Transfer Request (Annex 6)

Fill out this form to request a fund transfer.

Contract Details

Beneficiary name *

Grant program *

Contract No. and date *

Amount requested (MDL) *

Basis (check) *

Single instalment (100%)

Instalment no. X of Y

Other

Instalment number *

Total number of instalments *

Other basis *

Planned utilization from *

Planned utilization to *

Bank name *

IBAN *

BIC/SWIFT (optional)

Account holder name *

Tax ID / IDNO *

Draw your signature below

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