xxxxxxxxxxxxxxxxxxxxxxx <Prénom> xxxxxxxxxxx

<Adresse1>

xxxxxxxxxxxx <Ville>

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<Ville>, le <Date> xxxxxxxxxxxx

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Je soussigné xxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxxxxxxx de la xxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxx à xxxxxxxxxxxxxxxx assure xxx xxxxx xxxxxxxxxxxxxxx xxxxxxxxxxxxxxxx (adresse) xxx xxxxxxxxxxxxxx au xxxxxxxxxxxxx général de xxxxxxxxxxxxxxxxxxxxxx sociale en xxxx que (fonction) xxxx notre xxxxxxxxxxxxxxxxxxxxx

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xxxx à xxxxxxxxxxxxxxxxx le (date)