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Raiffeisen Bank SA

Nr/No _____________ Data/Date____________

MENTIUNI SPECIALE - PLATI


SPECIAL MENTIONS FOR PAYMENTS
F2
1. ORDONATOR/Payer:
Nume/Denumire/Name..........................................................................................
CNP/ Cod de identificare fiscala..............................................................................
2. DETALIILE ORDINULUI DE PLATA/Payment details
Nr/No./Data/Date...
Suma/Amount. Valuta/currency ....................
Cod IBAN platitor /Payer IBAN account
R
R O Z B R
BENEFICIAR/Beneficiary
Nume/Denumire/Name.......................................
Cod IBAN beneficiar/Beneficiary IBAN account

BANCA BENEFICIARULUI /Beneficiary Bank


3. SOLICITARE /Request:
CONFIRMAREA DE EFECTUARE A PLATII mai sus mentionate. Confirmation of the payment(s)
mentioned above (
ANULAREA (REVOCAREA) platii /Payment cancellation:

RECLAMAREA NEPRIMIRII DE CATRE BENEFICIAR A SUMEI dispuse prin OP/DPE/OPV mentionat


mai sus/The beneficiary claiming for not receiving the amount ordered by above
mentioned OP/DPE/OPV:

URMATOARELE MODIFICARI ALE INSTRUCTIUNILOR initiale dispuse prin OP/DPE/OPV


mentionat mai sus / Following changes for original intructions above mentioned OP/DPE/OPV .
................................................................................................................................................................................
. ..............................................................................................................................................................................
..
Subsemnatul Ordonator al platii, declar ca sunt de acord cu plata comisioanelor/spezelor bancare
aferente rezolvarii solicitarii si autorizez Banca sa incaseze contravaloarea comisionului aferent serviciului
solicitat din conturile mele, fara indeplinirea altor formalitati prealabile / Undersigned payment Ordering
customer, hereby declare that I agree with banks charges for solving my request and I authorize the Bank to
retain the fees for service requested from my accounts, without prior notice.

Se completeaza de catre Banca / Fill in by the Bank :


Referinta interna a platii /Payment
reference.............................................................................................................
Motivul revocarii /Cancellation reason.................................................................
...................................
Motivul pentru care nu poate fi procesata solicitarea/The reason for not processing customer
request: ............................................................................................................................................................
..................

Client Ordonator/Ordering cutomer,


Email: .. Raiffeisen Bank S.A.,
Fax: ............................
Telefon/Phone:................
Semnatura/Signature.. Semnatura/Signature..