‫ﻗ ﺎ ﺋ ﻤ ﺔ ﺑ ﺎ ﻟﺬ ھ ﺐ‬

‫ﻣ ﻠﻚ اﻟﺴ ﯿ ﺪ ‪/‬اﻟﺴ ﯿ ﺪ ة ‪ ............................ /‬اﻟﻤ ﻘﯿﻢ ﻓ ﻲ ‪ ..............................................................‬و ﺑﯿﺎﻧﮭ ﺎ ﻛ ﺎ ﻻ ﺗ ﻲ ‪:‬‬

‫و ﺻ ﻒ اﻟ ﺬ ھ ﺐ‬ ‫اﻟﻮ ز ن ﺑ ﺎﻟﺠ ﺮ ام‬ ‫م‬

‫اﻟﻤ ﺠ ﻤ ﻮ ع اﻟﻜ ﻠﻲ ﻟﻘ ﯿﻤ ﺔ اﻟﻘ ﺎﺋﻤ ﺔ‬

‫)ﻓﻘ ﻂ ‪.........................................................‬ﻻ ﻏ ﯿﺮ (‬

‫اﻧﮫ ﻓﻲ ﯾﻮم ‪ ........‬اﻟﻤﻮاﻓﻖ ‪ ٢٠٢٤/ .... / ....‬اﺳﺘﻠﻤﺖ اﻧﺎ اﻟﻤﻮﻗﻊ ادﻧﺎه‪ ............................................... /‬واﻟﻤﻘﯿﻢ ﻓﻲ‬
‫‪ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .‬و اﺣ ﻤ ﻞ ﺑﻄ ﺎﻗﺔ ﻗ ﻮ ﻣ ﻲ ر ﻗ ﻢ ‪ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .‬ﻣ ﻦ اﻟﺴ ﯿ ﺪ ‪ /‬اﻟﺴ ﯿ ﺪ ة ‪. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . /‬‬
‫‪ ,‬ا ﻟ ﺬ ھ ﺐ ا ﻟ ﻤ ﺒ ﯿ ﻦ ﻓ ﻲ اﻟﻘ ﺎ ﺋﻤ ﺔ ﻋ ﺎ ﻟ ﯿ ﮫ و ﺻ ﻔ ﺎ و ﻗ ﯿ ﻤ ﺔ و ذ ﻟ ﻚ ﻋ ﻠ ﻲ ﺳ ﺒ ﯿ ﻞ ا ﻻ ﻣ ﺎ ﻧ ﺔ ) ا ﻟ ﻮ د ﯾ ﻌ ﺔ ( ﻟ ﻤ ﺪ ة ﺳ ﻨ ﺔ ﻣ ﻦ ﺗ ﺎ ر ﯾ ﺦ ا ﻻ ﺳ ﺘ ﻼ م ﺳ ﺎ ﺑ ﻖ ا ﻟ ﺬ ﻛ ﺮ و‬
‫ا ﺗ ﻌ ﮭ ﺪ ﺑ ﺎ ﻟ ﻤ ﺤ ﺎ ﻓ ﻈ ﺔ ﻋ ﻠ ﯿ ﮭ ﺎ ﻣ ﻦ اﻟﺘﻠﻒ ﻛ ﻤ ﺎ ﻻ ﯾ ﺤ ﻖ ﻟ ﻲ ا ﻟ ﺘ ﺼ ﺮ ف ﻓ ﯿ ﮭ ﺎ و ا ﻟ ﺘ ﺰ م ﺑ ﺮ د ھ ﺎ ﻋ ﯿ ﻨ ﺎ ا و د ﻓ ﻊ ﺛ ﻤ ﻨ ﮭ ﺎ ﻧ ﻘ ﺪ ا ) و ﯾﻘ ﯿﻢ اﻟﺜ ﻤ ﻦ اﻟﻨﻘ ﺪ ي ﺑﺴ ﻌ ﺮ‬
‫اﻟﺴ ﻮ ق و ﻗ ﺖ اﻻ ﺳ ﺘﻼ م ( ﺑﻌ ﺪ اﻻ ﻧﺘﮭ ﺎء ﻣ ﻦ ﻣ ﺪ ة اﻟﻮ د ﯾﻌ ﺔ – و ا ذ ا ﻟﻢ اﻗﻢ ﺑﺮ د ھ ﺎ او دﻓ ﻊ ﺛﻤ ﻨﮭ ﺎ اﻛ ﻮ ن ﻣ ﺒ ﺪ د ا و ﺧ ﺎﺋﻨ ﺎ ﻟﻼ ﻣ ﺎﻧﮫ و اﺗﺤ ﻤ ﻞ‬
‫اﻟﻤ ﺴ ﺆ ﻟﯿﺔ اﻟﻤ ﺘﺮ ﺗﺒ ﺔ ﻋ ﻠﻰ ذ ﻟﻚ ‪.‬‬

