Nimi: .....................................................................................................................

Isikukood (Isikuandmete kaitse seadus § 14): ..............................................................

Aadress (tänav, maja, korter): ...................................................................................
(linn, maakond, indeks): .............................................................................................
Telefon: .................................................................................................................
E-post: ...................................................................................................................

MAKSU- JA TOLLIAMET

AVALDUS

Soovin tasuda õppelaenulepingust nr ........................... tuleneva võlgnevuse

tasumisgraafiku alusel.
Olen suuteline maksma iga kuu ...... kuupäeval .................. eurot.

Selgitused ja põhjendused: ....................................................................................

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(allkiri)

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(kuupäev)