‫ﺍﻟﺼـﻨـﺩﻭﻕ ﺍﻟـﻭﻁـﻨـﻲ ﻟـﻠـﻀـﻤـﺎﻥ ﺍﻻﺠـﺘـﻤـﺎﻋـﻲ ﻟـﻐـﻴـﺭ ﺍﻷﺠـﺭﺍﺀ‬

‫ﻁﻠـﺏ ﺍﻟﺤﺼـﻭل ﻋﻠﻰ ﺘﻘـﺎﻋﺩ ﻤﺒﺎﺸـﺭ‬

‫ﻓﺭﻉ ﻭﻻﻴﺔ ‪.................................... :‬‬ ‫ﺍﻟﻭﻜﺎﻟﺔ ﺍﻟﺠﻬﻭﻴﺔ ‪................................... :‬‬

‫ﺇﻁـــﺎﺭ ﻤﺨﺼﺹ ﻟﻤﺼﺎﻟــﺢ ﺍﻟﻭﻜــﺎﻟﺔ ) ﻻ ﻴﻤـــﻸ (‬

‫ﺍﻟﺘﻌﺭﻴﻑ ﻋﻠﻰ ﻤﺴﺘﻭﻯ ﺍﻟﻔﻬﺭﺱ ﺍﻟﻭﻁﻨﻲ ﻟﻠﺘﻘﺎﻋـﺩ‬
‫ﻏﻴﺭ ﻤﻭﺠﻭﺩ ‪:‬‬ ‫ﺍﻟﻤﺅﻤﻥ)ﺓ( ‪:‬‬
‫ﺭﻤﺯ ﺍﻟﻭﻻﻴﺔ ‪:‬‬ ‫ﺍﻟﺭﻗﻡ ‪:‬‬ ‫ﻤﻭﺠﻭﺩ ‪:‬‬
‫ﺘﺎﺭﻴﺦ ﺍﻹﻴﺩﺍﻉ‪:‬‬
‫ﻏﻴﺭ ﻤﻭﺠﻭﺩ ‪:‬‬ ‫ﺍﻟﺯﻭﺝ ‪:‬‬
‫ﺍﻟﺭﻗﻡ ﺍﻟﺘﺴﻠﺴﻠﻲ‪:‬‬
‫ﺭﻤﺯ ﺍﻟﻭﻻﻴﺔ ‪:‬‬ ‫ﺍﻟﺭﻗﻡ ‪:‬‬ ‫ﻤﻭﺠﻭﺩ ‪:‬‬
‫ﺨﺘﻡ ﻭﺘﻭﻗﻴﻊ ﻋﻭﻥ ﺍﻟﺘﺴﺠﻴل‬
‫ﻤﺤﻘﻕ ﻤﻥ ﻁﺭﻑ‬

