,null,null,null,null,"2020 r.*)"]
[null,null,null,null,null,null,null,null,"w tysiącach złotych"]
[null,null,"Nazwa","Wartość bazowa","Docelowa",null,null,null,"Ogółem\n(10+14+16+17)","Dotacje z budżetu państwa",null,null,null,"Środki otrzymane od innych jednostek SFP o których mowa w art. 9 pkt 5-7 i 14 uofp",null,"Budżet środków europejskich","Pozostałe środki ","Ogółem\n(19+23+25+26)","Dotacje z budżetu państwa",null,null,null,"Środki otrzymane od innych jednostek SFP o których mowa w art. 9 pkt 5-7 i 14 uofp",null,"Budżet środków europejskich","Pozostałe środki ","Ogółem\n(28+32+34+35)","Dotacje z budżetu państwa",null,null,null,"Środki otrzymane od innych jednostek SFP o których mowa w art. 9 pkt 5-7 i 14 uofp",null,"Budżet środków europejskich","Pozostałe środki ","Ogółem\n(37+41+43+44)","Dotacje z budżetu państwa",null,null,null,"Środki otrzymane od innych jednostek SFP o których mowa w art. 9 pkt 5-7 i 14 uofp",null,"Budżet środków europejskich","Pozostałe środki "]
[null,null,null,null,"2017 r.","2018 r.","2019 r.","2020 r.",null,"Kwota dotacji","Część budżetowa","Dział klasyfikacji budżetowej","Rozdział klasyfikacji budżetowej","Kwota przekazanych środków","Jednostka przekazująca",null,null,null,"Kwota dotacji","Część budżetowa","Dział klasyfikacji budżetowej","Rozdział klasyfikacji budżetowej","Kwota przekazanych środków","Jednostka przekazująca",null,null,null,"Kwota dotacji","Część budżetowa","Dział klasyfikacji budżetowej","Rozdział klasyfikacji budżetowej","Kwota przekazanych środków","Jednostka przekazująca",null,null,null,"Kwota dotacji","Część budżetowa","Dział klasyfikacji budżetowej","Rozdział klasyfikacji budżetowej","Kwota przekazanych środków","Jednostka przekazująca"]
[1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44]
[]
[]
[]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[]
["*) Kolumna \"2020 r.\"  dotyczy jedynie sporządzania materiałów na potrzeby Wieloletniego Planu Finansowego Państwa."]
[]
[]
["sporządził ....................................................................."]
[null,"          (imię i nazwisko, stanowisko służbowe)"]
[]
["nr telefonu .........................     adres e-mail ........................................"]
["data .........................              podpis ........................."]