Translation of Receipt (payment)

Receipt # —-

Date of payment: —- Date of conversion—

Total amount (in words) Five thousand six hundred and fifty euros 00 cents

Thirty nine thousand and seventy two hryvnias 41 kopecks.

Payer: —-

Payer’s code —–

Payer’s bank: —-BANK, department in —

Payee: —

Code of the payee: —

Payee’s account: —–

Payee’s bank: —-BANK, —-

Code of the payee’s bank: —-

Purpose of payment: Placing funds to the account in cash

Additional information:

Signatures:

Executor: Signature Controller_______ Cashier Signature

Seal

—–BANK