___________________________________

NAME OF AGENCY/ ENTITY

__________________________________
Address

Date : ________________

TO : THE BRANCH HEAD

Land Bank of the Philippines
Lopez Branch

Subject : Authority to Debit/Credit Account

Please debit (Account No./Account Name) _________________________________________

__________________________________________________________________the amount of
PESOS:________________________________________________________________________
(P ) and credit to (Account No./Account Name)_________________________
______________________________________________________________________________

Representing: _________________________________________________________________.

This also authorized you to debit my/ our account for the corresponding service charge.
For Join Account: I/ We declare under penalty of perjury that my/ our co-deposit/s is/are still
living.

__________________________________ __________________________________
(Name and Signature of Authorized Signatory) (Name and Signature of Authorized Signatory)

______________________________________________________________________________
FOR BANK’S USE ONLY
Signature Verified by: Checked by: Approved by: Sight Verified by:

_________________ ________________ ______________ ______________ ____________________

_ _

______________________________________________________________________________
Validation Print: