From:

  [ Name ]
  [ Address ]
  [ City ]
  [ Country ]
  [ Telephone, e-mail, fax ]



To:

[ Name Scientology entity ]
[ Name Person in Charge ]
[ Name Director of Special Affairs ]
[ Address ]
[ City ]
[ Country ]



   B Y   R E G I S T E R E D   and   S T A N D A R D   M A I L



[ city,]
[ date ]



Dear [Person in charge] and DSA,



I hereby request that you pay back my [ currency/amount (say, in
letters) ][ for example: euro 10.000 (TEN THOUSAND) ] that I've deposed
on your account. I want you to transfer this money to the [ name and
address of the bank ], [ accountnumber [ accountnumber ]before [
date-of-this-letter plus 2 or 3 weeks ].

I will hand over this case to either my collecting agency/attorney or
the ScientologyPayBack Organization without further notice to you in
case you fail to transfer the money before the mentioned date.

You're put on notice that from that moment on you will be held
accountable for any and all costs, including but not limited to those
of my agent(s), necessary to collect the money you owe me.

[ Here you can put reasons why you want your money back, this is not
necessary though. ]
Yours Sincerely,



[ Signature ]

[ Your name ]

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