Authorized ID: LDI61 PAYMENT INSTRUCTIONS FORM LatamDate.com PAYMENT INSTRUCTIONS FORM Please complete this form and provide accurate information to us. There is a separate sheet of guidelines to help you understand the payment instructions. Before filling up this form, please | O11. PayPal D2. Check: O 3. Blectronie Funds Transfer (EFT) rayee’s Full Name: [Residential Address: ity, State, Postal Code (country: [Daytime Telephone No: fr [Payee’s Full Name: rayee’s Postal Address: ity, State, Postal Code [Daytime Telephone No: | [Acc Name: [Bank Name/ Address: city, State, Postal Code’ Country: [Account Number: iBank Routing Number WIFT code (international fund use): [Account Type: Savings D checking D2 Deposit Only \dditional Information: DECLARATION 1. Thereby agree that the information furnished above is accurate, and accept LatamDate.com to issue payments to the Service Provider. 2. LatamDate.com is entitled to rely on the accuracy of all information provided by Service Provider, and LatamDate.com is not responsible for losses due to inaccuracies in such information, Full Name of Person-In-Charge (as on ID eard / passport): Gustavo Adolfo Escobar Acevedo PassporvID number: Signature of Person-In-Charge with Company Stamp: _onig Me % CF Payment Instructions Documents Page 1 of