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Certif Rentes Viageres
ﻭﺯﺍﺭﺓ ﺍﻟﻤﺎﻟﻴﺔ
ﺷﮭﺎدة ﻓﻲ ﺧﺼﻢ اﻟﻀﺮﯾﺒﺔ ﻋﻠﻰ اﻟﺪﺧﻞ
ﺑﻌﻨﻮان اﻟﻤﺮﺗﺒﺎت واﻷﺟﻮر واﻟﺠﺮاﯾﺎت واﻹﯾﺮادات اﻟﻌﻤﺮﯾﺔ
ﺧﻼل ﺳﻨﺔ………………
ﯾﺸﮭﺪ اﻟﻤﻤﻀﻲ أﺳﻔﻠﮫ ﺑﺄﻧﮫ ﺗﻢ ﺧﺼﻢ .....................................................................................................................ﺣﺴﺐ ﻣﺎﯾﺄﺗﻲ :
ﺃ ـ ﺍﻟﻤﺅﺠﺭ ﺃﻭ ﺍﻟﻘﺎﺌﻡ ﺒﺎﻟﺩﻓﻊ :
ﺭﻤﺯ ﺍﻷﺩﺍﺀ ﻋﻠﻰ
ﺭﻗﻡ ﺍﻟﻔﺭﻉ ﺍﻟﺜﺎﻨﻭﻱ ﺭﻤﺯ ﺍﻟﺼﻨﻑ ﺍﻟﻤﻌﺭﻑ ﺍﻟﺠﺒﺎﺌﻲ
ﺍﻟﻘﻴﻤﺔ ﺍﻟﻤﻀﺎﻓﺔ
07-5.020-02
ﺍﻻﺴﻡ ﻭﺍﻟﻠﻘﺏ .......................................................................:ﺭﻗﻡ ﺒﻁﺎﻗﺔ ﺍﻟﺘﻌﺭﻴﻑ ﺍﻟﻭﻁﻨﻴﺔ
ﻋﻨﻭﺍﻥ ﺍﻹﻗﺎﻤﺔ ..................................................................................................................................:
-ﺍﻟﺼﻨﺩﻭﻕ ﺍﻟﻭﻁﻨﻲ ﻟﻠﻀﻤﺎﻥ ﺍﻹﺠﺘﻤﺎﻋﻲ.........................................
-ﺍﻟﺼﻨﺩﻭﻕ ﺍﻟﻭﻁﻨﻲ ﻟﻠﺘﻘﺎﻋﺩ ﻭﺍﻟﺤﻴﻁﺔ ﺍﻹﺠﺘﻤﺎﻋﻴﺔ................................ ﺍﻟﺨﻁﺔ ﺍﻟﺘﻲ ﻴﺸﻐﻠﻬﺎ ..................................ﺍﻟﻤﻌﺭﻑ ﺍﻟﻭﺤﻴﺩ
ﺒﺼﻨﺩﻭﻕ ﺍﻻﻨﺨﺭﺍﻁ -ﺁﺨﺭ )ﺃﺫﻜﺭﻩ(.................................................................
ﻤﺩﺓ ﺍﻟﻌﻤل ﺨﻼل ﺍﻟﺴﻨﺔ ......................................................................................................................... :
ﺍﻟﺩﺨل ﺍﻟﺼﺎﻓﻲ ﺍﻟﻤﺒﻠﻎ ﺍﻟﻤﺨﺼﻭﻡ ﻤﻥ ﺍﻟﻤﻭﺭﺩ ﺍﻟﺩﺨل ﺍﻟﻤﻌﺎﺩ ﺍﺴﺘﺜﻤﺎﺭﻩ ﻤﺠﻤﻭﻉ ﺍﻟﺩﺨل ﺍﻟﺨﺎﻡ )ﺃ +ﺏ( ﻗﻴﻤﺔ ﺍﻻﻤﺘﻴﺎﺯﺍﺕ ﺍﻟﻌﻴﻨﻴﺔ )ﺏ( ﺍﻟﺩﺨل ﺍﻟﺨﺎﻀﻊ ﻟﻠﻀﺭﻴﺒﺔ )ﺃ(
ﺇﻨﻲ ﺍﻟﻤﻤﻀﻲ ﺃﺴﻔﻠﻪ ﺃﺸﻬﺩ ﺒﺼﺤﺔ ﺍﻟﺒﻴﺎﻨﺎﺕ ﺍﻟﺘﻲ ﺘﻀﻤﻨﺘﻬﺎ ﻫﺫﻩ ﺍﻟﺸﻬﺎﺩﺓ .
ﺒـ……………………… ﻓﻲ………………………
ﺍﻹﻤﻀﺎﺀ ﻭﺨﺘﻡ ﺍﻟﻤﺅﺠﺭ ﺃﻭ ﺍﻟﻘﺎﺌﻡ ﺒﺎﻟﺩﻓﻊ