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__ :
__AMOUNT__ __CURRENCY__
__DatePayment__ : __DATE__ __PaymentMode__ : __PAYMENTMODE_LIB__
__ThankYou__ |
__Date__ __Signature__ __NOW__