Cerfa No 11580 01

__DonationReceipt__
__FrenchArticle__

__DonationRef__

No: | __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__ :

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__DatePayment__ : __DATE__
__PaymentMode__ : __PAYMENTMODE_LIB__

__ThankYou__

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