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			<td colspan="2" style="vertical-align: middle; width: 15%; text-align: justify;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Pour un montant maximum correspondant &agrave; neuf&nbsp;ans de loyers charges comprises tels que fix&eacute;&nbsp;dans le bail, et ce, m&ecirc;me en cas&nbsp;de changement de bailleur, en vertu du bail dont la signature aura lieu post&eacute;rieurement, pour lequel un exemplaire me sera transmis et dont les principales caract&eacute;ristiques sont &eacute;num&eacute;r&eacute;es ci-apr&egrave;s :</span></td>
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			<td style="vertical-align: middle; width: 15%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Dur&eacute;e du bail :</span></td>
			<td style="width: 85%;">{% textinput_tag name=&quot;225993d8&quot; data_label=&quot;Dur&eacute;e&quot; data_map_field=&quot;nomap&quot; data_help=&quot;Dur&eacute;e&quot; maxlength=&quot;25&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
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<p><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">&agrave; compter du&nbsp;&nbsp;</span>{% dateinput_tag name=&quot;703a0cd6&quot; placeholder=&quot;jj/mm/aaaa&quot; data_label=&quot;Date d&#39;entree&quot; data_map_field=&quot;nomap&quot; data_help=&quot;Date d&#39;entree&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}<span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;"> pour le logement situ&eacute;&nbsp;:</span></p>

<table border="0" cellpadding="2" cellspacing="2" style="width:100%;">
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			<td>{% textarea_tag name=&quot;4ccb7480&quot; data_width=&quot;100&quot; rows=&quot;1&quot; data_label=&quot;Adresse du bien lou&eacute;&quot; data_map_field=&quot;nomap&quot; data_help=&quot;Adresse du bien lou&eacute;&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
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				<li><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Ai not&eacute; que :</span></li>
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				<li><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">le montant repr&eacute;sente&nbsp;pour la premi&egrave;re ann&eacute;e un loyer<strong> hors charges</strong> de &nbsp;(en lettres et en chiffres) :</span></li>
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			<td style="vertical-align: middle; width: 50%;">{% textarea_tag name=&quot;3ced8a68&quot; data_width=&quot;100&quot; rows=&quot;1&quot; data_label=&quot;Premi&egrave;re ann&eacute;e de loyer hors charges&quot; data_map_field=&quot;nomap&quot; data_help=&quot;Premi&egrave;re ann&eacute;e de loyer en chiffre et lettre&quot; maxlength=&quot;65&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
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				<li><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">le montant initial du loyer mensuel<strong> hors charges</strong> s&rsquo;&eacute;l&egrave;ve &agrave; &nbsp;(en lettres et en chiffres) :</span></li>
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			<td style="vertical-align: middle; width: 50%;">{% textarea_tag name=&quot;5f578195&quot; data_width=&quot;100&quot; rows=&quot;1&quot; data_label=&quot;Montant initial du loyer hors charges&quot; data_map_field=&quot;nomap&quot; data_help=&quot;Montant initial du loyer hors charges en chiffre et lettre&quot; maxlength=&quot;65&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
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				<li><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">{% radio_tag name=&quot;ee794b5a&quot; data_map_field=&quot;nomap&quot; data_help=&quot;provision ou forfait&quot; data_choices=&quot;La provision|la provision; Le forfait|le forfait;&quot; %}&nbsp;mensuel(le) de charges locatives (1)&nbsp;s&#39;&eacute;l&egrave;vent &agrave; &nbsp;(en lettres et en chiffres) :</span></li>
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			<td style="vertical-align: middle; width: 50%;">{% textarea_tag name=&quot;70964c73&quot; data_width=&quot;100&quot; rows=&quot;1&quot; data_label=&quot;Montant loyer + charges&quot; data_map_field=&quot;nomap&quot; data_help=&quot;Montant loyer + charges en chiffre et lettre&quot; maxlength=&quot;65&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
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			<td style="width: 45%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Les charges locatives et le loyer (1) &eacute;tant payables par :</span></td>
			<td style="width: 18%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">{% radio_tag name=&quot;4c69ac57&quot; data_label=&quot;Mois ou trimestre&quot; data_map_field=&quot;nomap&quot; data_help=&quot;Mois ou trimestre&quot; data_choices=&quot;mois|mois; trimestre|trimestre;&quot; %}</span></td>
			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">&nbsp;-&nbsp;</span></td>
			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">{% radio_tag name=&quot;af061de9&quot; data_label=&quot;&Agrave; &eacute;choir ou a terme &eacute;chu&quot; data_map_field=&quot;nomap&quot; data_help=&quot;&agrave; &eacute;choir ou a terme &eacute;chu&quot; data_choices=&quot;&agrave; &eacute;choir|&agrave; &eacute;choir; &agrave; terme &eacute;chu|&agrave; terme &eacute;chu;&quot; %}</span></td>
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			<td colspan="2" style="vertical-align: middle; width: 15%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Le loyer est r&eacute;vis&eacute; chaque ann&eacute;e selon les modalit&eacute;s pr&eacute;vues au bail :</span></td>
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			<td style="vertical-align: middle; width: 15%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Date de r&eacute;vision :</span></td>
			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">{% textinput_tag name=&quot;7bb3429b&quot; data_label=&quot;Date de r&eacute;vision&quot; data_help=&quot;Date de r&eacute;vision&quot; maxlength=&quot;99&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</span></td>
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			<td style="vertical-align: middle; width: 30%; white-space: nowrap;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Date ou trimestre de r&eacute;f&eacute;rence de l&rsquo;IRL :&nbsp;</span></td>
			<td>{% textinput_tag name=&quot;c5b98ce2&quot; data_label=&quot;Date de r&eacute;vision&quot; data_map_field=&quot;nomap&quot; data_help=&quot;Date de r&eacute;vision&quot; maxlength=&quot;65&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
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