Cerfa N° 11580*03 __DonationReceipt__
__FrenchArticle__
__DonationRef__
__REF__
__DonationRecipient__
__Name__ :
__MAIN_INFO_SOCIETE_NOM__
__Address__ :
__MAIN_INFO_SOCIETE_ADDRESS__
__Zip__ : __MAIN_INFO_SOCIETE_ZIP__
__Town__ : __MAIN_INFO_SOCIETE_TOWN__


__Donor__
__Name__ :
__DONATOR_FIRSTNAME__ __DONATOR_LASTNAME__
__Address__ :
__DONATOR_ADDRESS__
__Zip__ : __DONATOR_ZIP__
__Town__ : __DONATOR_TOWN__


__IConfirmDonationReception__ :
__AMOUNT__ __CURRENCY__
__DonationDatePayment__ : __DATE__
__PaymentMode__ : __PAYMENTMODE_LIB__

__Message__ : __DonationMessage__
__FrenchEligibility__
__ARTICLE200__ __ARTICLE238__ __ARTICLE885__
__Date__ & __Signature__
__NOW__