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Bank details for payments of Stichting Liliane Fonds to mediator

Name mediator: __________________________________________
Number:______________________________

(Payments not on the name of a private person and always through a bank account or a registered organization.)

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Bank account: _________________________________________
Name account holder: ___________________________________

(NGO/congregation/institute/Foundation)
Address: __________________________________________________

Domicile/district/country: _________________________________

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Name bank: ____________________________________________
Address bank: __________________________________________
Domicile bank: __________________________________________
District/country bank: _____________________________________

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Remarks:
· If you receive payments through a mission procure that is not based in the Netherlands, the data of this procure should be stated below.
· If you receive payments through a mission procure in the Netherlands, name domicile and number of bank/giro accountant will do.

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Name mission procure: __________________________________
Bank account number: ___________________________________
Address: _________________________________________________
Domicile/district/country: _________________________________

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Name bank: _____________________________________________
Address Bank: ___________________________________________
Domicile bank: ___________________________________________
District/country bank: ______________________________________

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Please return this form to:

Stichting Liliane Fonds
Havensingel 26
5211 TX s'-Hertogenbosch
Netherlands

E-mail: fwillockx@lilianefonds.nl

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