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ATTESTATION MINISTERE DE LA JUSTICE N 11527*02 (articles

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1
MINISTERE DE LA JUSTICE
N° 11527*02
ATTESTATION
(articles 200 à 203 du nouveau code de procédure civile, article 441-7 du nouveau code pénal)
Je soussigné,
NOM :
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Melle
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PRENOMS :
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Date de naissance : jour
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année
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Lieu de naissance : _________________________________________
(
ville, département
)
Profession : _______________________________________________
Demeurant à : ___________________________________________________________________
______________________________________________________________________________
Code postal :
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Commune : ____________________________________________
Lien de parenté, d’alliance, de subordination, de collaboration ou de communauté d’intérêts avec les
parties :
OUI
NON
(Cocher la case utile)
Si oui, précisez lequel : _______________________________________
Sachant que l’attestation sera utilisée en justice, et connaissance prise des dispositions de l’article
441-7 du code pénal, réprimant l’établissement d’attestation faisant état de faits matériellement
inexacts, ci-après rappelées :
“Est puni d’un an d’emprisonnement et de 15 000 euros d’amende le fait d’établir une attestation
ou un certificat faisant état de faits matériellement inexacts”.
(cette phrase doit être écrite, ci-dessous, entièrement de votre main)
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2
Indiquez ci-dessous les faits auxquels vous avez assisté ou que vous avez constatés personnellement :
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Votre signature :
Fait à : __________________________________
Le : jour
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PIECE A JOINDRE :
- un original ou une photocopie d’un document officiel justifiant de votre identité et comportant votre
signature.
La loi n°78-17 du 6 janvier 1978 relative aux fichiers nominatifs garantit un droit d’accès et de rectification
des données auprès des organismes destinataires du formulaire.
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ATTESTATION MINISTERE DE LA JUSTICE N 11527*02 (articles

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Completed 5 October 2020

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