‫ﺍﻟﺘﺎﺭﻴﺦ ‪................................. :‬‬

‫ﺤـﺎﻟـﺔ ﺍﻟـﻤـﺅﻤـﻥ)ﺓ( ﺍﻟـﻤﺘـﻭﻓـﻰ‬

‫ﺍﻟﻤﻔﺘـﺎﺡ ‪............ :‬‬ ‫ﺭﻗﻡ ﺍﻟﺘﺴﺠﻴل ‪ .............................. :‬ﺭﻗﻡ ﺍﻟﺤﺴﺎﺏ ﺍﻟﺠﺎﺭﻱ ﺍﻟﺒﺭﻴﺩﻱ ‪................................ :‬‬
‫ﺍﻟﻠﻘﺏ ‪ ........................................................... :‬ﺍﻻﺴﻡ ‪.............................................................. :‬‬
‫ﺍﺒﻥ)ﺓ( ‪ .................................................... :‬ﻭ ‪....................................................................... :‬‬
‫ﺍﻟﻠﻘﺏ ﺍﻷﺼﻠﻲ ﻟﻠﺯﻭﺠﺔ ‪.................................................................................... .............................. :‬‬
‫ﺘﺎﺭﻴﺦ ﺍﻟﻤﻴﻼﺩ ‪ ..................... :‬ﻤﻜﺎﻥ ﺍﻟﻤﻴﻼﺩ ‪ ............................................... :‬ﻭﻻﻴﺔ ‪........................... :‬‬
‫ﺘﺎﺭﻴﺦ ﺍﻟﻭﻓﺎﺓ ‪...................................... :‬‬ ‫ﺃ‬ ‫ﺍﻟﺠﻨﺴﻴﺔ‪ .............................:‬ﺍﻟﺠﻨﺱ ‪ :‬ﺫ‬
‫ﻤﻁﻠﻕ )ﺓ(‬ ‫ﺃﺭﻤل )ﺓ(‬ ‫ﻤﺘﺯﻭﺝ )ﺓ(‬ ‫ﺃﻋﺯﺏ‬ ‫ﺍﻟﺤﺎﻟﺔ ﺍﻟﻌﺎﺌﻠﻴﺔ‪:‬‬
‫ﺍﻟﻌﻨﻭﺍﻥ ‪........................................................................ ......................................................... :‬‬
‫‪......................................................................... ......................................................... ........‬‬

‫ﺍﻹﻤﺘﻴﺎﺯﺍﺕ ﺍﻟﺘﻲ ﻜﺎﻥ ﺍﻟﻤﺅﻤﻥ)ﺓ( ﺍﻟﻤﺘﻭﻓﻰ)ﺓ(‬

‫ﺍﻟﻬﻴﺌﺔ ﺍﻟﻤﺴﺩﺩﺓ‬ ‫ﺭﻗﻡ ﺍﻻﻤﺘﻴﺎﺯ‬ ‫ﺍﻟﻤﺒﻠﻎ ﺍﻟﺴﻨﻭﻱ‬
‫ﻧﻮﻋﯿﺔ اﻹﻣﺘﯿﺎز‬
‫‪.......................................………........‬‬ ‫‪……………………....…..‬‬ ‫……………………………‪....‬‬ ‫ﻣﻌﺎش اﻟﺘﻘﺎﻋﺪ ‪.............:‬‬
‫……………‪..................………….........‬‬ ‫……………‪………………..‬‬ ‫…………‪…………………....‬‬ ‫اﻟﺘﻘﺎﻋﺪ اﻟﺘﻜﻤﯿﻠﻲ‪............. :‬‬
‫……………‪……............………………..‬‬ ‫………‪……………………..‬‬ ‫………‪……………………....‬‬ ‫ﻣﺼﺎدر أﺧﺮى)ﺣﺪد(‪.........:‬‬

‫ﺍﻟﺯﻭﺠــــﺎﺕ‬
‫‪4‬‬ ‫‪3‬‬ ‫‪2‬‬ ‫‪1‬‬

‫‪..........................‬‬ ‫‪..........................‬‬ ‫‪.......................... ...........................‬‬ ‫ﺍﻟﻠﻘﺏ‪........................ :‬‬

‫‪..........................‬‬ ‫‪..........................‬‬ ‫‪..........................‬‬ ‫ﺍﻻﺴﻡ ‪........................... ....................... :‬‬
‫‪..........................‬‬ ‫‪..........................‬‬ ‫‪..........................‬‬ ‫‪...........................‬‬ ‫ﻤﻭﻟﻭﺩ)ﺓ( ‪...................:‬‬
‫‪...........................‬‬ ‫‪...........................‬‬ ‫‪...........................‬‬ ‫‪...........................‬‬ ‫ﺍﻟﻤﻬﻨﺔ‪.......................:‬‬
‫‪...........................‬‬ ‫‪...........................‬‬ ‫‪...........................‬‬ ‫‪...........................‬‬ ‫ﺍﻟﻤﻭﺍﺭﺩ‪..................... :‬‬
 ‫ﺍﻷﻁﻔﺎل ﺍﻟﻤﻜﻔﻭﻟﻭﻥ‬
‫ﻁﺒﻴﻌــﺔ ﺍﻟﺼﻠــﺔ ﺍﻟﻌــﺎﺌﻠﻴـــﺔ‬ ‫ﺍﻟﻭﻀﻌﻴـــﺔ)*(‬ ‫ﺘﺎﺭﻴــﺦ ﺍﻟﻤﻴــﻼﺩ‬ ‫ﺍﻟﻠﻘــﺏ ﻭﺍﻻﺴــﻡ‬

