‫اﻟﺟﻣﮭورﯾﺔ اﻟﺟزاﺋرﯾﺔ اﻟدﯾﻣﻘراطﯾﺔ اﻟﺷﻌﺑﯾﺔ‬

‫وﻻﯾﺔ ‪ :‬اﻟﺟﻠﻔﺔ‬

‫داﺋرة ‪ :‬ﻋﯾن وﺳﺎرة‬

‫ﺑﻠدﯾﺔ ‪ :‬ﻋﯾن وﺳﺎرة‬

‫إﺳﺗﻣﺎرة طﻠب إﺳﺗﻔﺎدة ﻣن إﻋﺎﻧﺔ ﻣﺎﻟﯾﺔ ﻟﻘﻔﺔ رﻣﺿﺎن ‪2020‬‬

‫رﻗم اﻟﺗﻌرﯾف اﻟوطﻧﻲ )‪............................................................................................................................... : (1‬‬

‫اﻻﺳم واﻟﻠﻘب ‪..................... ..................... ........................ ........................................................................ :‬‬

‫ﺗﺎرﯾﺦ وﻣﻛﺎن اﻟﻣﯾﻼد ‪.................. ...................... ..................... ..................................................................... :‬‬

‫اﻟﺟﻧﺳﯾﺔ ‪............ ..................... ..................... ..................... .................................................................... :‬‬

‫ﻋﻧوان اﻻﻗﺎﻣﺔ ‪.............. ..................... ..................... ..................... ............................................................:‬‬

‫ﻧوﻋﯾﺔ اﻻﻋﺎﻗﺔ ‪................................ .................................. :‬‬ ‫ﻻ‬ ‫ذوي اﻻﺣﺗﯾﺎﺟﺎت اﻟﺧﺎﺻﺔ ‪ :‬ﻧﻌم‬

‫اﻟوﺿﻌﯾﺔ اﻻﺟﺗﻣﺎﻋﯾﺔ ‪ ..................................... :‬ﻋدد اﻻﺑﻧﺎء ‪............................................. ................................. :‬‬

‫ﻋدد اﻗل ﻣن ‪ 18‬ﺳﻧﺔ ‪ ........................................ :‬ﻋدد اﻻﺣﺗﯾﺎﺟﺎت اﻟﺧﺎﺻﺔ اﻟﻣﺗﻛﻔل ﺑﮭم ‪.................................. ............. :‬‬

‫اﻟوظﯾﻔﺔ ‪ .................................................... :‬اﻟﻣؤﺳﺳﺔ ‪................................................................. ............... :‬‬

‫اﻟدﺧل اﻟﺷﮭري اﻟﺻﺎﻓﻲ ‪......................................... ..................... .................................................................. :‬‬

‫وظﯾﻔﺔ اﻟزوج )ة(‪ ..................................... :‬اﻟدﺧل اﻟﺷﮭري ‪........................................ ..................... ................. :‬‬

‫رﻗم اﻟﺣﺳﺎب اﻟﺑرﯾدي ‪.............................................................. ..................................................................... :‬‬

‫رﻗم اﻟﺿﻣﺎن اﻻﺟﺗﻣﺎﻋﻲ ‪........................................ ........................................................................................ :‬‬

‫ﻣﻠﻐﺎ اﻹﯾﺟﺎر ‪................................................... :‬‬ ‫إﯾﺟﺎر‬ ‫ﻋﻣوﻣﻲ‬ ‫ﻧوﻋﯾﺔ اﻟﺳﻛن ‪:‬‬

‫ﻻ‬ ‫ﻧﻌم‬ ‫ذوي اﻟﺣﻘوق ‪:‬‬

‫أﺻرح ﺑﺷرﻓﻲ أن اﻟﻣﻌﻠوﻣﺎت اﻟﻣﺻرح ﺑﮭﺎ أﻋﻼه ﺻﺣﯾﺣﺔ وﺑﺈﺳﺗﻌدادي أي وﺛﯾﻘﺔ ﻹﺛﺑﺎﺗﮭﺎ ﺣﺎل طﻠﺑﮭﺎ‬

‫‪.‬‬ ‫ﯾﺗﻌرض ﻛل ﺗﺻرﯾﺢ ﻛﺎذب ﺻﺎﺣﺑﮫ ﻟﻔﻘدان اﻟﺣق ﻓﻲ اﻹﻋﺎﻧﺔ وﻟﻠﺣﻘوﺑﺔ اﻟﻣﻧﺻوص ﻋﻠﯾﮭﺎ طﺑﻘﺎ ﻟﻠﺗﺷرﯾﻊ‪.‬‬

‫)‪ (1‬ﻓﻲ ﺣﺎل ﺗوﻓره‬

‫)‪ (2‬اﻟﻘﺎطﻧﯾن ﺑﻧﻔس اﻟﻣﺳﻛن‬

‫رﻗم ﺑطﺎﻗﺔ اﻟﺗﻌرﯾف‪ ...................:‬ﻋن ‪.......................................:‬‬

‫إﻣﺿﺎء اﻟﻣﻌﻧﻲ‬