Claim Request No.

:________

CLAIM REQUEST

Details of Claim

Name : Saul Banas III

Contact Details: 09212664940

Claim Amount : 500

Terminal Details : 210702

Details of the Claim :
Supporting Documents 1. Valid Government ID
2. Full Transaction Details or Picture of
Acknowledgement Receipt
3. Selfie Picture of Full Face (recent)
4. Full name, Home Address, Date of Birth

Declaration

By submitting this document, I hereby declare and confirm that all information and supporting documents I provided in
connection with this undertaking are true, accurate and complete.

I understand that it will be necessary for Electronic Transfer and Advance Processing, Inc. (eTap) and Electronic Transfer and
Advance Processing (ETAP) Solutions, Inc. to verify my identity and that eTap may contact me for more detailed information
in order to facilitate this claim request and I consent to the collection, use and disclosure of the personal data that I have
provided in this form for the purpose of this request.

I understand and agree that I shall not engage in any conduct or make any statements defamatory, disparaging, or derogatory to
eTap, or to any products or services offered by eTap or its Affiliates. Any unresolved issues can be dealt with discreetly
between myself and eTap.

Name & Signature of Customer:

Saul Banas III

Date : July 14, 2023

Acknowledgement (For eTapl Use)

Name & Signature of eTap Inc. Witness:

Date: