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ATTENTION ! PENSEZ &Agrave; JOINDRE UN EXTRAIT KBIS R&Eacute;CENT

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1 - &nbsp;Communication par un organisme de l&rsquo;identit&eacute; des personnes d&eacute;sign&eacute;es pour &eacute;tablir 
&nbsp; &nbsp; &nbsp;&nbsp;des d&eacute;clarations aupr&egrave;s de TRACFIN (article R. 561-23 du Code Mon&eacute;taire et Financier)

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<table border="1" cellpadding="10" cellspacing="0" style="width:100%;">
	<tbody>
		<tr>
			<td style="padding: 10px; width: 15%; text-align: center;">Nom et pr&eacute;nom du d&eacute;clarant</td>
			<td style="padding: 10px; width: 15%; text-align: center;">Fonction</td>
			<td style="padding: 10px; width: 12%; text-align: center;">T&eacute;l&eacute;phone</td>
			<td style="padding: 10px; width: 12%; text-align: center;">Fax</td>
			<td style="padding: 10px; width: 15%;">
			Courriel
			</td>
			<td style="padding: 10px; width: 20%; text-align: center;">s&rsquo;il s&rsquo;agit du remplacement, indiquez le nom de la (ou les) personne(s) qui n&rsquo;est plus en activit&eacute;</td>
		</tr>
		<tr>
			<td style="padding: 10px; width: 15%;">{% textarea_tag name=&quot;2d7b20ee&quot; data_width=&quot;100&quot; rows=&quot;2&quot; data_label=&quot;Nom et pr&eacute;nom du d&eacute;clarant 1&quot; data_map_field=&quot;nomap&quot; data_help=&quot;Nom et pr&eacute;nom du d&eacute;clarant&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
			<td style="padding: 10px; width: 15%;">{% textarea_tag name=&quot;34ce2a25&quot; data_width=&quot;100&quot; rows=&quot;2&quot; data_label=&quot;Fonction du d&eacute;clarant 1&quot; data_map_field=&quot;nomap&quot; data_help=&quot;Fonction du d&eacute;clarant &quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
			<td style="padding: 10px; width: 12%;">{% textarea_tag name=&quot;17c5302a&quot; data_width=&quot;100&quot; rows=&quot;2&quot; data_label=&quot;T&eacute;l&eacute;phone d&eacute;clarant 1&quot; data_map_field=&quot;nomap&quot; data_help=&quot;T&eacute;l&eacute;phone d&eacute;clarant 1&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
			<td style="padding: 10px; width: 12%;">{% textarea_tag name=&quot;807a10cd&quot; data_width=&quot;100&quot; rows=&quot;2&quot; data_label=&quot;Fax d&eacute;clarant 1&quot; data_map_field=&quot;nomap&quot; data_help=&quot;Fax d&eacute;clarant 1&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
			<td style="padding: 10px; width: 15%;">{% textarea_tag name=&quot;20278b56&quot; data_width=&quot;100&quot; rows=&quot;2&quot; data_label=&quot;Courriel du d&eacute;clarant 1&quot; data_map_field=&quot;nomap&quot; data_help=&quot;Courriel du d&eacute;clarant 1&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
			<td style="padding: 10px; width: 20%;">{% textarea_tag name=&quot;f6bb6971&quot; data_width=&quot;100&quot; rows=&quot;2&quot; data_label=&quot;Rempla&ccedil;ant du d&eacute;clarant 1&quot; data_map_field=&quot;nomap&quot; data_help=&quot;Rempla&ccedil;ant du d&eacute;clarant&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
		<tr>
			<td style="padding: 10px; width: 15%;">{% textarea_tag name=&quot;2d7x20ee&quot; data_width=&quot;100&quot; rows=&quot;2&quot; data_label=&quot;Nom et pr&eacute;nom du d&eacute;clarant 2&quot; data_map_field=&quot;nomap&quot; data_help=&quot;Nom et pr&eacute;nom du d&eacute;clarant&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
			<td style="padding: 10px; width: 15%;">{% textarea_tag name=&quot;34xe2a25&quot; data_width=&quot;100&quot; rows=&quot;2&quot; data_label=&quot;Fonction du d&eacute;clarant 2&quot; data_map_field=&quot;nomap&quot; data_help=&quot;Fonction du d&eacute;clarant &quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
			<td style="padding: 10px; width: 12%;">{% textarea_tag name=&quot;17x5302a&quot; data_width=&quot;100&quot; rows=&quot;2&quot; data_label=&quot;T&eacute;l&eacute;phone d&eacute;clarant 2&quot; data_map_field=&quot;nomap&quot; data_help=&quot;T&eacute;l&eacute;phone d&eacute;clarant 1&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
			<td style="padding: 10px; width: 12%;">{% textarea_tag name=&quot;807x10cd&quot; data_width=&quot;100&quot; rows=&quot;2&quot; data_label=&quot;Fax d&eacute;clarant 2&quot; data_map_field=&quot;nomap&quot; data_help=&quot;Fax d&eacute;clarant 1&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
			<td style="padding: 10px; width: 15%;">{% textarea_tag name=&quot;20x78b56&quot; data_width=&quot;100&quot; rows=&quot;2&quot; data_label=&quot;Courriel du d&eacute;clarant 2&quot; data_map_field=&quot;nomap&quot; data_help=&quot;Courriel du d&eacute;clarant 1&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
			<td style="padding: 10px; width: 20%;">{% textarea_tag name=&quot;f6xb6971&quot; data_width=&quot;100&quot; rows=&quot;2&quot; data_label=&quot;Rempla&ccedil;ant du d&eacute;clarant 2&quot; data_map_field=&quot;nomap&quot; data_help=&quot;Rempla&ccedil;ant du d&eacute;clarant&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
	</tbody>
</table>

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