TO BE FILLED-OUT BY THE AUTHORIZED PERSONNEL OF THE BANK

DEPOSITS

NAME & SIGNATUREOF PERSON COMPLETING:

DATE OPENED
TYPE ACCT. NO. ACCT. NAME AVE. DAILY BALANCE
( ) C/A ( ) S/A LAST MO. LAST MO. 1YR.
( ) C/A ( ) S/A LAST MO. LAST MO. 1YR.
( ) C/A ( ) S/A LAST MO. LAST MO. 1YR.
Other Accounts

Are any of the accounts above the subject to "hold out" agreements? If so who are the assignees name under the Deed of Agreements?

Have you ever had any incidence of "returned checks" on this If yes, how many times within the Reason of return?
client? month?

Depositor maintains daily average account balance of Pesos:

O Below (4) digits O Below (5) digits O Below (6) digits O Below (7) digits

O Low (4) digits O Low (5) digits O Low (6) digits O Low (7) digits

O Middle (4) digits O Middle (5) digits O Middle (6) digits O Middle (7) digits

O High (4) digits O High (5) digits O High (6) digits O High (7) digits

Please identify status of the account by checking appropriate boxes:

One of our valued accounts Account is closed since
Accounts has credit line of Account is inactive since
Php: Others (please specify):

NAME & SIGNATURE OF PERSON COMPLETING:

AMOUNT PRINCIPAL
TYPE BORROWED
EXPERIENCE INTEREST INTEREST TERM BALANCE
( ) TERM LOAN % ₱ ₱
( ) CREDIT LOAN ( ) FIXED ( ) M ONTHLY YRS.
( ) VARIABLE ( ) QUARTERLY

( ) TERM LOAN % ₱ ₱
( ) CREDIT LOAN ( ) FIXED ( ) M ONTHLY
( ) VARIABLE ( ) QUARTERLY

Security Held:
Any and all information shared with us will be held in strictest confidence and shall be used solely
for the purpose intended. Please retain copy for your file.

Thank you very much

Very truly yours,

JEREMIE LO