Fiche d'adhésion CAS fin année

FICHE D’ADHESION AU COMITE D’ACTION SOCIALE

(Renseignements confidentiels)

I – L’AGENT

1. ETAT CIVIL

Matricule :

Nom * :

Prénom * :

Nom de naissance :

Date de naissance * : {"name":"DATENAISSANCEOD","value":"","required":true,"disabled":false,"showTime":false,"rows":1,"cols":1,"title":false,"showDate":true,"preloadCalendar":false,"id":null,"placeholder_date":false,"placeholder_time":false,"size":"","start_id":"","class":"","class-time":"","calendar":{"cols":1,"rows":1,"dateCursor":"pointer"},"valueViewDate":"","valueViewTime":"","formatDate":"d\/m\/Y","formatTime":"H:i","checkDateOnLoad":false,"autocomplete":null}

Adresse * :

Complément d'adresse :

Code Postal * :

Ville * :

Téléphone portable :

Téléphone fixe :

Adresse électronique :

2. EMPLOI

Date d’entrée dans la collectivité : {"name":"DATEENTREECOLL","value":"","required":false,"disabled":false,"showTime":false,"rows":1,"cols":1,"title":false,"showDate":true,"preloadCalendar":false,"id":null,"placeholder_date":false,"placeholder_time":false,"size":"","start_id":"","class":"","class-time":"","calendar":{"cols":1,"rows":1,"dateCursor":"pointer"},"valueViewDate":"","valueViewTime":"","formatDate":"d\/m\/Y","formatTime":"H:i","checkDateOnLoad":false,"autocomplete":null}

Autre employeur :

II – LE CONJOINT, CONCUBIN, PACSE (rayer les mentions inutiles)

Nom * :

Nom de naissance :

Prénom * :

Date de naissance * : {"name":"DATENAISSANCEAD","value":"","required":false,"disabled":false,"showTime":false,"rows":1,"cols":1,"title":false,"showDate":true,"preloadCalendar":false,"id":null,"placeholder_date":false,"placeholder_time":false,"size":"","start_id":"","class":"","class-time":"","calendar":{"cols":1,"rows":1,"dateCursor":"pointer"},"valueViewDate":"","valueViewTime":"","formatDate":"d\/m\/Y","formatTime":"H:i","checkDateOnLoad":false,"autocomplete":null}

Nom collectivité ou entreprise :

III – ENFANTS A CHARGE

NOM et PRENOM :

Date de naissance : {"name":"DATENAISSENF1","value":"","required":false,"disabled":false,"showTime":false,"rows":1,"cols":1,"title":false,"showDate":true,"preloadCalendar":false,"id":null,"placeholder_date":false,"placeholder_time":false,"size":"","start_id":"","class":"","class-time":"","calendar":{"cols":1,"rows":1,"dateCursor":"pointer"},"valueViewDate":"","valueViewTime":"","formatDate":"d\/m\/Y","formatTime":"H:i","checkDateOnLoad":false,"autocomplete":null}

NOM et PRENOM :

Date de naissance : {"name":"DATENAISSENF2","value":"","required":false,"disabled":false,"showTime":false,"rows":1,"cols":1,"title":false,"showDate":true,"preloadCalendar":false,"id":null,"placeholder_date":false,"placeholder_time":false,"size":"","start_id":"","class":"","class-time":"","calendar":{"cols":1,"rows":1,"dateCursor":"pointer"},"valueViewDate":"","valueViewTime":"","formatDate":"d\/m\/Y","formatTime":"H:i","checkDateOnLoad":false,"autocomplete":null}

NOM et PRENOM :

Date de naissance : {"name":"DATENAISSENF3","value":"","required":false,"disabled":false,"showTime":false,"rows":1,"cols":1,"title":false,"showDate":true,"preloadCalendar":false,"id":null,"placeholder_date":false,"placeholder_time":false,"size":"","start_id":"","class":"","class-time":"","calendar":{"cols":1,"rows":1,"dateCursor":"pointer"},"valueViewDate":"","valueViewTime":"","formatDate":"d\/m\/Y","formatTime":"H:i","checkDateOnLoad":false,"autocomplete":null}

NOM et PRENOM :

