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คู่มือการปฏิบัติงาน กระบวนการจดทะเบียนสิทธิและนิติกรรม ประเภทจำนอง (ปี 2553)

สำนักมาตรฐานการทะเบียนที่ดิน

Keywords: ด้านการทะเบียนที่ดิน

˜´ª°¥µn Š®¤µ¥Á¨… Ù (š.—. Ò×)

´œš„¹ …°o ˜„¨ŠŸ°n œ˜oœÁŠ·œ‹µ„‹µÎ œ°Š

š¸—É œ·
¦³ªµŠ.......………………..........................…..˜µÎ ¨...........……………………………..…………….............
Á¨…š¸—É œ· ……………………®œµo ­Îµ¦ª‹......………...............°ÎµÁ£°..............…........……................................
̜—®¤µ¥Á¨…š…¸É …………………………….……….‹Š´ ®ª´—................................…….…...........................
š¸ªÉ µn „µ¦…………..….…………………………
ª´œš…ɸ ………Á—º°œ………….…….…¡.«. ……………

Á¨…ž¦³‹µÎ ˜´ªž¦³µœ

…oµ¡Á‹µo ..……….....œ...µ.¥...„.......……Ÿo‹¼ …εœ..°.…Š .........................………....... † †††† ††††† †† †
..……….....œ..µ..¥...….......…Ÿ…¼¦o …´‹..ε.œ…°.Š........................………....... † †††† ††††† †† †

°µ¥» ................ že ÁÊº°µ˜…· ………….…… ­´ µ˜·........................... ·—µ / ¤µ¦—µ°Éº ..........….….........................................
°¥n¼š¸É µo œ/®¤¼n µo œ ...................... Á¨…š¸É ................. ˜¦°„/Ž°¥ ....…….........….......... ™œœ ..........…….…………..®¤n¼š¸É .....…...
˜Îµ¨/…ªŠ ...................... °ÎµÁ£°/Á…˜ ............................ ‹Š´ ®ª´— ...…......………................®¤µ¥Á¨…Ú¦«´¡šr .….....................
…///°//ž//’///· //µ//–///˜//œ///Â//¨//³//Ä/®///o™//°o//¥//‡//ε//˜//n°/ …Å…—oš…兝´œ…š…¹„……°o ˜…„…¨Š…˜°n …Á‹…oµ¡…œ´„…Š…µœ…š¸É—…·œ……………………………………………………..
—///oª//¥/‡///ª//µ/¤//­///˜´ //¥//‹r //¦/Š· —´Š˜°n ޜʸ : -
…………š…ɸ—…·œÂ…ž…¨Š…Á‡…¦Éº°…Š®…¤…µ¥……oµ…Š…œ…œÊ¸……oµ…¡…Á‹oµ…œ.…µ¥…„…. Ÿ…¼o‹Îµ…œ°…ŠÅ.…—o‹…圅°…ŠÅ…ªo„…´…œ…µ¥………. Ÿ…o¼¦´…‹Îµ…œ.°.…Š …˜µ…¤­…´……µ‹…圅°Š….
…¨Š…ª´œ…š…¸É…………..Á…—º°…œ………………….……….………………….¡….«……………..………Á¡…ºÉ°Á…ž}œ…ž…¦³…„´œ…„…µ¦…„¼o¥.…º¤Á…Š·œ…ŽÉ¹Š…Ÿ…¼o‹µÎ …œ°…Š„…¼o¥…º¤Å…ž‹..…µ„…Ÿo¼¦…´‹…圅°…ŠÁ…ž}œ….
…‹µÎ œ…ª…œ……………….….……………….…µš…(……………………………………………..).…—´ …œ¸Ê …œµ…¥ „…. …ŗ.o…ε…¦³…®œ…¸ÊÁŠ…·œ„…o¥¼ …¤º —…´Š„…¨nµ…ªÂ…¨…oª‹…εœ..ª…œ………………………………….µ…š.
…(……………………………………..)…¥´Š…‡…ŠÁ®…¨…º°®.…œÊÁ¸ …Š·œ…„o¼¥…¤º °…„¸ …‹Îµ…œª…œ………………………………………µ…š…(….………………………………………) Ž…ŠÉ¹ ¥…Š´ ‡..…ŠÄ®…o¤…¸„µ…¦‹…圅°…ŠÁž…œ} .
…ž¦…³„…´œ…°¥…n¼˜°n …Ş…˜…µ¤…Á—…·¤ …………………………….……………….…………………………………..……………………….
……………´œ…š¹„………°o ˜…„¨…Š…œšÊ¸ …εŅª®o.…œ…ɹŠŒ…´…Á…„È …Ū…o –…­…µÎ œ…´„…Šµ…œš…ɗ¸ ·œ…š…´ÊŠ…­°…Š …µi ¥.…ŗ…˜o ¦…ª‹…—…¼œ´ …š…¹„……o°˜…„…¨Š..…¨…³Á……oµ…ċ……o°…‡ª…µ¤….
…˜¨…°—…Â…¨oª…‹¹Š…¨…Š¨…µ¥…¤º°…°Éº…®…¦º°…¨Š…¨…µ¥¡…·¤…¡…œr Ê·ª…¤°º…Å…ªÁo ž.…}œ®…¨…´„“…µœ…˜…n°®.…œoµ…¡…¥µœ…Â…¨³…Á‹…µo ¡…œ…„´ Š…µœ…š¸É—…·œ…..……………………….

