SEPA Direct Debit Mandate
CREDITOR'S NAME & LOGO
By signing this mandate form, you authorise (A) the creditor to send instructions to your bank to debit your account and (B) your bank to debit your account in accordance with the instructions from the creditor.
As part of your rights, you are entitled to a refund from your bank under the terms and conditions of your agreement with your bank. A refund must be claimed within 8 weeks starting from the date on which your account was debited.
Please complete all the fields in this section.
Your name
Your address
Your account number
Creditor's name
Type of payment Recurrent payment or One-off payment
City or town in which you are signing
Signature(s)
Note: Your rights regarding the above mandate are explained in a statement that you can obtain from your bank.
Details regarding the underlying relationship between the Creditor and the Debtor - for information purposes only.
Debtor identification code
Person on whose behalf payment is made
Party on whose behalf the Creditor collects the payment
In respect of the contract
Please return to
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