Date de naissance : {"name":"DATENAISSENF4","value":"","required":false,"disabled":false,"showTime":false,"rows":1,"cols":1,"title":false,"showDate":true,"preloadCalendar":false,"id":null,"placeholder_date":false,"placeholder_time":false,"size":"","start_id":"","class":"","class-time":"","calendar":{"cols":1,"rows":1,"dateCursor":"pointer"},"valueViewDate":"","valueViewTime":"","formatDate":"d\/m\/Y","formatTime":"H:i","checkDateOnLoad":false,"autocomplete":null}

NOM et PRENOM :

Date de naissance : {"name":"DATENAISSENF5","value":"","required":false,"disabled":false,"showTime":false,"rows":1,"cols":1,"title":false,"showDate":true,"preloadCalendar":false,"id":null,"placeholder_date":false,"placeholder_time":false,"size":"","start_id":"","class":"","class-time":"","calendar":{"cols":1,"rows":1,"dateCursor":"pointer"},"valueViewDate":"","valueViewTime":"","formatDate":"d\/m\/Y","formatTime":"H:i","checkDateOnLoad":false,"autocomplete":null}

NOM et PRENOM :

Date de naissance : {"name":"DATENAISSENF6","value":"","required":false,"disabled":false,"showTime":false,"rows":1,"cols":1,"title":false,"showDate":true,"preloadCalendar":false,"id":null,"placeholder_date":false,"placeholder_time":false,"size":"","start_id":"","class":"","class-time":"","calendar":{"cols":1,"rows":1,"dateCursor":"pointer"},"valueViewDate":"","valueViewTime":"","formatDate":"d\/m\/Y","formatTime":"H:i","checkDateOnLoad":false,"autocomplete":null}

NOM et PRENOM :

Date de naissance : {"name":"DATENAISSENF7","value":"","required":false,"disabled":false,"showTime":false,"rows":1,"cols":1,"title":false,"showDate":true,"preloadCalendar":false,"id":null,"placeholder_date":false,"placeholder_time":false,"size":"","start_id":"","class":"","class-time":"","calendar":{"cols":1,"rows":1,"dateCursor":"pointer"},"valueViewDate":"","valueViewTime":"","formatDate":"d\/m\/Y","formatTime":"H:i","checkDateOnLoad":false,"autocomplete":null}

IV – DOCUMENTS A FOURNIR :

Photo de l'agent :

{"name":"Photo","label":"Parcourir...","required":false,"typeMimes":{"application\/msword":["doc"],"application\/vnd.openxmlformats-officedocument.wordprocessingml.document":["docx"],"application\/vnd.ms-excel":["xla","xls","xlt","xlw"],"application\/vnd.openxmlformats-officedocument.spreadsheetml.sheet":["xlsx"],"image\/jpeg":["jpg","jpeg"],"image\/gif":["gif"],"image\/png":["png"],"application\/pdf":["pdf"],"application\/x-download":["pdf"],"application\/download":["pdf"],"application\/octet-stream":["pdf"],"application\/octetstream":["pdf"]},"size_max":"5M","multiple":false,"increment":false,"valueIsHtml":true,"label_files":"Parcourir ([total] fichier[s])","id":"6636abd5103c7","transmit":true,"label_max":"","title":"Le poids d'un fichier \u00e0 transmettre ne peut exc\u00e9der 5M. Les formats de fichier accept\u00e9s sont doc, docx, xla, xls, xlt, xlw, xlsx, jpg, jpeg, gif, png, pdf.","class":"","value":false,"html":"","initializeJS":true,"size_max_byte":5242880,"button":{"value":"Parcourir...","title":"Le poids d'un fichier \u00e0 transmettre ne peut exc\u00e9der 5M. Les formats de fichier accept\u00e9s sont doc, docx, xla, xls, xlt, xlw, xlsx, jpg, jpeg, gif, png, pdf.","class":"","id":"6636abd5103c7"}}

