According to the Appendix No. 2 to the Act of May 30, 2014 on Consumer Rights (Journal of Laws of 2014, item 827)

 

Model Withdrawal Form

 

Complete and return this form only if you wish to withdraw from the contract.

 

To:

The trader’s name Kutikai limited liability company
Address [ul. Witolda Gomrowicza 1, 62-050 Mosina]
Phone number
E-mail address

 

I/We (*) hereby give notice that I/We (*) withdraw from my/our (*) contract of sale of the following goods (*) / supply of the following goods (*) / contract to perform a specified task (*) / for the provision of the following service (*),

 

Name of consumer(s),
Address of consumer(s),
Date
Signature of consumer(s) (only if this form is notified on paper),

(*) Delete as appropriate

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