If you want to preserve accounts in more than one Member State, please provide the information below for each Member State concerned (when filling in the form on paper, please use separate sheets and number each page).
Más mian leat cuntais a chaomhnú atá suite i níos mó ná Ballstát amháin, tabhair an fhaisnéis seo a leanas i dtaca le gach Ballstát lena mbaineann (agus an fhoirm á líonadh agat ar pháipéar, bain úsáid as duilleoga ar leith agus uimhrigh gach leathanach).