How to fill in the CERFA 12504 (C2S, France)

What the form is for

The C2S covers the part of your health costs that the Assurance maladie does not reimburse. It is free, or you pay a monthly participation, depending on your income. It means no extra doctor's fees (dépassements d'honoraires), no franchise médicale, no paying up front (tiers payant, if you follow the parcours de soins: you see your médecin traitant first), and extra cover for dental care, glasses and hearing aids.

You can apply online through your ameli account, or on paper with this form. Send the paper form to your caisse d'assurance maladie (CPAM), or to the MSA if you are in the agricultural scheme. If people in your household are on different schemes, send only one request, to your own scheme.

The caisse must answer within 2 months. If you hear nothing after 2 months, the request counts as accepted (mainland France). The C2S lasts 1 year: to renew it, ask again between 4 and 2 months before the end date on your attestation. If you are refused, you can contest at the commission de recours amiable (CRA) within 2 months of the notification. This guide follows the rules for mainland France.

Who needs it

You can ask for the C2S if you meet these conditions (from the form's notice and service-public.gouv.fr):

• Stable and regular residence in France (or health cover through work). The notice asks this of you and of every adult in your household.
• If you are a foreigner and have been in France for more than 3 months, you need a valid residence permit and uninterrupted residence. If you have been here less than 3 months, only some situations count (for example work, school, training). If you live in France without papers, you can ask for the AME (Aide médicale de l'État) instead.
• Income under a yearly ceiling. Since 1 April 2026, in mainland France, for one person: up to €10,421 for a free C2S and up to €14,069 for a C2S with participation. For 2 people: €15,632 and €21,103. The ceilings for more people, and the higher ones for the overseas departments, are on the official info page.
• Participation, if you pay one, per month and per insured person, by age on 1 January: €8 (29 and under), €14 (30 to 49), €21 (50 to 59), €25 (60 to 69), €30 (70 and over). In Alsace-Moselle the rules differ.
• Some benefits make it automatic or simpler. With the RSA you get a free C2S unless you object, and you skip the resources part. The notice also lists the ASPA, ASI, AAH, ASS and ACEJ, each with its own conditions (for example no work in the last 3 months, or living alone with no dependent child). Check pages 5 and 6 of the PDF for your case.
• Cost. Neither the form nor service-public.gouv.fr mentions a fee for applying. The only cost is the monthly participation, if your C2S is "avec participation".

Before you start

• For you and every person in your household: the latest avis d'impôt (tax notice) or avis de situation déclarative à l'impôt (ASDIR). Originals or legible photocopies.
• If you lived abroad during the 12-month period (see page 2 below): proof of your tax and social situation in each country concerned.
• If you are self-employed and in your first year: proof of the turnover you declare.
• service-public.gouv.fr also lists your avis de taxe foncière and avis de taxe d'habitation, and, if you are applying for the RSA, a CAF or MSA certificate of your resources. The caisse may ask for more.

Section by section

The form is in German. Here is what each part asks, in plain words, in the order it appears.

1. 1

   Page 1: Vous-même

   Fill in black, in capital letters, with accents. Your name(s) (birth name first, then your usual name if different), your social security number and your CAF file number only if you have them, date of birth, nationality (tick française, européenne or autre) and address. If you have no address of your own, give the body where you have your postal address (élection de domicile), such as a CCAS or an approved association. Then say whether your family situation changed in the last 12 months.

2. 2

   Votre conjoint(e), concubin(e) ou partenaire PACS

   The same details for your spouse, partner or PACS partner. If you don't have one, leave this part empty.

3. 3

   Les autres personnes de moins de 25 ans à votre charge

   Your household is you, your spouse or partner and the under-25s in your real and continuous care (the notice gives the exact cases). For each of them write the name, nationality, relationship, birth date and social security number, and tick the box if the child is in shared custody (garde alternée) for tax. Nationality is a code: FRA if French, EEE for a country on the form's European list (it includes Switzerland, Norway, Iceland and Liechtenstein), AUT for all others. Don't write the country in full.

