13. Correction of Embossed Name (Embossed Name should appear as):

8.

1.

BRANCH:

RECEIVED BY/DATE:

12.

2.

3.

to

CUSTOMER REQUEST FORMDATE:

A. GENERAL INFORMATION

Cellphone No.:

Status: eSOA

Change in Account Information Additional Account Information

Nationality: Country:

Reactivation of Dormant Account (Requires deposit or withdrawal transaction)

9. E-mail Address:

4.

5.

6.

7.

10.

E. BANK FORMS REQUEST

Signature Over Printed Name

requested herein:

CUSTOMER'S SIGNATUREBy signing this form, you assume full responsibility for the correctness, genuineness and validity of all information indicated herein. You also authorize the bank to debit your account for the payment of fees / charges related to your above request. You also acknowledge hereby that you specifically requested the bank to facilitate the specific instruction you ticked-off above. You further undertake to indemnify SBC, should any claim, of whatsoever nature, arise against SBC or results in damage to SBC as a result of, or in connection with the above request. You further declare under the penalties of perjury that your co-depositor/s is/are still living.

If via Authorized Representative: This is to authorize, whose signature appears below, to receive my/our

Signature Over Printed Name

Signature Over Printed Name of Representative

ID Details of Representative:

Change in signature requirement from

Addition of Signatory/ies

Deletion of Signatory/ies

SMS opt out ATM OTC

Others, please specify:11.

Signature Over Printed NameSignature Over Printed Name

REPUBLIC OF THE PHILIPPINES) S.S MAKATI CITY )

AFFIDAVIT OF LOSS

I/We, _____________________________________ of legal age, Filipino, (single, married, or legally separated), with address at ______________________________________ ___________________________________________________________________, and _____________________________________, of legal age, Filipino, (single, married, or legally separated), with address at ________________________________________________________________________________________________________________, after being duly sworn in accordance with law, do hereby depose and say:

2. That the Bank issued to me/us, as evidence of said deposit, a passbook/Certificate of Deposit No. ____________________________________;

3.That as of _____________________________________, my/our deposit has credit balance in the amount of ____________________________________;

4.That sometime on ______________________________________, I/we lost said Passbook/Certificate of Deposit under the folllowing circumstances: (Please indicate reason/justification) __________________________________________________________________________________________________________________________________________________________________ 5. That despite diligent search on my/our part, said Passbook/Certificate of Deposit_________________________________________________________________. cannot be found;

6. That I/we have not signed, transferred, or in any manner conveyed, to a third person said Passbook/Certificate of Deposit or the money covered thereby;

7. That I/we am/are executing this Affidavit in order to request from the Bank the issuance of a new Passbook/Certificate of Deposit in lieu of the lost one;

8.That I/we and my/our surety do hereby undertake, jointly and severally to hold the Bank free and harmless from any liability, suit, claim or action that may be filed or instituted against it by any person, including the undersigned, and to indemnify the Bank for any loss or damage that it may suffer or sustain by reason of the use of the Passbook/Certificate of Deposit by any person or by virtue of any transaction entered into by the undersigned with respect to my/our deposit covered by the lost Passbook/Certificate of Deposit.

(Signature over printed name) AFFIANT

Signed in the presence of: ____________________________________ and ____________________________________.SUBSCRIBED AND SWORN TO ME BEFORE THIS ____________ day of ____________________, 20____ at ________________________. Affiant exhibited to me his/her/their Residence Certificate Number/s ______________________, issued on _______________ at ______________________.

NOTARY PUBLICDoc No. ________; Page No. ________;Book No. ________; Series of ___________ Th

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FOR BANK'S USE ONLY BR 154-01/18APPROVED BY: PROCESSED BY:

C. ACCOUNT MAINTENANCE

Lost Card

MODE OF PAYMENT:

B. PAYMENT DETAILS

Cash

SBC Check No.

Debit Account No.

Replacement of: Damaged

which was lost sometime on

1.That I/We have a Savings/AIOCA/ISA/Time Deposit account at the ______________________________ Branch of the Security Bank Corporation (the "Bank") under SA/

CA/ISA/TD No. ___________________________________________;

Demagnetized

Amount 1

For Pick-up at Branch.

AMOUNT DUE:

Amount 2

TOTAL AMOUNT

at

under the following circumstances:

WITNESS MY/OUR HAND this _____________________ day of _____________________________ in _________________________________.

New Name:

TIN/SSS/GSIS:

Landline No.:

New Address:

Please use Universal Transaction Slip to validate transaction.

Replacement of Lost Passbook (Fill-out Affidavit of Loss below)

Bank Certification

Purpose of Request:

ACCOUNT NAME:

CARD NUMBER:

ACCOUNT NUMBER:

D. CARD MAINTENANCE REQUEST

with Security Bank Online with TelebankerPlease check