DOCUMENT CONFIRMING THE INTRA-COMMUNITY DELIVERY OF GOODS

1. Vendor (consignor)

2. Purchaser (consignee):

Name

Address

VAT No:

3. Date of delivery:

4. Place of delivery:

5. Description of goods (name, kind of packages, quantity, gross weight)

6. Identifying documents:

Invoice number

Bill of lading number

Additional documents (specification, order, etc.)/

Kind and registration number of means of transport

For (NAME OF COMPANY) this confirmation represents a verification of an intra-community supply of goods (in accordance with Art. 42 of the Act of 11 March 2004. the tax on goods and services (Dz. U. No. 54, item. 535, as amended). Please return us this confirmation latest until (data). Otherwise, we are forced to issue a correction to the sales invoice and charge you VAT at 23%.

Place and date

Signature and stamp of authorized representative of purchaser (consignee)

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