4. 4

   Vous-même et les personnes de votre foyer bénéficiaires d'aides

   For each person, tick the benefits they receive (for the RSA, also if they have only asked for it): RSA, AAH, ASPA (or ASV), ASI, ASS, ACEJ. These are French benefits for low-income, elderly, disabled or young people. Leave the row empty if there are none.

5. 5

   Page 2: Précisez cette période de douze mois

   Write the month and year it starts (du) and ends (au). It is 12 civil months, from the 13th to the 2nd month before the month of your request. The notice's own example: a request in July 2026 means June 2025 to May 2026.

6. 6

   The columns of the resources table

   The columns are for you, your spouse or partner, and two children or dependants under 25 (write their name and first name). Leave the columns of people you don't have empty. If you need more columns, add the rest on plain paper.

7. 7

   Rows 1 to 7

   Write the total over the 12 months, and 0 if there is nothing. Row 1: income as self-employed when you start (turnover without VAT of the last four civil quarters). Row 2: exceptional indemnities that are not taxed. Row 3: tick oui or non for sick leave over 6 months, paid unemployment, the ASS, and training pay. Row 4: daily sickness allowances, invalidity pension, work-accident annuity. Row 5: family benefits and housing aid from the CAF or MSA. Row 6: tick if you own your home or are housed free. Row 7: other resources, such as gambling winnings, and write what they are on the line "Précisez la nature".

8. 8

   What you don't have to declare

   Salaries, replacement incomes (such as sickness allowances) and social benefits: the caisse takes them from the bodies that pay them. Taxed income from self-employment, investments and property comes from your latest tax notice or ASDIR. By sending the form you accept this use.

9. 9

   Page 3: Le choix de votre organisme complémentaire

   Choose who handles your C2S: your caisse d'assurance maladie (CPAM) or a mutuelle on the official list (complementaire-sante-solidaire.gouv.fr). Tick your situation in the flow chart (do you have a complementary insurer now, do you already get the C2S, is it on the list), then write the name and address of the organisme in box 2 if you chose a mutuelle. If you tick no choice, the CPAM becomes your organisme. For a first request, if your current mutuelle manages the C2S, you must choose it. If household members choose different organismes, photocopy pages 3 and 4 for each.

10. 10

    Page 4: sections 3 and 4 (only with a mutuelle)

    Skip them if you chose the CPAM. Otherwise, in 3 list the household members (you included) who chose the same organisme: name, relationship, shared custody, birth date and social security number. In 4 give the contact details (name, address, e-mail, phone) of one person from that list.

11. 11

    Fait à / Le / Signature du demandeur

    Write the town (Fait à), the date (Le) and sign. You certify that the information is accurate and sincere. The caisse checks it with tax and social bodies: a false statement can mean penalties, fines or prison, and the C2S can be cancelled and the money repaid.

Common mistakes

• Leaving household members out

  List your spouse or partner and every under-25 in your care. The C2S ceiling depends on the number of people.

• Leaving a blank instead of 0

  Write "0" when you have no resources, as the form asks. Don't leave the cell empty.

• Using the wrong 12 months

  It is not always the last calendar year. Count 12 civil months from the 13th to the 2nd month before the month of your request.

• Writing the nationality in full for the under-25s

  In that table write only FRA, EEE or AUT. For you and your partner, tick française, européenne or autre.

• Filling columns for people you don't have

  If you have no partner or no children, leave their columns empty, without zeros.

• Forgetting the date and signature

  Fill in "Fait à" and "Le" and sign on page 4, even if you chose the CPAM.

• Not attaching the avis d'impôt or ASDIR

  Send one for every person in the household, plus proof from other countries if you lived abroad in the period.

• Ticking nothing on page 3 when you already have a mutuelle that manages the C2S

  If this is your first request and your current mutuelle manages the C2S, you must choose it. With no choice ticked, the CPAM is chosen instead.

• Children's nationality boxes left for you

  On this PDF the Nationalité boxes in rows 1 to 4 of the under-25s table are linked to the "Précisez la nature" lines on page 2, so Formamigo leaves them for you to write by hand (FRA, EEE or AUT) on the printout.