Les 2 derniers avis d’impôt sur les revenus pour l’agent, son conjoint ou concubin(e) : {"name":"IMPOTS","label":"Parcourir...","required":false,"typeMimes":{"application\/msword":["doc"],"application\/vnd.openxmlformats-officedocument.wordprocessingml.document":["docx"],"application\/vnd.ms-excel":["xla","xls","xlt","xlw"],"application\/vnd.openxmlformats-officedocument.spreadsheetml.sheet":["xlsx"],"image\/jpeg":["jpg","jpeg"],"image\/gif":["gif"],"image\/png":["png"],"application\/pdf":["pdf"],"application\/x-download":["pdf"],"application\/download":["pdf"],"application\/octet-stream":["pdf"],"application\/octetstream":["pdf"]},"size_max":"5M","multiple":true,"increment":true,"valueIsHtml":true,"label_files":"Ajouter d'autres fichiers ([total] s\u00e9lectionn\u00e9[s])","id":"6636abd510820","transmit":true,"label_max":"","title":"Le poids d'un fichier \u00e0 transmettre ne peut exc\u00e9der 5M. Les formats de fichier accept\u00e9s sont doc, docx, xla, xls, xlt, xlw, xlsx, jpg, jpeg, gif, png, pdf.","class":"","value":false,"html":"","initializeJS":true,"size_max_byte":5242880,"button":{"value":"Parcourir...","title":"Le poids d'un fichier \u00e0 transmettre ne peut exc\u00e9der 5M. Les formats de fichier accept\u00e9s sont doc, docx, xla, xls, xlt, xlw, xlsx, jpg, jpeg, gif, png, pdf.","class":"","id":"6636abd510820"}}

Bulletin de salaire du mois de décembre de l’année précédente : {"name":"SALAIRE","label":"Parcourir...","required":false,"typeMimes":{"application\/msword":["doc"],"application\/vnd.openxmlformats-officedocument.wordprocessingml.document":["docx"],"application\/vnd.ms-excel":["xla","xls","xlt","xlw"],"application\/vnd.openxmlformats-officedocument.spreadsheetml.sheet":["xlsx"],"image\/jpeg":["jpg","jpeg"],"image\/gif":["gif"],"image\/png":["png"],"application\/pdf":["pdf"],"application\/x-download":["pdf"],"application\/download":["pdf"],"application\/octet-stream":["pdf"],"application\/octetstream":["pdf"]},"size_max":"5M","multiple":true,"increment":true,"valueIsHtml":true,"label_files":"Ajouter d'autres fichiers ([total] s\u00e9lectionn\u00e9[s])","id":"6636abd510ae6","transmit":true,"label_max":"","title":"Le poids d'un fichier \u00e0 transmettre ne peut exc\u00e9der 5M. Les formats de fichier accept\u00e9s sont doc, docx, xla, xls, xlt, xlw, xlsx, jpg, jpeg, gif, png, pdf.","class":"","value":false,"html":"","initializeJS":true,"size_max_byte":5242880,"button":{"value":"Parcourir...","title":"Le poids d'un fichier \u00e0 transmettre ne peut exc\u00e9der 5M. Les formats de fichier accept\u00e9s sont doc, docx, xla, xls, xlt, xlw, xlsx, jpg, jpeg, gif, png, pdf.","class":"","id":"6636abd510ae6"}}

Pour les agents divorcés et n’ayant pas leur(s) enfant(s) à charge :

le justificatif de versement de pension alimentaire (photocopie)

{"name":"JUSTIFPENSIONALIMENT","label":"Parcourir...","required":false,"typeMimes":{"application\/msword":["doc"],"application\/vnd.openxmlformats-officedocument.wordprocessingml.document":["docx"],"application\/vnd.ms-excel":["xla","xls","xlt","xlw"],"application\/vnd.openxmlformats-officedocument.spreadsheetml.sheet":["xlsx"],"image\/jpeg":["jpg","jpeg"],"image\/gif":["gif"],"image\/png":["png"],"application\/pdf":["pdf"],"application\/x-download":["pdf"],"application\/download":["pdf"],"application\/octet-stream":["pdf"],"application\/octetstream":["pdf"]},"size_max":"5M","multiple":true,"increment":true,"valueIsHtml":true,"label_files":"Ajouter d'autres fichiers ([total] s\u00e9lectionn\u00e9[s])","id":"6636abd510d96","transmit":true,"label_max":"","title":"Le poids d'un fichier \u00e0 transmettre ne peut exc\u00e9der 5M. Les formats de fichier accept\u00e9s sont doc, docx, xla, xls, xlt, xlw, xlsx, jpg, jpeg, gif, png, pdf.","class":"","value":false,"html":"","initializeJS":true,"size_max_byte":5242880,"button":{"value":"Parcourir...","title":"Le poids d'un fichier \u00e0 transmettre ne peut exc\u00e9der 5M. Les formats de fichier accept\u00e9s sont doc, docx, xla, xls, xlt, xlw, xlsx, jpg, jpeg, gif, png, pdf.","class":"","id":"6636abd510d96"}}

