Modulo SEPA SDD - Inglese B - hosted by PolesineInnovazione.it

SEPA “CORE” DIRECT DEBIT MANDATE
PLEASE COMPLETE ALL THE FIELDS MARKED *.
Mandate reference – to be completed by the creditor:
*A97QM3……………………………………………………
(inserire Debtor Tax code/VAT number )
By signing this mandate form, you authorise:
A) CONSORZIO DI BONIFICA ADIGE PO to send instructions to your bank to debit your account and;
B) your bank to debit your account in accordance with the instructions from CONSORZIO DI BONIFICA ADIGE PO;
As part of your rights, you are entitled to a refund from your bank under the terms and conditions of your agreement with your
bank. A refund must be claimed within 8 weeks starting from the date on which your account was debited.
1*
Debtor Name/Business Name
2*
Indirizzo: Via e numero civico
3*
4*
Postal code
City
Country
5*
Account number - IBAN
6*
SWIFT BIC
7*
Debtor Tax code/VAT number
8
Creditor Name/ Business Name
CONSORZIO DI BONIFICA ADIGE PO
9
Creditor identifier
IT440010000093030520295
10
Street name and number
Piazza Garibaldi, 8
11
Postal code
City
45100
Rovigo
12
Country
Italy
13*
Type of payment
x
Recurrent payment
INFORMATION ABOUT SUBSCRIBER IS REQUIRED IF SUBSCRIBER AND DEBTOR ARE NOT THE SAME
PERSON
14* Subscriber Name
15*
Subscriber tax code
*City or town and date in which you are signing
* Signature
Note: Your rights regarding the above mandate are explained in a statement that you can obtain from your bank.

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