2013 Summit Visa Application Reimbursement

Beneficiary Name: Rutilio Medina

*The account number is of my dad, his name is Rutilio Med

Beneficiary

ddress:

vda Bruno !u""iari N#$%& casi 'elicidad

*(n )heet* are the descri+tion and the amount Visa Reimbursed Amount: .urrency: Bank Name: Bank 1ocation: 2city, .ountry3 Bank (B N 7 or Bank )=ift .ode: Bank Routin" Number ccount Number: BB0 6>6 *&,,-/ollar BB0 sunci4n 5 6ara"uay 8--8&,*&9: 2(B N 7 is re;uired for <uro+e3 2Re;?d for all international countries3 2'or @) Bank Only3

For Canadian Bank Only: Transit Number Branch Number

s Rutilio Medina Ojeda, i dont have account in a bank

SERVICE
0() 0 . 0() )(N!1< <NTR N.< .O@R(<R

TOTAL Gs
$&&--99,*,$8%A89 1230 !3

TOTAL $
8-A &, :$ 2"#