02 // Model withdrawal form

Unofficial translation notice: This page is an unofficial English translation of the statutory model withdrawal form (Annex 2 to the Polish Consumer Rights Act). The Polish-language version is authoritative; in case of any discrepancy, the Polish text prevails.

The form below is one of several equally valid ways to submit a withdrawal declaration. The fastest channel remains the withdrawal portal, which automatically generates a durable-medium confirmation of receipt — using this form is not mandatory. You may also send a declaration in any form by e-mail to the address below.

Addressee: Piotr Kolasa, ul. Fabryczna 2, 45-349 Opole, Poland, e-mail address:

[email protected]

I/We() hereby give notice that I/we() withdraw from my/our() contract of sale of the following goods() contract for the supply of the following goods() contract for the provision of the following service()

  • Date of conclusion of the contract()/receipt()
  • Name of consumer(s)
  • Address of consumer(s)
  • Signature of consumer(s) (only if this form is submitted on paper)
  • Date

(*) Delete as appropriate.