<?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>08:58:13.084</FormCreationHour>
		<AttestationStatus>0</AttestationStatus>
		<TypeForm>RE</TypeForm>
		<Reference>
			<ReferenceType>5</ReferenceType>
			<ReferenceOrigin>2</ReferenceOrigin>
			<ReferenceNbr>340000JED400L</ReferenceNbr>
		</Reference>
		<NaturalPerson>
			<NaturalPersonSequenceNbr>1</NaturalPersonSequenceNbr>
			<INSS>80111405125</INSS>
			<WorkerName>KELKUNE</WorkerName>
			<WorkerFirstName>SEBASTIEN</WorkerFirstName>
			<WorkerBirthdate>1981-12-15</WorkerBirthdate>
			<WorkerSex>1</WorkerSex>
			<Nationality>150</Nationality>
			<EmployerId>
				<NOSSRegistrationNbr>70500472</NOSSRegistrationNbr>
				<CompanyID>400767772</CompanyID>
				<ServiceData>
					<EmployerWorkerRelationStatus>0</EmployerWorkerRelationStatus>
				</ServiceData>
			</EmployerId>
		</NaturalPerson>
		<AskedDeclaration>
			<Identification>ZIMA001</Identification>
			<IdentificationOfRisk>001</IdentificationOfRisk>
			<ParticularSituationIndicator>1</ParticularSituationIndicator>
			<ReferencePeriod>
				<RefStartingDate>2021-05-06</RefStartingDate>
			</ReferencePeriod>
		</AskedDeclaration>
		<CoordinatesContactPerson>
			<Name>Smith</Name>
			<FirstName>John</FirstName>
			<Address>
				<Street>Testtraat</Street>
				<HouseNbr>10</HouseNbr>
				<ZIPCode>9000</ZIPCode>
				<City>Gent</City>
				<Country>150</Country>
			</Address>
			<Communication>
				<PhoneNbr>091111111</PhoneNbr>
				<EmailAddress>john@smith.be</EmailAddress>
			</Communication>
		</CoordinatesContactPerson>
	</Form>
</AADD501>