<?xml version='1.0' encoding='UTF-8'?>
<AADD501 xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xsi:noNamespaceSchemaLocation="AADD501_20261.xsd">
	<Form>
		<Identification>AADD501</Identification>
		<FormCreationDate>2021-05-16</FormCreationDate>
		<FormCreationHour>08:56:13.084</FormCreationHour>
		<AttestationStatus>0</AttestationStatus>
		<TypeForm>RE</TypeForm>
		<Reference>
			<ReferenceType>5</ReferenceType>
			<ReferenceOrigin>2</ReferenceOrigin>
			<ReferenceNbr>340000JEDB00M</ReferenceNbr>
		</Reference>
		<NaturalPerson>
			<NaturalPersonSequenceNbr>1</NaturalPersonSequenceNbr>
			<INSS>80000079512</INSS>
			<WorkerName>KELKUN</WorkerName>
			<WorkerFirstName>ISABELLE</WorkerFirstName>
			<WorkerBirthdate>1979-11-30</WorkerBirthdate>
			<WorkerSex>1</WorkerSex>
			<Nationality>262</Nationality>
			<EmployerId>
				<NOSSLPARegistrationNbr>8280047</NOSSLPARegistrationNbr>
				<CompanyID>0212147796</CompanyID>
				<ServiceData>
					<EmployerWorkerRelationStatus>1</EmployerWorkerRelationStatus>
					<ServiceEndingDate>2019-12-15</ServiceEndingDate>
				</ServiceData>
			</EmployerId>
		</NaturalPerson>
		<AskedDeclaration>
			<Identification>ZIMA001</Identification>
			<IdentificationOfRisk>001</IdentificationOfRisk>
			<ParticularSituationIndicator>0</ParticularSituationIndicator>
			<ReferencePeriod>
				<RefStartingDate>2021-05-06</RefStartingDate>
			</ReferencePeriod>
		</AskedDeclaration>
		<CoordinatesContactPerson>
			<Name>John</Name>
			<FirstName>Smith</FirstName>
			<Address>
				<Street>Teststraat</Street>
				<HouseNbr>20</HouseNbr>
				<ZIPCode>7000</ZIPCode>
				<City>Mons</City>
				<Country>150</Country>
			</Address>
			<Communication>
				<PhoneNbr>091111111</PhoneNbr>
				<EmailAddress>john.smith@test.be</EmailAddress>
			</Communication>
		</CoordinatesContactPerson>
	</Form>
</AADD501>