‫و ھ ﺬ ا اﻗ ﺮ ا ر ﻣ ﻨ ﻲ ﯾ ﻔ ﯿ ﺪ ا ﻻ ﺳ ﺘ ﻼ م ‪. . .‬‬

‫اﻟﻤ ﻘﺮ ﺑﻤ ﺎ ﻓ ﯿﮫ‬ ‫ﺑ ﺼ ﻤ ﺔ ا ﻻ ﺻ ﺒﻊ ‪.‬‬

‫ﺷ ﮭﻮد‬

‫اﻟﺸ ﺎھ ﺪ اﻟﺜ ﺎﻧ ﻲ‬ ‫اﻟﺸ ﺎھ ﺪ اﻻ و ل‬

‫ﺑﻄ ﺎﻗ ﺔ ر ﻗﻢ‬ ‫ﺑﻄ ﺎﻗ ﺔ ر ﻗﻢ‬

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 ‫ﻣ ﺜ ﺎ ل ﺗ ﻮ ﺿ ﯿ ﺤ ﻲ ﻛ ﯿ ﻔ ﯿ ﺔ ﻣ ﻠ ﺊ ا ﻟ ﻘ ﺎ ﺋ ﻤ ﺔ ﻣ ﻘ ﺪ م ا ﻟ ﯿ ﻜ ﻢ ھ ﺪ ﯾ ﮫ ﻣ ﻦ ا ﻟ ﻌ ﺎ ﺋ ﻠ ﺔ ا ﻻﻗ ﺘ ﺼ ﺎ د ﯾ ﺔ ﺑ ﺮ ﻋ ﺎ ﯾ ﺔ د ‪ .‬ﻣ ﺤ ﻤ ﺪ ﻣ ﺤ ﻲ ا ﻟ ﺪ ﯾ ﻦ‬

‫ﻗ ﺎ ﺋ ﻤ ﺔ ﺑ ﺎ ﻟﺬ ھ ﺐ‬
‫ﻣﻠﻚ اﻟﺴﯿﺪ‪/‬اﻟﺴﯿﺪة ‪ ............................ /‬اﻟﻤﻘﯿﻢ ﻓﻲ ‪..............................................................‬و ﺑﯿﺎﻧﮭﺎ ﻛﺎﻻﺗﻲ‪:‬‬