‫)*( ﺍﻟﻭﻀﻌﻴﺔ‪ :‬ﻁﺎﻟﺏ )ﺓ(‪ ،‬ﻤﺘﺭﺒﺹ )ﺓ( ﺇﻟﺦ ‪...‬‬

‫ﺍﻷﺼﻭل ﺍﻟﻤﻜﻔﻭﻟﻭﻥ‬
‫ﺁﺨﺭ ) ﻴﺠﺏ ﺍﻟﺘﺩﻗﻴﻕ (‬ ‫ﺍﻷﻡ‬ ‫ﺍﻷﺏ‬

‫ﺍﻟﻠﻘــﺏ‬
‫ﺍﻻﺴــﻡ‬
‫ﺘﺎﺭﻴﺦ ﺍﻟﻤﻴــﻼﺩ‬
‫ﺍﻟﻤﻬﻨـــﺔ‬

‫ﻨﺸـــﺎﻁ ﺍﻟﻤﺅﻤـــﻥ )ﺓ(‬

‫ﺍﻟﺼﻨﺩﻭﻕ ﺍﻟﻤﻨﺘﻤﻲ ﺇﻟﻴﻪ‬ ‫ﺍﻟﻔﺘﺭﺓ‬

‫ﺼﺎﺤﺏ ﺍﻟﻌﻤل )ﺍﻟﻤﺴﺘﺨﺩﻡ( ﻭﻋﻨﻭﺍﻨﻪ‬ ‫ﺍﻟﻤﻬﻨﺔ‬
‫ﻭﺭﻗﻡ ﺍﻟﻀﻤﺎﻥ ﺍﻻﺠﺘﻤﺎﻋﻲ‬ ‫ﻤﻥ ‪ ..........‬ﺇﻟﻰ ‪.........‬‬

‫ﺤﺭﺭ ﺒـ ‪ ................................ ..........‬ﻓﻲ ‪.....................‬‬

‫ﻟﻤﺎﺩﺓ ‪ 78‬ﻤﻥ ﻗﺎﻨﻭﻥ ﺭﻗﻡ ‪ 15-83‬ﺍﻟﻤﺅﺭﺥ ﻓﻲ ‪ 2‬ﻴﻭﻟﻴﻭ ﺴﻨﺔ ‪ 1983‬ﻴﺘﻌﻠﻕ ﺒﺎﻟﻤﻨﺎﺯﻋﺎﺕ ﻓﻲ ﻤﺠﺎل‬
‫ﺍﻟﻀﻤﺎﻥ ﺍﻻﺠﺘﻤﺎﻋﻲ‪ ،‬ﺍﻟﻤﻌﺩل ﻭﺍﻟﻤﺘﻤﻡ‪ :‬ﻴﺘﻌﺭﺽ ﻜل ﺸﺨﺹ ﻋﺭﺽ ﺨﺩﻤﺎﺕ ﺃﻭ ﻗﺒﻠﻬﺎ ﻭﻫﻲ ﻤﺨﺎﻟﻔﺔ‬
‫ﻟﻸﺤﻜﺎﻡ ﺍﻟﻤﻌﻤﻭل ﺒﻬﺎ ﻓﻲ ﻤﺠﺎل ﺍﻟﻀﻤﺎﻥ ﺍﻻﺠﺘﻤﺎﻋﻲ‪ ،‬ﻭﻜﺫﺍ ﻜل ﺸﺨﺹ ﻴﺩﺍﻥ ﺒﺎﻟﻐﺵ ﺃﻭ ﺒﺎﻟﺘﺼﺭﻴﺤﺎﺕ‬
‫ﺍﻟﻤﺯﻴﻔﺔ ﻟﻠﺤﺼﻭل ﻟﻪ ﺃﻭ ﺤﺼﻭل ﻏﻴﺭﻩ ﻋﻠﻰ ﺃﺩﺍﺀﺍﺕ ﻻ ﻴﺴﺘﺤﻘﻬﺎ ﻟﻐﺭﺍﻤﺔ ﻗﺩﺭﻫﺎ ﻀﻌﻑ ﻤﺒﻠﻎ ﺍﻷﺩﺍﺀﺍﺕ‬
‫ﺍﻟﻤﻘﻤﺔ ﺨﻁﺎﺀ ﻤﻥ ﻁﺭﻑ ﻫﻴﺌﺔ ﺍﻟﻀﻤﺎﻥ ﺍﻻﺠﺘﻤﺎﻋﻲ‪.‬‬