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……………………………………………………………………….……………………………………….………………¨Š……º°É ………………….……………………œ………µ¥.………„.……………………………………………Ÿ‹¼o ……圅…°….Š.…..…………………………………………..
……………………………………………………….………¨Š…°ºÉ ………….………………œ……µ¥……….……………………………Ÿo¦¼ …´ ‹…εœ..…°Š…………………….
………………………………….……………………………¨Š…°Éº ……………………………….…………………………………¡¥…µœ……..…………………….
……………………………………………………….………¨Š…ºÉ°………….………………………………………………………¡¥…µœ…..……………………….
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……………………………………………………….………¨Š…É°º ………….………………………………………………………Á‹µo…¡…œ´„..Š…µœ…š…ɗ¸ ·œ……………….
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˜ª´ °¥µn Š®¤µ¥Á¨… Ù
­µ¦´ ‹—š³Á¸¥œ

Áœ°ºÊ šÉ—¸ œ· ÁœÊ°º šÉ¸—·œ ¦³ªµŠ Á‹µo ¡œ´„Šµœš—¸É ·œ
Á¨…š¸É—œ· ¨Š¨µ¥¤º°ºÉ°
‹—š³Á¥¸ œ ž¦³Á£š„µ¦ Ÿ¼oÄ®­o ´µ Ÿ¼o¦´ ­´µ ˜µ¤­´µ ‡ŠÁ®¨º°
ªœ´ Á—°º œ že ‹—š³Á¥¸ œ ̜—šÉ—¸ ·œÄ®¤n ž¦³š´ ˜¦µ
œµ¥ …. Ŧn Šµœ ˜µ¦µŠ Ŧn Šµœ ˜µ¦µŠ
Ÿ¦¼o ´ ‹Îµœ°Š ªµ ªµ

ªœ´ š¸É…………. Ÿn°œÁ˜oœÁŠ·œ‹µ„ œµ¥ „. Ò- - --- - (¨Š°Éº )……………
Á—º°œ………… ‹µÎ œ°Š
¡.«. …………

˜´ª°¥µn Š®¤µ¥Á¨… Ú † š¸É µo œ (š.—. Ò)

† šÉ¸­ªœ/Ŧn
¨³„µ¦­°­ª‡œµÎ …­°š· ‹›—Ä· œšš³Á—¸É ·œ¸¥œž­¦·š³Á›£Â· š¨³...œ..˜·.¨..·„—..¦Á.Š.¦.·œ.¤..‹…µ„…‹Îµ…œ°…Š ……..†††......šœš. œ¸Éɸ°..„µ..Á.…...˜......
˜µÎ ®œnŠš¸—É ·œ † ĜÁ…˜

¦³ªµŠ..........................................…..........................................……..˜µÎ ¨.........................................……......….....................................................…..

Á¨…š¸—É ·œ..................................................................………............…°ÎµÁ£°.....................................…...........................................……....................…..

®œµo ­Îµ¦ª‹...................................................................……..............‹Š´ ®ª—´ ...........................................................................................……........…….
̜—š—¸É ·œ
Á¨…š.¸É .............................................................……..........................Á¨¤n ..........………..………........................®œµo ......………….…..…...……......…..

