Application for return of a payment

I (name)  apply for a return of a payment made to Nordea bank account
 No. 39511046292 of Embassy. I encloses a receipt of the payment.

Details of the sum of the money paid to the Embassy's bank account

Amount paid:

  SEK

Service which the money was paid for:

Amount to be returned:

 SEK

Details of applicant and his/ her bank account

First name:

Last name:

Tel. nr.

Bank's name:

Bank account No. ( Do not give Plusgiro / Bankgiro accounts):

  Date

Full name

Signature

Do not fill in the box below:

Officer's notes:

Officer's name and signature: