‫اﻟﺠﻤﻬﻮرﻳﺔ اﻟﺘﻮﻧﺴﻴﺔ‬

‫وزارة اﻟﻤﺎﻟﻴﺔ‬

‫)*(‬ ‫ﺗﺼﺮﯾﺢ ﺑﻜﺮاء ﺷﻔﻮي‬

‫ﺍﺴﻡ ﺍﻟﻤﺎﻟﻙ)ﺓ( ﺃﻭ ﻤﻥ ﻴﻤﺜﻠﻪ)ﻫﺎ( ﻭﻟﻘﺒﻪ)ﻫﺎ( ‪.......................................................‬‬

‫ﻋﻨﻭﺍﻨــﻪ)ﻫﺎ(‪.................................................................................‬‬

‫ﺍﺴﻡ ﺍﻟﻤﺘﺴ ‪‬ﻭﻍ)ﺓ( ﻭﻟﻘﺒﻪ)ﻫﺎ(‪.......................................................................‬‬

‫ﻋﻨﻭﺍﻨﻪ)ﻫﺎ(‪......................................................................................‬‬
‫ﺘﺤﺩﻴﺩ ﻤﻔﺼل ﻟﻠﻌﻘﺎﺭﺍﺕ‪..........................................................................‬‬
‫ﺍﻟﻤﺘﺴﻭﻏﺔ )ﺍﻟﻌﻨﻭﺍﻥ ﺒﺩﻗﺔ(‪........................................................................‬‬
‫ﺘﺎﺭﻴﺦ ﺒﺩﺍﻴﺔ ﺍﻻﻨﺘﻔﺎﻉ‪.............................................................................‬‬

‫‪07-5.016-02‬‬
‫ﻤﺩﺓ ﺍﻟﻜﺭﺍﺀ‪..........................................................................................‬‬

‫ﻤﻌﻴﻥ ﺍﻟﻜﺭﺍﺀ ﺍﻟﺴﻨﻭﻱ‪...............................................................................‬‬

‫ﻗﻴﻤﺔ ﺍﻷﻋﺒﺎﺀ ‪...................................................................................‬‬

‫ﺍﻟﻤﺒﻠﻎ ﺍﻟﺠﻤﻠﻲ ﻟﻠﻜﺭﺍﺀ‪.............................................................................‬‬

‫ﺘﺎﺭﻴﺦ ﺤﻠـﻭل ﺃﺠـل ﻤﻌﻴﻨﺎﺕ‪....................................................................‬‬
‫ﺍﻟﻜﺭﺍﺀ‬

‫ﺇﻨﻲ ﺍﻟﻤﻤﻀﻲ ﺃﺴﻔﻠﻪ‪ ،‬ﺃﺸﻬﺩ ﺒﺼﺤﺔ ﺍﻟﺒﻴﺎﻨﺎﺕ ﺍﻟﺘﻲ ﺘﻀﻤﻨﻬﺎ ﻫﺫﺍ ﺍﻟﺘﺼﺭﻴﺢ ﻭﺍﻟﺘﻲ ﺃﺘﻌﺭﺽ ﺒﻤﻘﺘﻀﺎﻫﺎ‬
‫ﻟﻠﻌﻘﻭﺒﺎﺕ ﺍﻟﻤﻨﺼﻭﺹ ﻋﻠﻴﻬﺎ ﺒﺎﻟﻘﺎﻨﻭﻥ ﻋﻨﺩ ﻜل ﻤﺨﺎﻟﻔﺔ ‪.‬‬

‫‪………………………..‬ﻓﻲ‪………………………..‬‬ ‫ﺒـ‬

‫ﺇﻤﻀــﺎﺀ ﺍﻟﻤﺼﺭ‪‬ﺡ‬

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‫)*( ﻴﺘﻡ ﺘﻌﻤﻴﺭﻩ ﻤﻥ ﻗﺒل ﺍﻟﻤﺎﻟﻙ ﺃﻭ ﻤﻥ ﻴﻤﺜﻠﻪ ﺃﻭ ﺍﻟﻤﺘﺴﻭ‪‬ﻍ ‪.‬‬