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<table border="0" cellpadding="1" cellspacing="5" style="width:100%;">
	<tbody>
		<tr>
			<td style="text-align: left; vertical-align: middle; width: 30%;">
			&nbsp;

&nbsp;
			</td>
			<td style="text-align: left; vertical-align: middle; width: 35%;">Relev&eacute;</td>
			<td style="text-align: left; vertical-align: middle; width: 15%;">Coup&eacute;</td>
			<td style="text-align: left; vertical-align: middle;">BE&nbsp; EM&nbsp; &nbsp;D&nbsp; &nbsp;HS</td>
		</tr>
		<tr>
			<td style="width: 30%;">Electrique</td>
			<td style="width: 35%;">{% textinput_tag name=&quot;00280ee8&quot; data_label=&quot;Relev&eacute; du compteur &eacute;lectrique&quot; data_help=&quot;Relev&eacute; du compteur &eacute;lectrique&quot; maxlength=&quot;20&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
			<td style="width: 15%;">{% radio_tag name=&quot;8575e5ab&quot; data_label=&quot;Compteur &eacute;lectrique coup&eacute; &quot; data_choices=&quot;OUI|OUI; NON|NON;&quot; %}</td>
			<td>{% radio_tag name=&quot;9016d37b&quot; data_label=&quot;&eacute;tat du compteur&quot; data_choices=&quot;|Bon &eacute;tat;|Etat moyen;|D&eacute;grad&eacute;;|Hors d&#39;usage;&quot; %}</td>
		</tr>
		<tr>
			<td style="width: 30%;">Gaz</td>
			<td style="width: 35%;">{% textinput_tag name=&quot;00280ee9&quot; data_label=&quot;Relev&eacute; de gaz&quot; data_help=&quot;Relev&eacute; de gaz&quot; maxlength=&quot;20&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
			<td style="width: 15%;">{% radio_tag name=&quot;8575e5ad&quot; data_label=&quot;Compteur gaz coup&eacute; &quot; data_choices=&quot;OUI|OUI; NON|NON;&quot; %}</td>
			<td>{% radio_tag name=&quot;156ac0f5&quot; data_label=&quot;&eacute;tat du compteur&quot; data_choices=&quot;|Bon &eacute;tat;|Etat moyen;|D&eacute;grad&eacute;;|Hors d&#39;usage;&quot; %}</td>
		</tr>
		<tr>
			<td style="width: 30%;">Eau chaude</td>
			<td style="width: 35%;">{% textinput_tag name=&quot;00280ee10&quot; data_label=&quot;Relev&eacute; du compteur d&#39;eau chaude&quot; data_help=&quot;Relev&eacute; d&#39;eau chaude&quot; maxlength=&quot;20&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
			<td style="width: 15%;">{% radio_tag name=&quot;8575e5ae&quot; data_label=&quot;Compteur d&#39;eau chaude coup&eacute; &quot; data_choices=&quot;OUI|OUI; NON|NON;&quot; %}</td>
			<td>{% radio_tag name=&quot;c175ef5a&quot; data_label=&quot;&eacute;tat du compteur&quot; data_choices=&quot;|Bon &eacute;tat;|Etat moyen;|D&eacute;grad&eacute;;|Hors d&#39;usage;&quot; %}</td>
		</tr>
		<tr>
			<td style="width: 30%;">Eau froide</td>
			<td style="width: 35%;">{% textinput_tag name=&quot;00280ee11&quot; data_label=&quot;Relev&eacute; d&#39;eau froide&quot; data_help=&quot;Relev&eacute; d&#39;eau froide&quot; maxlength=&quot;20&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
			<td style="width: 15%;">{% radio_tag name=&quot;8575e5af&quot; data_label=&quot;Compteur d&#39;eau froide coup&eacute; &quot; data_choices=&quot;OUI|OUI; NON|NON;&quot; %}</td>
			<td>{% radio_tag name=&quot;a185d335&quot; data_label=&quot;&eacute;tat du compteur&quot; data_choices=&quot;|Bon &eacute;tat;|Etat moyen;|D&eacute;grad&eacute;;|Hors d&#39;usage;&quot; %}</td>
		</tr>
		<tr>
			<td style="width: 30%;">{% textinput_tag name=&quot;4b23e2b1&quot; data_label=&quot;Autre type de compteur&quot; data_help=&quot;Autre type de compteur&quot; maxlength=&quot;15&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
			<td style="width: 35%;">{% textinput_tag name=&quot;00280ee12&quot; data_label=&quot;Autre relev&eacute;&quot; data_help=&quot;Autre relev&eacute;&quot; maxlength=&quot;20&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
			<td style="width: 15%;">{% radio_tag name=&quot;8575e5ac&quot; data_label=&quot;Compteur coup&eacute; &quot; data_choices=&quot;OUI|OUI; NON|NON;&quot; %}</td>
			<td>{% radio_tag name=&quot;4bbad00d&quot; data_label=&quot;&eacute;tat du compteur&quot; data_choices=&quot;|Bon &eacute;tat;|Etat moyen;|D&eacute;grad&eacute;;|Hors d&#39;usage;&quot; %}</td>
		</tr>
	</tbody>
</table>

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