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Remittance Note Date: Referral No:

Name:

Home: Your order:

City and State: Conditions:

Amount Concept Price Amount

Subtotal
VAT
Total TO
I hereby pay, acknowledge my duty and have the obligation to pay wherever I am required to pay. to your order the
day_____________________________ the amount of ___________________value received in merchandise. this promissory
note
It is commercial and is governed by the General Law of Credit Titles and Operations in its article 173 for final and other correlatives
because it is not a domiciled promissory note. Sign in accordance