Separate before paying in

Receipt

Account / Payable to

CH93 0076 2011 6238 5295 7
Thomas LeClaire
Rue examplaire 22a
1000 Lausanne

Reference

RF18 5390 0754 7034

Payable by (name/address)

Currency

CHF

Amount

25.90

Acceptance point

Payment part

Currency

CHF

Amount

25.90

Account / Payable to

CH93 0076 2011 6238 5295 7
Thomas LeClaire
Rue examplaire 22a
1000 Lausanne

Reference

RF18 5390 0754 7034

Payable by (name/address)