‫ﺍﻟﻤﺎﺩﺓ ‪ 17‬ﻤﻥ ﻤﺭﺴﻭﻡ ﺭﻗﻡ ‪ 35-85‬ﻤﺅﺭﺥ ﻓﻲ ‪ 9‬ﻓﺒﺭﺍﻴﺭ ﺴﻨﺔ ‪ 1985‬ﻴﺘﻌﻠﻕ ﺒﺎﻟﻀﻤﺎﻥ ﺍﻻﺠﺘﻤﺎﻋﻲ‬
‫ﻟﻸﺸﺨﺎﺹ ﻏﻴﺭ ﺍﻷﺠﺭﺍﺀ ﺍﻟﺫﻴﻥ ﻴﻤﺎﺭﺴﻭﻥ ﻋﻤﻼ ﻤﻬﻨﻴﺎ‪ ،‬ﺍﻟﻤﻌﺩل ﻭﺍﻟﻤﺘﻤﻡ ‪ :‬ﻴﻠﺯﻡ ﺍﻷﺸﺨﺎﺹ ﺍﻟﺫﻴﻥ ﺘﻤﺕ‬
‫ﺇﺤﺎﻟﺘﻬﻡ ﻋﻠﻰ ﺍﻟﺘﻘﺎﻋﺩ‪ ،‬ﻭﻴﻌﻭﺩﻭﻥ ﺃﻭ ﻴﺴﺘﻤﺭﻭﻥ ﻓﻲ ﻤﻤﺎﺭﺴﺔ ﻋﻤل ﻏﻴﺭ ﻤﺄﺠﻭﺭ‪ ،‬ﺒﺎﻻﻨﺘﺴﺎﺏ ﻤﻥ ﺠﺩﻴﺩ‬
‫ﺇﻟﻰ ﺍﻟﻀﻤﺎﻥ ﺍﻻﺠﺘﻤﺎﻋﻲ ﻤﻊ ﺠﻤﻴﻊ ﺍﻻﻟﺘﺯﺍﻤﺎﺕ ﺍﻟﻨﺎﺠﻤﺔ ﻋﻥ ﺫﻟﻙ‪.‬ﻻ ﻴﺅﺩﻱ ﻫﺫﺍ ﺍﻻﻨﺘﺴﺎﺏ ﺍﻟﺠﺩﻴﺩ‬
‫ﺇﻟﻰ ﺍﻋﺘﻤﺎﺩ ﻤﻥ ﺃﺠل ﺍﻟﺤﺼﻭل ﻋﻠﻰ ﻤﻌﺎﺵ ﺠﺩﻴﺩ ﻭﻻ ﺇﻟﻰ ﻤﻌﺎﺵ ﺍﻟﻌﺠﺯ ﻭﻻ ﻓﻲ ﺍﻟﻨﻬﺎﻴﺔ ﺇﻟﻰ ﻤﺭﺍﺠﻌﺔ‬
‫ﻤﻌﺎﺵ ﺍﻟﺘﻘﺎﻋﺩ ﺍﻟﺫﻱ ﻴﺘﻤﺘﻌﻭﻥ ﺒﻪ‪.‬‬