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<h1 style="text-align: center;"><span style="color:#000000;"><strong>D&eacute;tail provenance des fonds &amp; financement</strong></span></h1>

<p>Je soussign&eacute; :</p>

<p>{% select_tag name=&quot;29c8a534&quot; data_label=&quot;Civilit&eacute;&quot; data_choices=&quot;Madame|madame; Monsieur|monsieur;&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}&nbsp;{% textinput_tag name=&quot;d339f779&quot; data_label=&quot;Nom prenom&quot; style=&quot;max-width:300px;min-width:300px;width:300px;&quot; fixedwidth=&quot;300&quot; data_align_text=&quot;left&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}, n&eacute; le&nbsp;{% textinput_tag name=&quot;84b72314&quot; data_label=&quot;n&eacute; le&quot; style=&quot;max-width:100px;min-width:100px;width:100px;&quot; fixedwidth=&quot;100&quot; data_align_text=&quot;left&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %} &agrave;&nbsp;{% textinput_tag name=&quot;7d775b0d&quot; data_label=&quot;lieu de naissance&quot; style=&quot;max-width:150px;min-width:150px;width:150px;&quot; fixedwidth=&quot;150&quot; data_align_text=&quot;left&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}<br />
Et<br />
{% select_tag name=&quot;29c8a531&quot; data_label=&quot;Civilit&eacute;&quot; data_choices=&quot;Madame|madame; Monsieur|monsieur;&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}&nbsp;{% textinput_tag name=&quot;d339f772&quot; data_label=&quot;Nom prenom&quot; style=&quot;max-width:300px;min-width:300px;width:300px;&quot; fixedwidth=&quot;300&quot; data_align_text=&quot;left&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}, n&eacute; le&nbsp;{% textinput_tag name=&quot;84b32314&quot; data_label=&quot;n&eacute; le&quot; style=&quot;max-width:100px;min-width:100px;width:100px;&quot; fixedwidth=&quot;100&quot; data_align_text=&quot;left&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %} &agrave;&nbsp;{% textinput_tag name=&quot;7d775b4d&quot; data_label=&quot;lieu de naissance&quot; style=&quot;max-width:150px;min-width:150px;width:150px;&quot; fixedwidth=&quot;150&quot; data_align_text=&quot;left&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</p>

<p>Atteste que les fonds utilisés en apport d&rsquo;un montant de&nbsp;{% textinput_tag name=&quot;ce28ef2e&quot; data_label=&quot;Atteste que les fonds utilis&eacute;s en apport d&rsquo;un montant de&quot; style=&quot;max-width:200px;min-width:200px;width:200px;&quot; fixedwidth=&quot;200&quot; data_align_text=&quot;left&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}&nbsp;Euros pour le règlement de l&rsquo;achat du bien&nbsp;immobilier objet de l&rsquo;offre d&rsquo;achat ci-avant, ont pour origine :</p>

<p>{% checkbox_tag name=&quot;ab3a3616&quot; data_label=&quot;Epargne &ndash; Banque&quot; %}&nbsp;Epargne &ndash; Banque :&nbsp;{% textinput_tag name=&quot;c1644f51&quot; data_label=&quot;Epargne &ndash; Banque :&quot; style=&quot;max-width:500px;min-width:500px;width:500px;&quot; fixedwidth=&quot;500&quot; data_align_text=&quot;left&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}<br />
{% checkbox_tag name=&quot;ab3a3216&quot; data_label=&quot;Cession d&rsquo;actifs (immobiliers ou mobiliers) date&quot; %}&nbsp;Cession d&rsquo;actifs (immobiliers ou mobiliers) date :&nbsp;{% textinput_tag name=&quot;c1642f51&quot; data_label=&quot;Cession d&rsquo;actifs (immobiliers ou mobiliers) date :&quot; style=&quot;max-width:200px;min-width:200px;width:200px;&quot; fixedwidth=&quot;200&quot; data_align_text=&quot;left&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}<br />
{% checkbox_tag name=&quot;ab3a32x6&quot; data_label=&quot;Héritage, Notaire en charge du dossier&quot; %}&nbsp;Héritage, Notaire en charge du dossier :&nbsp;{% textinput_tag name=&quot;c164xf51&quot; data_label=&quot;Héritage, Notaire en charge du dossier&quot; style=&quot;max-width:200px;min-width:200px;width:200px;&quot; fixedwidth=&quot;200&quot; data_align_text=&quot;left&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}<br />
{% checkbox_tag name=&quot;ab3a32a6&quot; data_label=&quot;Donation, Notaire en charge du dossier&quot; %}&nbsp;Donation, Notaire en charge du dossier :&nbsp;{% textinput_tag name=&quot;c16axf51&quot; data_label=&quot;Donation, Notaire en charge du dossier&quot; style=&quot;max-width:200px;min-width:200px;width:200px;&quot; fixedwidth=&quot;200&quot; data_align_text=&quot;left&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}<br />
{% checkbox_tag name=&quot;ab3v32a6&quot; data_label=&quot;Réemploi de fonds : précisez l&rsquo;origine :&quot; %}&nbsp;Réemploi de fonds : précisez l&rsquo;origine :&nbsp;{% textinput_tag name=&quot;c1vaxf51&quot; data_label=&quot;Réemploi de fonds : précisez l&rsquo;origine :&quot; style=&quot;max-width:200px;min-width:200px;width:200px;&quot; fixedwidth=&quot;200&quot; data_align_text=&quot;left&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}<br />
{% checkbox_tag name=&quot;ab3v32ax&quot; data_label=&quot;Autre :&quot; %} Autre :&nbsp;{% textinput_tag name=&quot;c1vaxf5x&quot; data_label=&quot;Autre&quot; style=&quot;max-width:400px;min-width:400px;width:400px;&quot; fixedwidth=&quot;400&quot; data_align_text=&quot;left&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}<br />
{% checkbox_tag name=&quot;ab3v32ap&quot; data_label=&quot;Pr&ecirc;t de la totalit&eacute;&quot; %} Pr&ecirc;t de la totalit&eacute;<br />
<br />
<strong>Je certifie que ces fonds n&rsquo;ont pas d&rsquo;origine d&eacute;lictueuse ou criminelle au sens de la r&eacute;glementation Je certifie que ces fonds n&rsquo;ont pas d&rsquo;origine d&eacute;lictueuse ou criminelle au sens de la r&eacute;glementation relative &agrave; la lutte contre le blanchiment de capitaux.</strong></p>

<h1 style="text-align: center;"><span style="color:#000000;"><strong>Conditions particuli&egrave;res</strong></span></h1>

<p>{% textarea_tag name=&quot;58369e2e&quot; data_width=&quot;100&quot; rows=&quot;3&quot; data_label=&quot;Conditions particuli&egrave;res&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</p>

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