pour les enfants à charge (photocopie) :

la copie du bulletin de salaire de votre conjoint s’il perçoit le supplément familial
ou l’attestation de paiement de la caisse d’allocations familiales
ou un certificat de scolarité
ou une attestation d’assurance scolaire par enfant.

{"name":"JUSTIFENFANT","label":"Parcourir...","required":false,"typeMimes":{"application\/msword":["doc"],"application\/vnd.openxmlformats-officedocument.wordprocessingml.document":["docx"],"application\/vnd.ms-excel":["xla","xls","xlt","xlw"],"application\/vnd.openxmlformats-officedocument.spreadsheetml.sheet":["xlsx"],"image\/jpeg":["jpg","jpeg"],"image\/gif":["gif"],"image\/png":["png"],"application\/pdf":["pdf"],"application\/x-download":["pdf"],"application\/download":["pdf"],"application\/octet-stream":["pdf"],"application\/octetstream":["pdf"]},"size_max":"5M","multiple":true,"increment":true,"valueIsHtml":true,"label_files":"Ajouter d'autres fichiers ([total] s\u00e9lectionn\u00e9[s])","id":"6636abd511037","transmit":true,"label_max":"","title":"Le poids d'un fichier \u00e0 transmettre ne peut exc\u00e9der 5M. Les formats de fichier accept\u00e9s sont doc, docx, xla, xls, xlt, xlw, xlsx, jpg, jpeg, gif, png, pdf.","class":"","value":false,"html":"","initializeJS":true,"size_max_byte":5242880,"button":{"value":"Parcourir...","title":"Le poids d'un fichier \u00e0 transmettre ne peut exc\u00e9der 5M. Les formats de fichier accept\u00e9s sont doc, docx, xla, xls, xlt, xlw, xlsx, jpg, jpeg, gif, png, pdf.","class":"","id":"6636abd511037"}}

pour les couples non-mariés (photocopie) Justificatif de domicile aux deux noms : {"name":"JUSTIFICATIFDOMICILE","label":"Parcourir...","required":false,"typeMimes":{"application\/msword":["doc"],"application\/vnd.openxmlformats-officedocument.wordprocessingml.document":["docx"],"application\/vnd.ms-excel":["xla","xls","xlt","xlw"],"application\/vnd.openxmlformats-officedocument.spreadsheetml.sheet":["xlsx"],"image\/jpeg":["jpg","jpeg"],"image\/gif":["gif"],"image\/png":["png"],"application\/pdf":["pdf"],"application\/x-download":["pdf"],"application\/download":["pdf"],"application\/octet-stream":["pdf"],"application\/octetstream":["pdf"]},"size_max":"5M","multiple":true,"increment":true,"valueIsHtml":true,"label_files":"Ajouter d'autres fichiers ([total] s\u00e9lectionn\u00e9[s])","id":"6636abd5112ec","transmit":true,"label_max":"","title":"Le poids d'un fichier \u00e0 transmettre ne peut exc\u00e9der 5M. Les formats de fichier accept\u00e9s sont doc, docx, xla, xls, xlt, xlw, xlsx, jpg, jpeg, gif, png, pdf.","class":"","value":false,"html":"","initializeJS":true,"size_max_byte":5242880,"button":{"value":"Parcourir...","title":"Le poids d'un fichier \u00e0 transmettre ne peut exc\u00e9der 5M. Les formats de fichier accept\u00e9s sont doc, docx, xla, xls, xlt, xlw, xlsx, jpg, jpeg, gif, png, pdf.","class":"","id":"6636abd5112ec"}}

« J’atteste sur l’honneur l’exactitude des renseignements ci-dessus »

certifie avoir lu et compris les mentions décrites ci-jointes et être en accord avec celles-ci. MENTIONS LEGALES

Toute fausse déclaration entraînera la radiation.