Withdrawal form

Withdrawal form

- pursuant to Article 49, comma 1, lett. h) -

To.

Istituto Poligrafico e Zecca dello Stato S.p.A.

Direzione Sviluppo Soluzioni integrate

UO Zecca

Via Salaria, 691

00138 Roma

Italy

fax n.: +39 06 8508.3710

via email: ordini.zecca@ipzs.it

The undersigned _____________________________, Fiscal code ___________________, address _______________________________________________________________________, herewith informs you that, pursuant to artt. 52 and ff. of D.Lgs. n. 206/05, the intention of withdrawing from the sales contract concerning the following products:

- __________________________ ordered on __________ delivered on ___________

The reimbursement of the amounts paid by the undersigned for the purchase of the aforementioned products, equal to € ________, may be made to the following bank account

Bank account details _____________________________________

Date _____________________________________

Signature _____________________________________

(only if this form is forwarded on paper)

NB. Sign only if this form is forwarded in paper form