<?xml version='1.0' encoding='UTF-8'?>
<ZIMA006 xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xsi:noNamespaceSchemaLocation="ZIMA006_20261.xsd">
	<Form>
		<Identification>ZIMA006</Identification>
		<FormCreationDate>2021-05-16</FormCreationDate>
		<FormCreationHour>09:52:13.084</FormCreationHour>
		<AttestationStatus>3</AttestationStatus>
		<TypeForm>SU</TypeForm>
		<CoordinatesContactPerson>
			<Name>Nom</Name>
			<FirstName>Lauren</FirstName>
			<Communication>
				<EmailAddress>Lauren.Nom@skynet.be</EmailAddress>
			</Communication>
		</CoordinatesContactPerson>
		<DclInformation>
			<LanguageCodePdf>1</LanguageCodePdf>
		</DclInformation>
		<RiskIdentification>
			<IdentificationOfRisk>001</IdentificationOfRisk>
		</RiskIdentification>
		<Reference>
			<ReferenceType>3</ReferenceType>
			<ReferenceOrigin>2</ReferenceOrigin>
			<ReferenceNbr>340000103H01U</ReferenceNbr>
		</Reference>
		<CommentDeclaration>
			<CommentOfDeclaration>ANNULATIE / ANNULATION</CommentOfDeclaration>
		</CommentDeclaration>
		<EmployerDeclarationLink>
			<NOSSRegistrationNbr>042745862</NOSSRegistrationNbr>
			<Trusteeship>0</Trusteeship>
			<CompanyID>0</CompanyID>
			<NaturalPerson>
				<NaturalPersonSequenceNbr>000702</NaturalPersonSequenceNbr>
				<INSS>65052599999</INSS>
				<WorkRecovery>
					<WorkRecoveryDate>2021-05-19</WorkRecoveryDate>
				</WorkRecovery>
			</NaturalPerson>
		</EmployerDeclarationLink>
	</Form>
</ZIMA006>