AL SINDACO DEL COMUNE DI    PORTO SAN GIORGIO

Oggetto: Richiesta di rimborso __________________________ anno _______

        Il sottoscritto _____________________________________________________________________

nato a ___________________________ il _______________ residente a ___________________________

__________________________ in via _______________________________________________________

chiede il rimborso della somma di L. __________________________________   per il seguente motivo _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Si allegano:

Ricevute del versamento

______________________________________________________________________________________________________________________________________________________________________________

        Distinti saluti.

                                                     IL DICHIARANTE

                                             ________________________