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Unitatea………………......................……………………….

Codul Fiscal......................………………………………….
Nr De Inmatriculare De La Registrul
Comertului/Anul………....................……………………..
Sediul (Localitate, Str, Nr)................…………………..
Chitanta Nr……………............................
………………………………………………............................
Data…………….................…………………
Judetul………………………………………….....................

Am Primit De La …………...………………………………………....................................…
Adresa ……………………………………………............................................………………
Suma De................………………………….Adica……........................……………...……
……………………………..........…………....................................………………………………
Reprezentand ………………………….................................…………………….........……
…………………………………….........................................……………………………......…

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