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RECUEIL DES ACTES ADMINISTRATIFS - Vosges

RECUEIL DES ACTES ADMINISTRATIFS - Vosges

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AUTORISATION PAIEMENT TIERS<br />

Je soussigné(e),<br />

Nom, Prénom<br />

....................................................................................................... ...................................<br />

Domicilié(e)<br />

....................................................................................................... ...................................<br />

....................................................................................................... .................................<br />

Né(e) le ................ ........................... à ................................ ........... ...............................<br />

Autorise le versement de l’aide financière au tiers suivant :<br />

Nom de l’organisme<br />

....................................................................................................... .................................<br />

....................................................................................................... .................................<br />

Adresse :<br />

....................................................................................................... .................................<br />

....................................................................................................... .................................<br />

D’un montant de :<br />

………………………………….<br />

Fait le … / … / …à ……………………….<br />

Signature

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