ACCOUNT MAINTENANCE AND INSTRUCTION FORM

Date Account Name Branch of Account

Please effect the follow ing instructions, as m arked below .

Request for Automatic Transfer Arrangement (ATA)

 Tag  Untag

 CA  SA  Others ______________ Account Number _____________________________

Reactivate Dormant Account

 CA  SA  Others ______________ Account Number _____________________________

Closing of Account

 CA  SA  Others _____________ Account Number _____________________________

Reason for Closing of Account

Replace the following Reason for Replacement

 Passbook  Certificate of Time Deposit  Lost/Stolen  Others ___________________

 Others ____________________________  Damaged

* Please accomplish the Affidavit of Loss of Card(s)/Passb ook(s)/Check(s)/Certificate(s)/Confirmation at the b ack.

Other Client Instructions/Account Maintenance Requests

Accountholder's Name and Signature Accountholder's Name and Signature

For Bank's Use Only

Processed By Review ed / Approved By

M B -III-CR-80/Jul. '19 Original - Branch

 A F F ID A V IT O F LO S S O F C A R D ( S ) / P A S S B O O K( S ) / C H E C K( S ) / C E R T IF IC A T E ( S ) / C O N F IR M A T IO N

I/We, the undersigned depo sito r(s)/trusto r(s), with address at ______________________________________________________ , after being duly swo rn in
acco rdance with law, depo se and state that:

1. I/We have depo sit(s)/fund(s) with M E T R O P O LIT A N B A N K & T R US T C O M P A N Y ("M E T R O B A N K ") with acco unt name
_________________________ ______________________________________ under the fo llo wing acco unt(s):
P eso /Fo reign Currency Depo sit A cco unt/s
P eso Depo sit A cco unt/s
Savings A cco unt No . Certificate
Certificate
of oTime
f Time
Current A cco unt No . Depo sit A cco unt No .
Fo reign Currency Depo sit A cco unt/s (P ls. specify the currency o f the acco unt)
Savings A cco unt No . Certificate o f Time
Current A cco unt No . Depo sit A cco unt No .

2. The fo llo wing do cument(s) evidencing the afo resaid acco unt/s was/were lo st/misplaced/sto len and co uld no lo nger be fo und/reco vered despite
diligent effo rts:
P assbo o k No .
CA Check No .
CTD No .

3. I/We undertake to surrender the abo ve-mentio ned do cuments o f the acco unt(s) to M E T R O B A N K sho uld it be fo und/reco vered.
4. The said depo sit(s)/fund(s) has/have no t been assigned, nego tiated, pledged o r o therwise dispo sed o r encumbered to o ther perso ns/entities.
5. I/We are executing this affidavit fo r the purpo se o f cancelling the abo ve do cuments and requesting M E T R O B A N K to issue a new o ne
6. I/We are allo wing the B ank to circularize the details o f the lo st do cument (s) to all its branches o r to o ther banks as the case may be, to facilitate
my/o ur request to cancel the do cument(s).
7. I agree to indemnify and ho ld M E T R O B A N K , its o fficers and staff free and harmless fro m any suit, actio n, liability, lo ss and/o r damage that it
may sustain by reaso n o f the lo ss and cancellatio n o f the afo rementio ned do cuments, including the claims o f third parties who may have o btained
said lo st do cuments o r instruments in go o d faith.

IN WITNESS WHEREOF, I/We, have affixed my/o ur signature(s) at _________________________________________ o n _____________________.

SIGNA TURE OVER P RINTED NA M E/ SIGNA TURE OVER P RINTED NA M E/

DESIGNA TION/P OSITION DESIGNA TION/P OSITION

S IG N E D IN T H E P R E S E N C E O F :

REP UB LIC OF THE P HILIP P INES ) S.S

)

SUB SCRIB ED A ND SWORN to befo re me this _________________ day o f ______________________________ , 20 ________ in ______________
______________________, P hilippines, affiants exhibiting their respective Go vernment-issued IDs as fo llo ws:

NAM E G O V 'T - IS S UE D ID / ID N O . D A T E / P LA C E IS S UE D

Do c. No . __________;
P age No . __________;
B o o k No . __________;
Series o f __________;