‹µÎ œªœšÉ—¸ œ· ....................................…....................Ŧn.....……………………….....................Šµœ.................……………...….................…....˜µ¦µŠªµ

Ò. …oµ¡Á‹oµŸ¼o¤œ¸ µ¤˜n°ÅžœÊ¸ ¤‡¸ ªµ¤ž¦³­Š‡r…°‹—š³Á¸¥œ­·š›·Â¨³œ·˜·„¦¦¤Á„ɸ¥ª„´ °­Š´ ®µ¦·¤š¦´¡¥šr Ʉ¸ ¨µn ª…oµŠœœ¸Ê ¨³Å—ož’·µ–˜œÂ¨oª
…°Ä®™o o°¥‡Îµ—oª¥‡ªµ¤­´˜¥‹r ¦Š· ™oµ…oµ¡Á‹µo Ä®o™o°¥‡µÎ ŤÁn žœ} ‡ªµ¤‹¦·ŠÄ®Äo o™°o ¥‡µÎ œÊ¸¥œ´ …oµ¡Á‹oµÄœšµŠ‡—¸°µµÅ—o

Á¨…ž¦³‹µÎ ˜´ªž¦³µœ

Ó. …oµ¡Á‹µo ..................œ..µ..¥...„.......……..................... † †††† ††††† †† † Ÿo¼ ........‹..µÎ.…œ°…Š….....….....…..

°µ¥» .............................. že ­´µ˜· ..............................…………............. ·—µ / ¤µ¦—µºÉ° ........................................................................…......…..
† í— † ®¤oµ¥ † ‡n¼­¤¦­É°º .................………….......…...............…............…...........…………..
°¥šn¼ ɸµo œ/®¤n¼ oµœ ..................……....... Á¨…šÉ¸ ........................ ˜¦°„/Ž°¥ ...........…...…................. ™œœ ..….......……..….....….....®¤¼nšÉ¸ ..…......……
˜Îµ¨/…ªŠ .....................….............°µÎ Á£°/Á…˜ ..............…….................. ‹´Š®ª—´ ..........….…...........…........®¤µ¥Á¨…Ú¦«¡´ šr .............…............…

Á¨…ž¦³‹µÎ ˜´ªž¦³µœ

Ô. …µo ¡Á‹oµ ..................œ...µ.¥………. ............................... † †††† ††††† †† † Ÿo¼ ........¦..´…‹.µÎ ..œ..°...Š....…..……..

°µ¥» .............................. že ­´µ˜· .....…....................................... ·—µ / ¤µ¦—µÉº° ...............………............................…................…...........…..…
† í— † ®¤oµ¥ † ‡n­¼ ¤¦­ºÉ° .....................……....................­´ µ˜· ………..…...…….........……
°¥¼nšÉ¸ oµœ/®¤n¼µo œ ................................ Á¨…š¸É .....……............ ˜¦°„/Ž°¥ ..................……............. ™œœ ................……...…..........®¤¼šn ¸É ...…......…...

˜Îµ¨/…ªŠ ................................. °µÎ Á£°/Á…˜ ................……..................‹´Š®ª´— ......……......….…..............®¤µ¥Á¨…Ú¦«´¡šr ..............….......…....

Õ. …oµ¡Á‹oµ…°Â­—Š¦µ‡µš¦¡´ ¥šr Ʌ¸ °šµÎ œ˜· „· ¦¦¤œ¸ÊÁžœ} ÁŠ·œ .........................…….......................... µš ....…….......…............­˜µŠ‡r
Ö. …oµ¡Á‹oµ…°¦´ ¦°Šªnµ
. (Ò) …oµ¡Á‹oµÅ¤Ån —¦o ´Ã°œÂšœ®¦º°Á¡Éº°ž¦³Ã¥œr„n»‡‡¨˜nµŠ—µo ª
(Ó) ¦.Á.—µ..‡¤·..µ.‹.š.µÎ.¦.œ..´¡°..¥.Š.rš.˜..¸Âɵ..¤­..­.—..´.Š.Å...ª.µ.Äo .‹.œ.µÎ..œÕ...°...ŠÁ.ž..¨.œ}..Š.¦ª..µ.œ´ .‡.š.µ..š…¸É...ɸÂ.….š..…‹o…¦…·ŠÁ—…°º œ..…....…....…....…....…....¡.....«..…....…...........................................................…...................……
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(Õ) .‡..„¼n...¦..–...¸Å..—..o˜...„..¨...Š..¨..—..‹...µÎ .œ...ª..œ...Á.Š..œ·...š..¸ÅÉ...—..o‹..ε..œ...°..Š..Á.ž...œ} ..ž...¦..³..„…´œ…Ū…¨o Š..Á.®...¨..°º....Á.ž...}œ..‹..ε..œ...ª..œ...…....…....…....…....…....…....….......µ.š...................…...............……
(Ö) .Á.Š..°Éº ..œ...Å..…..Â...¨..³..…...°o ..˜..„...¨..Š..°...œºÉ ...Ç....Á.ž...}œ..Å...ž..˜...µ.¤...­...´ ......µ..‹..ε..œ.…°Š…Á—…·¤ ....................................................................…..........…...............……
ªœ´ š.¸É ................. Á—º°œ ...............................…........ ¡.«. ...........…….......
¨Šº°É .......................œ...µ..¥...„............................ Ÿ…o¼ ° ‹µÎ œ°Š
¨Š°Éº .......................œ...µ..¥...…............................ Ÿo…¼ ° ¦´‹µÎ œ°Š
¨ŠºÉ° ........................................................... Ÿ­¼o °­ªœ

