‫ﻨﻤﻭﺫﺝ ﺭﻗﻡ ‪AAP049A-11I‬‬ ‫ﺍﻟﻤﻤﻠﻜﺔ ﺍﻟﻤﻐﺮﺑﻴﺔ‬

‫اﻟﻤﺪﻳﺮﻳﺔ اﻟﺠﻬﻮﻳﺔ أو اﻹﻗﻠﻴﻤﻴﺔ ل‪:‬‬

‫‪.........................................‬‬
‫ﺗﺎرﻳﺦ اﻹﻳﺪاع‪.................... :‬‬ ‫ﺗﻘﺴﻴﻤﺔ‪..............................:‬‬
‫رﻗﻢ اﻹﻳﺪاع‪...................... :‬‬
‫ﻁـﻠـﺏ‬
‫‪ o‬ﺸﻬﺎﺩﺓ ﺍﻟﺩﺨل‬
‫‪ o‬ﻴﺘﻌﻠﻕ ﺒﻤﻠﻑ ﺍﻟﻤﻨﺤﺔ‬

‫ﻫﻭﻴﺔ ﺍﻟﺸﺨﺹ ﺍﻟﺼﺎﺩﺭ ﻋﻨﻪ ﺍﻟﻁﻠﺏ‬

‫ﺍﻹﺴﻡ ﺍﻟﻌﺎﺌﻠﻲ ﻭ ﺍﻟﺸﺨﺼﻲ ‪.................................................................................................................:‬‬
‫ﺍﻟﻤﻭﻁﻥ ﺍﻟﺠﺒﺎﺌﻲ ‪.......................................................................................................................... :‬‬
‫ﺭﻗﻡ ﺍﻟﺒﻁﺎﻗﺔ ﺍﻟﻭﻁﻨﻴﺔ ﻟﻠﺘﻌﺭﻴﻑ ﺃﻭ ﺒﻁﺎﻗﺔ ﺍﻹﻗﺎﻤﺔ‪ /__/__/__/__/__/__/__/__/ :‬ﺭﻗﻡ ﺍﻟﺘﻌﺭﻴﻑ ﺍﻟﻀﺭﻴﺒﻲ ‪/__ /__/__/__/__/__/__/__/ :‬‬

‫ﺭﻗﻡ ﺍﻟﺘﺄﺠﻴﺭ‪/__/__/__/__/__/__/__/__/ :‬‬ ‫ﺭﻗﻡ ﺍﻟﻘﻴﺩ ﻓﻲ ﺍﻟﺼﻨﺩﻭﻕ ﺍﻟﻭﻁﻨﻲ ﻟﻠﻀﻤﺎﻥ ﺍﻹﺠﺘﻤﺎﻋﻲ‪/__/__/__/__/__/__/__/__/ :‬‬

‫ﺍﻟﻬﺎﺘﻑ ‪ ...................... :‬ﺍﻟﻔﺎﻜﺱ ‪ ...................... :‬ﺍﻟﺒﺭﻴﺩ ﺍﻹﻟﻜﺘﺭﻭﻨﻲ ‪....................................................... :‬‬

‫ﺘﺼﺭﻴﺢ ﺒﺎﻟﺸﺭﻑ‬
‫)ﺨﺎﺹ ﺒﺎﻟﻤﻠﺯﻤﻴﻥ ﺍﻟﻐﻴﺭ ﺍﻟﺨﺎﻀﻌﻴﻥ ﻟﻺﻗﺭﺍﺭ ﺍﻟﺴﻨﻭﻱ ﺒﻤﺠﻤﻭﻉ ﺍﻟﺩﺨل(‬

‫ﺼﺎﺤﺏ ﺍﻟﻁﻠﺏ ﺍﻟﻤﺒﻴﻥ ﺃﻋﻼﻩ ﻴﺼﺭﺡ ﺒﺎﻟﺸﺭﻑ‪ ،‬ﺒﺄﻨﻪ ﻟﻡ ﻴﺘﻘﺎﻀﻰ ﺨﻼل ﺴﻨﺔ‪ ،.............‬ﺃﻱ ﺩﺨل ﺁﺨﺭ ﺒﺎﺴﺘﺜﻨﺎﺀ‪:‬‬
‫‪ :‬ﺍﻟﻤﺒﻠﻎ ﺍﻟﺼﺎﻓﻲ ﺍﻟﻤﻔﺭﻭﻀﺔ ﻋﻠﻴﻪ ﺍﻟﻀﺭﻴﺒﺔ ‪........................ :‬‬ ‫ﺃﺠﺭﻩ‬
‫‪ :‬ﺍﻟﻤﺒﻠﻎ ﺍﻟﺼﺎﻓﻲ ﺍﻟﻤﻔﺭﻭﻀﺔ ﻋﻠﻴﻪ ﺍﻟﻀﺭﻴﺒﺔ ‪........................ :‬‬ ‫ﻤﻌﺎﺸﻪ‬
‫‪ :‬ﺍﻟﻤﺒﻠﻎ ‪......................................:‬‬ ‫ﺩﺨﻭل ﺃﺨﺭﻯ )ﺘﺤﺩﻴﺩﻫﺎ( ‪................................................... :‬‬

