[your company logo] SEPA Direct Debit Mandate
Date : 01/10/2020
Unique Mandate Reference (UMR) : UMR-XXXXX-XXXX-1-XXXXXX [ your UMR system generated]
Creditor Identifier (Creditor Identifier CI) :
Creditor Name : [YOUR COMPANY NAME]
Address :
[YOUR COMPANY ADDRESS]
By signing this mandate form, you authorize (A) [YOUR COMPANY NAME] to send instructions to your bank to debit your account and (B) your bank to debit your account in accordance with the instructions from [YOUR COMPANY NAME]. As part of your rights, you are entitled to a refund from your bank under the terms and conditions of your agreement with your bank. A refund must be claimed within 8 weeks starting from the date on which your account was debited. Your rights regarding the above mandate are explained in a statement that you can obtain from your
bank.
Your name *: [YOUR CUSTOMER NAME]
Address: [YOUR CUSTOMER ADDRESS]
Your Bank Account Name (IBAN) * : [IBAN CODE]
Your Bank Identifier Code (BIC) * : [BIC or SWIFT CODE]
Please return this mandate form by email to
[YOUR COMPANY EMAIL ADDRESS] or by mail to:
[YOUR COMPANY ADDRESS]
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