Formulaire

Private signature power of attorney valid for 3 months for a single payment (Form 11353*03)

Cerfa 11353*03 (40178 - DIP)

Allows the insured person to delegate to a third party the collection of benefits due to him by the National Military Social Security Fund in connection with the care provided.

    Fill out the form

    To whom shall I send this form ?

    J'ai réalisé une démarche administrative

    Je donne mon avis sur Services Publics +. L'administration concernée me répondra.

    Je donne mon avis

    Émetteur du formulaire administratif : National Military Social Security Fund (CNMSS)

    Verified 04 October 2018 - Directorate for Legal and Administrative Information (Prime Minister)