Separate before paying in

# Receipt

## Account / Payable to

CH93 0076 2011 6238 5295 7
Thomas LeClaire
Rue examplaire 22a
1000 Lausanne

## Payable by (name/address)

## Currency

CHF

## Amount

25.90

## Acceptance point

# Payment part

## Currency

CHF

## Amount

25.90

## Account / Payable to

CH93 0076 2011 6238 5295 7
Thomas LeClaire
Rue examplaire 22a
1000 Lausanne

## Payable by (name/address)