‫وﺻﻒ اﻟﺬھﺐ‬ ‫اﻟﻮزن ﺑﺎﻟﺠﺮام‬ ‫م‬

‫ﺳﺒﯿﻜﺔ ذھﺒﯿﺔ ﻋﯿﺎر ‪ ٢٤‬ﻣﻦ ﺷﺮﻛﺔ ‪ ......‬ﻣﻐﻠﻔﺔ‬ ‫‪ ٢٠‬ﺟﺮام‬ ‫‪١‬‬

‫ﺳﺒﯿﻜﺔ ذھﺒﯿﺔ ﻋﯿﺎر ‪ ٢٤‬ﻣﻦ ﺷﺮﻛﺔ ‪ ......‬ﻣﻐﻠﻔﺔ‬ ‫‪ ١٠‬ﺟﺮام‬ ‫‪٢‬‬

‫ﺟﻨﯿﮫ ذھﺐ ﻋﯿﺎر ‪٢١‬ﻣﻦ ﺷﺮﻛﺔ‪ .....‬ﻣﻐﻠﻔﺔ‬ ‫‪ ٨‬ﺟﺮام‬ ‫‪٣‬‬

‫ﺑﻌﺪ اﻻﺗﻔﺎق ﻋﻠﻰ اﻟﺘﺤﻮﯾﻞ ﯾﺬﻛﺮ اﺳﻢ اﻟﺸﺮﻛﺔ اﻟﻤﺮاد‬
‫اﻻﺳﺘﻼم اﻟﺬھﺐ ﺑﯿﮫ و ﻛﺘﺎﺑﺔ اﻟﻌﯿﺎر و اﻧﮫ ﻣﻐﻠﻒ ام ﻻ‬
‫ﺛﻼﺛﻮن ﺟﺮام ذھﺐ ﻋﯿﺎر ‪٢٤‬‬
‫ﺛﻤﺎﻧﯿﺔ ﺟﺮام ذھﺐ ﻋﯿﺎر ‪٢١‬‬
‫ﻓﻲ ﺣﺎل ﺗﻘﺪﯾﻢ ذھﺐ ﻣﺸﻐﻮل ﯾﺘﻢ ﺗﺤﻮﯾﻠﮫ اﻟﻰ ﺳﺒﺎﺋﻚ او ﺟﻨﯿﮭﺎت و اﻻﺗﻔﺎق ﻋﻠﻰ‬ ‫‪٤‬‬
‫اﺳﺘﻼﻣﮭﺎ ﺳﺒﺎﺋﻚ او ﺟﻨﯿﮭﺎ ﺣﺴﺐ اﻻﺗﻔﺎق‬
‫اﻟﻤﺠﻤﻮع اﻟﻜﻠﻲ ﻟﻘﯿﻤﺔ اﻟﻘﺎﺋﻤﺔ‬
‫)ﻓﻘﻂ ﺛﻤﺎﻧﯿﺔ و ﺛﻼﺛﻮن ﺟﺮام ذھﺐ ﻻﻏﯿﺮ(‬

‫ﻣﻠﺤﻮظﺔ‪ :‬ﯾﺠﺐ ﻛﺘﺎﺑﺔ ﻛﺎﻣﻞ اﻟﺬھﺐ اﻟﻤﺴﻠﻢ اﻟﻰ اﻟﺘﺎﺟﺮ ﺑﺎﻹﺿﺎﻓﺔ اﻟﻰ اﻟﻨﺴﺒﺔ‬
‫اﻟﻤﺘﻔﻖ ﻋﻠﯿﮭﺎ ذھﺐ ﻣﺜﺎل ﺗﻮﺿﯿﺤﻲ‪ :‬ﺳﻠﻤﺖ اﻟﻰ اﻟﺘﺎﺟﺮ ‪ ١٠٠‬ﺟﺮام ذھﺐ و‬
‫ﺗﻢ اﻻﺗﻔﺎق ﻣﻌﻲ ﻋﻠﻰ ﻧﺴﺒﺔ ‪ ٪١٠‬ﺳﻨﻮﯾﺎ ﺗﺪﻓﻊ اﺧﺮ اﻟﻤﺪة ﻓﯿﻜﻮن اﺟﻤﺎﻟﻰ‬
‫اﻟﺠﺮاﻣﺎت اﻟﻤﻜﺘﻮﺑﺔ اﻟﻤﺴﻠﻤﺔ اﻟﻰ اﻟﺘﺎﺟﺮ ھﻲ ‪ ١١٠‬ﺟﺮام ذھﺐ‬