‫ﺍﻟﻭﺜﺎﺌﻕ ﺍﻟﺘﻲ ﻴﺠﺏ ﺇﺭﻓﺎﻗﻬﺎ ﺒﺎﻟﻁﻠﺏ‪:‬‬

‫ﺒﺎﻟﻨﺴﺒﺔ ﻟﻠﻤﻠﺯﻤﻴﻥ ﺍﻟﺨﺎﻀﻌﻴﻥ ﻟﻺﻗﺭﺍﺭ ﺍﻟﺴﻨﻭﻱ‬
‫ﺒﺎﻟﻨﺴﺒﺔ ﻟﻠﻤﻠﺯﻤﻴﻥ ﺍﻟﻐﻴﺭ ﺨﺎﻀﻌﻴﻥ ﻟﻺﻗﺭﺍﺭ ﺍﻟﺴﻨﻭﻱ ﺒﻤﺠﻤﻭﻉ ﺍﻟﺩﺨل‬
‫ﺒﻤﺠﻤﻭﻉ ﺍﻟﺩﺨل‬
‫‪ -‬ﻨﺴﺨﺔ ﻤﻥ ﺍﻟﺒﻁﺎﻗﺔ ﺍﻟﻭﻁﻨﻴﺔ ﻟﻠﺘﻌﺭﻴﻑ ﺃﻭ ﻤﻥ ﺒﻁﺎﻗﺔ ﺍﻹﻗﺎﻤﺔ ؛‬ ‫‪ -‬ﻨﺴﺨﺔ ﻤﻥ ﺍﻟﺒﻁﺎﻗﺔ ﺍﻟﻭﻁﻨﻴﺔ ﻟﻠﺘﻌﺭﻴﻑ ﺃﻭ ﻤﻥ ﺒﻁﺎﻗﺔ‬
‫‪ -‬ﺸﻬﺎﺩﺓ ﺍﻷﺠﺭ ﻟﻠﺴﻨﺔ ﺍﻟﻔﺎﺭﻁﺔ ﺒﺎﻟﻨﺴﺒﺔ ﻟﻠﻤﻭﻅﻔﻴﻥ ؛‬ ‫ﺍﻹﻗﺎﻤﺔ‪.‬‬
‫‪ -‬ﺃﻭ ﺸﻬﺎﺩﺓ ﺍﻟﻤﻌﺎﺵ ﻟﻠﺴﻨﺔ ﺍﻟﻔﺎﺭﻁﺔ ؛‬
‫‪ -‬ﺃﻭ ﺸﻬﺎﺩﺓ ﺍﻷﺠﺭﺓ ﻟﻠﺴﻨﺔ ﺍﻟﻔﺎﺭﻁﺔ ﺘﺘﻀﻤﻥ ﺨﻁﺎﺏ ﻤﺼﻠﺤﺔ ﺍﻟﻭﻋﺎﺀ ﺍﻟﻀﺭﻴﺒﻲ ﺒﺎﻟﻨﺴﺒﺔ‬
‫ﻟﻠﻌﺎﻤﻠﻴﻥ ﻓﻲ ﺍﻟﻘﻁﺎﻉ ﺍﻟﺨﺎﺹ ؛‬
‫‪ -‬ﺃﻭ ﺸﻬﺎﺩﺓ ﻋﺩﻡ ﺍﻟﻌﻤل ) ﺇﺫﺍ ﻜﺎﻥ ﺼﺎﺤﺏ ﺍﻟﻁﻠﺏ ﻋﺎﻁل ﻋﻥ ﺍﻟﻌﻤل(‪.‬‬

‫ﻓﻲ‪.......................‬ﺘﺎﺭﻴﺦ‪..................‬‬ ‫* ﻴﺠﺏ ﺃﻥ ﻴﻜﻭﻥ ﺍﻹﻤﻀﺎﺀ ﻤﺼﺎﺩﻗﺎ ﻋﻠﻴﻪ ﺒﺎﻟﻨﺴﺒﺔ ﻟﻠﻤﻠﺯﻤﻴﻥ ﺍﻟﻐﻴﺭ‬

‫ﺇﻤﻀﺎﺀ*‪:‬‬ ‫ﺨﺎﻀﻌﻴﻥ ﻟﻺﻗﺭﺍﺭ ﺍﻟﺴﻨﻭﻱ ﻟﻤﺠﻤﻭﻉ ﺍﻟﺩﺨل‪.‬‬