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Contribuabilul ................................

...............................................
MONETAR Nr. ........
Data ..........................
Magazinul ................ Casa ..........
....................... buci
....................... buci
....................... buci
....................... buci
....................... buci
....................... buci
....................... buci
....................... buci
....................... buci

x 1.000.000 lei
x 500.000 lei
x 100.000 lei
x
50.000 lei
x
10.000 lei
x
5.000 lei
x
1.000 lei
x
500 lei
x
100 lei

...................
...................
...................
...................
...................
...................
...................
...................
...................

TOTAL LEI:
................................................................................
Casier predtor,
.....................

Casier primitor,
.....................
Responsabil,
.....................

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