‫اﻧﮫ ﻓﻲ ﯾﻮم اﻻﺣﺪ اﻟﻤﻮاﻓﻖ ‪ ٢٠٢٤/ ١ / ١٤‬اﺳﺘﻠﻤﺖ اﻧﺎ اﻟﻤﻮﻗﻊ ادﻧﺎه‪ /‬اﺳﻢ ﻣﺴﺘﻠﻢ اﻟﺬھﺐ واﻟﻤﻘﯿﻢ ﻓﻲ ‪ ....................................‬واﺣﻤﻞ ﺑﻄﺎﻗﺔ ﻗﻮﻣﻲ‬
‫رﻗﻢ ‪ ..............................‬ﻣﻦ اﻟﺴﯿﺪ ‪ /‬اﻟﺴﯿﺪة ‪ /‬اﺳﻢ ﻣﺎﻟﻚ اﻟﺬھﺐ ‪,‬اﻟﺬھﺐ اﻟﻤﺒﯿﻦ ﻓﻲ اﻟﻘﺎﺋﻤﺔ ﻋﺎﻟﯿﮫ وﺻﻔﺎ و ﻗﯿﻤﺔ و ذﻟﻚ ﻋﻠﻲ ﺳﺒﯿﻞ اﻻﻣﺎﻧﺔ)اﻟﻮدﯾﻌﺔ(‬
‫ﻟﻤﺪة ﺳﻨﺔ ﻣﻦ ﺗﺎرﯾﺦ اﻻﺳﺘﻼم ﺳﺎﺑﻖ اﻟﺬﻛﺮ و اﺗﻌﮭﺪ ﺑﺎﻟﻤﺤﺎﻓﻈﺔ ﻋﻠﯿﮭﺎ ﻣﻦ اﻟﺘﻠﻒ ﻛﻤﺎ ﻻ ﯾﺤﻖ ﻟﻲ اﻟﺘﺼﺮف ﻓﯿﮭﺎ و اﻟﺘﺰم ﺑﺮدھﺎ ﻋﯿﻨﺎ او دﻓﻊ ﺛﻤﻨﮭﺎ ﻧﻘﺪا ) و‬
‫ﯾﻘﯿﻢ اﻟﺜﻤﻦ اﻟﻨﻘﺪي ﺑﺴﻌﺮ اﻟﺴﻮق وﻗﺖ اﻻﺳﺘﻼم ( ﺑﻌﺪ اﻻﻧﺘﮭﺎء ﻣﺪة اﻟﻮدﯾﻌﺔ – واذا ﻟﻢ اﻗﻢ ﺑﺮدھﺎ او دﻓﻊ ﺛﻤﻨﮭﺎ اﻛﻮن ﻣﺒﺪدا و ﺧﺎﺋﻨﺎ ﻟﻼﻣﺎﻧﮫ و اﺗﺤﻤﻞ‬
‫اﻟﻤﺴﺆﻟﯿﺔ اﻟﻤﺘﺮﺗﺒﺔ ﻋﻠﻰ ذﻟﻚ‪.‬‬

‫و ھﺬا اﻗﺮار ﻣﻨﻲ ﯾﻔﯿﺪ اﻻﺳﺘﻼم‪...‬‬

‫اﻟﻤﻘﺮ ﺑﻤﺎ ﻓﯿﮫ‬ ‫ﺑﺼﻤﺔ اﻻﺻﺒﻊ‪.‬‬

‫اﻟﺘﻮﻗﯿﻊ ﯾﺠﺐ ان ﯾﻜﻮن ﻛﺘﺎﺑﺔ و ﻟﯿﺲ ﻓﻮرﻣﺔ‬

‫ﺷﮭﻮد‬

‫اﻟﺸﺎھﺪ اﻟﺜﺎﻧﻲ‬ ‫اﻟﺸﺎھﺪ اﻻول‬

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