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­Îµ®¦´ ¡œ´„ŠµœÁ‹oµ®œµo šÉ¸

Ò) ¦µ‡µž¦³Á¤·œšœ» š¦´¡¥.r .......................................………........……………...................………….µš..........…….…….............…..............­˜µŠ‡r
Ó) ̜—š¸É—œ· Ä®¤n¦³ªµŠ...................……....................Á¨…šÉ—¸ œ· ..........…....………….......……..........®œoµ­µÎ ¦ª‹....................……………...............

̜—š—¸É ·œÁ¨…š.ɸ .......................……................….....Á¨n¤.................………….......................……..®œµo …………………..……….………………
‹µÎ œªœšÉ—¸ ·œ....................….........………......….......Ŧn...............……......……………....................Šµœ...............……....…........…...........˜µ¦µŠªµ
‡ŠÁ®¨°º .........................................………......….....Ŧn.............……..........……………..............….Šµœ.........…….........…..…..................˜µ¦µŠªµ
Ô) ŗ‹o —š³Á¸¥œÂ¨ªo ˜ªn ´œš.¸É ..............…...............Á—°º œ...............................¡.«. ……………….

¨Šº°É ....................................................................
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Á‹oµ¡œ„´ Šµœš—¸É œ·

˜ª´ °¥µn Š®¤µ¥Á¨… Ú (š.—. Ò×)

´œš„¹ …°o ˜„¨Š¨—ÁŠœ· ‹µ„‹Îµœ°Š

š—¸É œ·
¦³ªµŠ.......………………..........................…..˜Îµ¨...........……………………………..…………….............
Á¨…š¸—É œ· ……………………®œoµ­Îµ¦ª‹......………...............°ÎµÁ£°..............…........……................................
̜—®¤µ¥Á¨…š…ɸ …………………………….……….‹Š´ ®ª´—................................…….…...........................
šªÉ¸ µn „µ¦…………..….…………………………
ªœ´ š…ɸ ………Á—°º œ………….…….…¡.«. ……………

Á¨…ž¦³‹Îµ˜´ªž¦³µœ

…µo ¡Á‹oµ ..………........œ...µ.¥...„....……Ÿo‹¼…εœ...°…Š.........................………....... † †††† ††††† †† †
..………........œ..µ..¥...…....……Ÿ¦o¼ …´‹..µÎ.…œ°..Š.......................………....... † †††† ††††† †† †

