ANNEX 2 FORM

Quito ………………………………

Gentlemen

Banco Pichincha C.A.

I, …………………………………………………………………….……………… debit card holder ………………………….

Number ……………………………. formally certify that the following unauthorized transactions are
recorded on my account statement:

Date of Transaction Name of Merchant / ATM Value

……………………………………… …………………………………… …………………….

……………………………………… ……………………………………. ……………………
……………………………………… ……………………………………… …………………….

I request that the corresponding analysis be carried out.

OBSERVATIONS:

……………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………

Yours truly,

Name: ……………………………………………………………………………………Signature: ……………………………

C.I. ……………………………………………

Please attach a copy of ID, Account Statement showing the transactions, perforated plastic
without damaging the card number

For additional international consumption (outside the country) attach a Passport copy
MANDATORY to cancel the card with which the unauthorized transactions are reflected. The
claim must be presented and signed by the client.