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Numro dengagement juridique:
Titre du film:
Je soussign (nom et prnom)
reprsentant la socit de production/distribution(*)
dclare que le Centre du Cinma et de lAudiovisuel de la Fdration Wallonie-Bruxelles mest redevable de la somme de euros en remboursement: de lavance/de la 1re tranche/de la 2me tranche de laide la promotion(*).
Certifi sincre et vritable la somme de (montant en toutes lettres).
verser au compte IBAN n:
Nom de la socit/asbl:
Adresse:
Numro dentreprise:
Fait :
Date:
Signature:
(*) Biffer la mention inutile
DCLARATION DE CRANCE
LE CENTRE DU CINMA ET DE LAUDIOVISUEL de la federation wallonie-BRUXELLESBOULEVARD LOPOLD II, 44 - 1080 BRUXELLES
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