CUSTOMER REQUEST FORM

This form is a proprietary product of Security Bank Corporation intended for its sole use. Any unauthorized review, alteration, amendment, use, disclosure, distribution, importation, removal, alteration, substitution, modification, storage, uploading, downloading, communication, making available to the public, or broadcasting of this material without the consent and
BRANCH: TOMAS MORATO DATE:

A. GENERAL INFORMATION B. PAYMENT DETAILS

ACCOUNT NUMBER: MODE OF PAYMENT: AMOUNT DUE:

Cash Amount 1
ACCOUNT NAME:
SBC Check No. Amount 2
CARD NUMBER: TOTAL AMOUNT
Debit Account No.
Please use Universal Transaction Slip to validate transaction.
Please check with Security Bank Online with Telebanker

C. ACCOUNT MAINTENANCE

1. Change in Account Information 2. Additional Account Information 4. Change in signature requirement from to

New Name: 5. Addition of Signatory/ies

6. Deletion of Signatory/ies
New Address:
7. SMS opt out ATM OTC
Cellphone No.: Landline No.: E. BANK FORMS REQUEST

Status: TIN/SSS/GSIS: 8. eSOA

E-mail Address: 9. Replacement of Lost Passbook (Fill-out Affidavit of Loss below)

10. Bank Certification
Nationality: Country:
Purpose of Request:
3. Reactivation of Dormant Account (Requires deposit or withdrawal transaction)
D. CARD MAINTENANCE REQUEST 11. Others, please specify:
D. CARD MAINTENANCE REQUEST

12. Replacement of: Damaged Demagnetized Lost Card CUSTOMER'S SIGNATURE

By signing this form, you assume full responsibility for the correctness, genuineness and validity of
which was lost sometime on at
all information indicated herein. You also authorize the bank to debit your account for the
under the following circumstances: 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.
13. New PIN Mailer

14. Correction of Embossed Name (Embossed Name should appear as): If via Authorized Representative: This is to authorize,
whose signature appears below, to receive my/our requested herein:

knowledge of Security Bank Corporation is prohibited and is punishable by a fine and/or imprisonment under Republic Act No. 8792, otherwise known as the Electronic Commerce Act.
For Pick-up at Branch.

RECEIVED BY/DATE: Signature Over Printed Name Signature Over Printed Name

Signature Over Printed Name of Representative

Signature Over Printed Name Signature Over Printed Name ID Details of Representative:
BANK USE ONLY PROCESSED BY: APPROVED BY: BR 154-06/16

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:

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. ___________________________________________;
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.

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

(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 ______________________.

Doc No. ________; NOTARY PUBLIC

Page No. ________;
Book No. ________;
Series of ___________