PDIC PHiLipPiNe DEPOSIT INSURANCE CORPORATION Makati City, Metro Manila Receivership and Bank Management Group InRet Liquidation of [Name of Bank} Claim Ne Date CLAIM FORM Pursuant to Monetary & under lauie pank i uilly ndabied to me/us n the ie or the tobowings Resolution No. dated placing le, the undersigned claimanl/s de hereby cerfly thal the sum of PESOS: igament of the same or any her legal or equitabe detense to s 9 myfour elair’s er any part therwot Myfour claim/s is/are evidencee by the following decuments, copies of which are hereto attached, the erigina of which willbe produced upon demand Purchase Ord Delivery Receipt Official Receipt [if with patlial payment) Photocopy of valid ID T secretary's Certitcate authorizing representative For uninsured deposi's: passbook/CThoroot of deposits — Others, please specily It fs understood that personal information collected or pracessed by PDIC as a result of my/our Ihis cloim will be Used for the purpose of verilication ang selilement of claims agcins! closed 1d may be shared with other goverment oifices in relation ta the pertarmance es to promote and stable banking system, Signature of Claman! over Printed Name Gov't Issued ID No. = {Io be filled up by Ihe Liquidator) - - Received by = Claim No.: Signalure over hinted Name Deputy Receiver/ Assisting Deputy Receiver For the closed