°µ¥» ................ že ÁºÊ°µ˜…· ………….…… ­´µ˜·........................... ·—µ / ¤µ¦—µ°ºÉ ..........….….........................................
°¥nš¼ ɸoµœ/®¤n¼ oµœ ...................... Á¨…š¸É ................. ˜¦°„/Ž°¥ ....…….........….......... ™œœ ..........…….…………..®¤¼nš¸É .....…...
˜Îµ¨/…ªŠ ...................... °µÎ Á£°/Á…˜ ............................ ‹Š´ ®ª—´ ...…......………................®¤µ¥Á¨…Ú¦«¡´ šr .….....................
…///°//ž//’///· //µ//–///˜//œ///Â//¨//³//Ä/®///o™//o°//¥//‡//ε//˜//n°/ …Å…—oš…µÎ …´œ…š…¹„……°o ˜…„…¨Š…˜°n …Á‹…oµ¡…œ´„…Š…µœ…š—¸É…œ· ……………………………………………………..
—///ªo //¥/‡///ª//µ/¤//­///´˜//¥//r‹//¦//·Š/ —´Š˜°n Şœ¸Ê : -
…………š…¸É—…·œÂ…ž…¨Š…Á‡…¦ºÉ°…Š®…¤…µ¥……oµ…Š…œ…œÊ¸……oµ…¡Á…‹oµ…œ.µ…¥…„.…Ÿo¼‹…µÎ œ…°…Š Å.…—o‹…圅°…ŠÅ…ªo„…´…œ…µ¥…….…Ÿ…¼o¦´…‹µÎ…œ.°.…Š …˜µ…¤­…´……µ‹…圅°…Š .
…¨Š…ª´œ…š…¸É………………..Á—…º°…œ…………………….……………….………¡.…«………….…Á¡…ºÉ°…Áž…}œž…¦…³„…´œ…®œ…¸Êš…»„.…œ·—…š…¸É¤¸°…¥…¼n¨…oª®…¦…º°š…ɸ‹…³Á„..·—…¤…¸…ʹœ…Ä…œ£…µ¥…®…œoµ….
…Áž}œ…‹…圅ªœ…………………………….………….…µ…š…(………………………………….………………………..)…´—.…œ…ʸ …oµ…¡…Á‹µo …š´ÊŠ…­…°Š… µi …¥Å…—˜o …„…¨Š…¨—..‹…圅ª…œÁŠ…·œ…š…¸ÅÉ —…‹o µÎ …œ°…Š.
…Áž}œ…ž…¦³…„´œ…¨…ŠÁ®…¨…º°Á…žœ} …‹…圅ªœ…….…………….………………..…µ…š (…………………………………………………..).…­nª…œ…ÁŠÉº°…œ…Ņ…¨…³……o°…˜„…¨Š..°…œºÉ …Ç…‡Š…Áž…œ} …Ş…˜µ…¤.
…­´ ……µ‹…圅°Š…Á—…·¤š…»„…ž¦…³„…µ¦………………………….……………….…………………………………..……………………….
……………œ´ …š„¹………o°˜…„¨…Š…œÊ¸š…εŅªo®.…œ…ɹŠŒ…´…Á…„È …Ū…o –…­…µÎ œ…´„…Šµ…œš…ɸ—œ·…š…´ÊŠ…­°…Š …iµ¥.…ŗ…o˜¦…ª‹…—…¼´œ…š…¹„……o°…˜„…¨Š..…¨…³Á……oµ…ċ……o°…‡…ªµ…¤˜.¨°—
…¨…ªo ‹…¹Š¨…Š…¨µ…¥¤…º°…°Éº …®¦…º°¨…Š¨…µ¥…¡…·¤¡…œr …ʪ· ¤…°º Å…ª…Áo ž}œ…®…¨„´.…“µ…œ…˜n°…®œ…µo …¡¥.…µœ…¨…³Á…‹µo …¡œ…„´ …Šµ…œš…¸É—…·œ ………..……………………….

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……………………………………………………….………¨Š…ºÉ°………….…………………œ…µ…¥…„……. ………………………..Ÿ…¼o‹Îµ…œ°..…Š …………………….
………………………………….……………………………¨Š…º°É ……………………………œ…µ.…¥…………. ………………………..Ÿ…¼o¦´…‹Îµ…œ.°.…Š ………………….
……………………………………………………….………¨Š…º°É ………….………………………………………………………..¡…¥µ…œ..……………………….
………………………………….……………………………¨Š…º°É ……………………………….…………………………………..¡…¥µ…œ…..…………………….
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˜ª´ °¥nµŠ®¤µ¥Á¨… Ú
­µ¦´‹—š³Á¸¥œ

Áœ°Êº š—ɸ œ· ÁœºÊ°šÉ—¸ œ· ¦³ªµŠ Á‹µo ¡œ´„Šµœš—¸É ·œ
Á¨…šÉ—¸ œ· ¨Š¨µ¥¤º°É°º
‹—š³Á¥¸ œ ž¦³Á£š„µ¦ Ÿo¼Ä®o­´ µ Ÿo¼¦´ ­´ µ ˜µ¤­´µ ‡ŠÁ®¨°º
ªœ´ Á—°º œ že ‹—š³Á¸¥œ ̜—š¸—É ·œÄ®¤n ž¦³š´ ˜¦µ
œµ¥ …. Ŧn Šµœ ˜µ¦µŠ Ŧn Šµœ ˜µ¦µŠ
Ÿo¼¦´‹µÎ œ°Š ªµ ªµ

ª´œš¸É…………. ¨—ÁŠ·œ‹µ„‹Îµœ°Š œµ¥ „. Ò- - --- - (¨Š°Éº )……………
Á—º°œ…………
¡.«. …………

˜´ª°¥µn Š®¤µ¥Á¨… ÒÑ † šÉ¸ oµœ (š.—. Ò)

† š­É¸ ªœ/Ŧn
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