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Unitatea:…………………………………………….… Seria Nr.

Reg. Com./an:……………………………………….
C.I.F.:………………………………………………………

Sediu:……………………………………………………..
CHITANTA NR. …….……………
Judetul:………………………………………………….. Data20

Am primit de la…………………………………………………………………………………………………………………………
C.I.F: …………………………………………………. Nr. Inm. In Reg.com/an:………………………………………………
Adresa:……………………………………………………………………………………………………………………………………..
Suma de …………………………………….. adica……………………………………………………………………...............
…………………………………………………………………………………………………………………………………………………
Reprezentand………………………………………………………………………………..…………………….…………………..
Casier,

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