You must send us this attestation, duly completed and signed.
Articles L. 136-7 of the Social Security Code, Article 16 of Order no. 96-50 of 24 January 1996 on the repayment of the social debt, and D. 136-1 of the Social Security Code_.
I hereby _________________________________________________________________________________, living ____________________________________________________________________________________, requests exemption from deduction of the CSG (Contribution Sociale Généralisée) provided for in Article L. 136-7 of the French Social Security Code and the contribution au remboursement de la dette sociale (CRDS) provided for in Article 16 of Order no. 96-50 of 24 January 1996 relating to the reimbursement of social debt.
I certify on my honour that, in application of the provisions of Regulation (EC) No 883/2004 of the European Parliament and of the Council of 29 April 2004 on the coordination of social security systems, I am covered by legislation subject to these provisions, and that I am not dependent on a compulsory French social security scheme.
I have been covered since (date of entitlement), in the State of (specify the State of affiliation or membership of the European Union Common System), the social security fund of (specify the affiliation body), in the capacity of (delete as appropriate):
employed / self-employed / receiving a pension or annuity (retirement, invalidity, accident at work and occupational disease) / other (specify).
I certify that I am in possession of one of the following documents, valid to date, and undertake to produce it if requested by the authorities:
1° Form S1 "Registration for sickness insurance benefits" issued in application of European Regulations (EC) No 883/04 and (EC) No 987/09 and stating that the person is registered with one of the Member States of the European Union, the European Economic Area or Switzerland;
2° Form A1 "Certificate concerning the social security legislation applicable to the holder" issued in application of European Regulations (EC) No 883/04 and (EC) No 987/09;
3° A certificate of affiliation equivalent to the forms referred to in 1° and 2°, issued by the institution with which the person is affiliated;
4° A certificate of affiliation to the joint social security scheme of the institutions of the European Union.
I undertake to notify the paying institution of any change in my social security situation within one month of the change, and to regularise my social security deductions situation spontaneously, if necessary, as part of my tax return.
I also undertake to make available to the authorities any of the supporting documents referred to above that are valid for the period in respect of which I am requesting exemption from the above-mentioned contributions.
I am aware that this certificate is valid for a maximum of three years and that at the end of this period, the continuation of the exemption from the above-mentioned contributions is subject to the submission of a new certificate, all other conditions being met.
I certify the accuracy of the information given in this document.
I am aware that this declaration is binding on me and that any false declaration, or failure to notify a change of situation, may expose me, in addition to the payment of the taxes evaded, to tax increases (1) and, where applicable, criminal penalties (2).
Signed in __________________ , on __________________ (Signature)