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| {{{kista}}}: {{{beloppkista}}} |
| {{{nr1}}}: {{{belopp1}}} |
| {{{nr2}}}: {{{belopp2}}} |
| {{{banken1}}} |
| {{{nr3}}}: {{{belopp3}}} |
| {{{nr4}}}: {{{belopp4}}} |
| {{{banken2}}} |
| {{{nr5}}}: {{{belopp5}}} |
| {{{nr6}}}: {{{belopp6}}} |
| {{{banken3}}} |