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<Adresse>
<Code postal> <Ville>
<Nom de l’Administration>
<Adresse de l’administration>
<Code postal> <Ville>
Objet : attestation sur l’honneur d’absence de ressources
Madame, Monsieur,
Je soussigné (e) <Nom et prénom>, né(e) le <Date de naissance> à <Lieu de Naissance>, demeurant à <Adresse>, déclare sur l’honneur ne percevoir ni traitement, ni salaire, ni indemnité de chômage, ni aide généralement quelconque du CPAS (pour la Belgique), ni revenus locatifs, ni tous autres moyens financiers susceptibles de subvenir à mes besoins.
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