NLBANCO LACAIXA AMSTERDAM NETHERLANDS

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					BANCO LACAIXA AMSTERDAM NETHERLANDS
Tel: +31-61-909-8936 Fax: +31-84-724-9563
FOREIGN OPERATION DEPARTMENT CLAIMS AND FUND RELEASE SECTION

FUND RELEASE ORDER FORM
THIS FORM SHOULD BE COMPLETED BY THE BENEFICIARY OF THIS MAIL, AND SENT BACK BY EMAIL IMMEDIATELY, TO FAX NUMBER FOR VERIFICATION, BEFORE TRANSFER CAN BE EFFECTED.
YOUR RE No: ……………………………………… ANNUAL INCOME

………………………………………………

EMAIL ADDRESS………………………………………………. …………….LAST CLAIM DATE: …………………… AMOUNT WON:…………...................................NAME: …………………………………………………MIDDLE……………………………………….. SURNAME: ……………………………………………………………………DATE OF BIRTH:……………………………………………… HOME ADDRESS:…………………………………………………………………………………………………. ZIP CODE: ………………… CITY………………………………………………. COUNTRY: ………………………………………. NATIONALITY:…………………………………. TELEPHONE: ……………………………………………… FAX: ………………………………………MOBILE: ……………………………………… OCCUPATION: ………………………………………..AGE:……… MARITAL STATUS ( S)…….(M)……...(D):……...(W)……SEX: ……………

Payment options
I WANT TO BE PAID BY: IF FUND ARE TO BE REMITTED THROUGH BANK WIRE TRANSFER PLEASE COMPLETE THE FOLLOWING:

(BANK TRANSFER)

(ENDORSED CHEQUE)

BANK NAME: ………………………………………………………………………………………….. BANK ACCOUNT NUMBER: ……………………………………………………………………… SORT CODE: …………………………………………………… SWIFT CODE: ………………………………………………….. BANK ADDRESS: ……………………………………………………………………………………… BANK TELEPHONE: ………………………………………
(IN THE ABSENT OR LOST OF CONTACT WITH YOU, PLEASE INCLUDE YOUR NEXT OF KIN INFORMATION)

NE XT OF KIN

NAME: (MR/MRS) …………………………………………… LAST NAME: ……………………………………………………….. HOME ADDRESS: ………………………………………………………………….. CITY: ……………………………..STATE: ………………………… COUNTRY: ………………………………………………….ZIP CODE: …………………………………………… OCCUPATION: ………………………………………………MARITAL STATUS: s (m) …………………………. AGE: .......... TELEPHONE: …………………………………………………FAX: …………………………………………………..

I (MR/MRS) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ HEREBY DECLARE THAT I HAVE NEVER RECEIVED ANY PAYMENT ON MY BEHALF BY BANCO LACAIXA NOR HAVE ANY OF MY FAMILY MEMBERS FILED A CLAIM ON MY BEHALF. I HEREBY GIVE THE AUTHORIZATION TO BANCO LACAIXA TO ACT ON MY BEHALF IN PROCESSING AND TRANSFER OF MY PAYMENT TO THE DESIGNATED BANK INFORMATIONS STATED ABOVE. I ALSO AGREED TO PAY 10% COMMISSIONN TO BANCO LACAIXA UPON RECEIPT OF MY MONEY IN MY ACCOUNT.

SIGNATURE: …………………………………………….. DATE: ……………………………………………….ABS


				
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