REPLACEMENT OF DEBIT CARD/ REGENERATION

OF PIN MAILER

Store Date (mm-dd-yyyy) Account Number or Card Number

- -- -

DETAILS OF THE REQUEST

Name of Accountholder (Last Name, First Name, Middle Name) Customer Number (For Bank's Use Only)

Type of Request
Replacement of Card Regeneration of PIN Mailer Form

Reason for Replacement of Debit Card Reason for Regeneration of PIN Mailer Form
Lost/Stolen Date of Discovery of Loss _____________________________ PIN is forgotten

Expired Expiry Date __________________________________________ PIN is unreadable*

Damaged * Accountholder's request shall not be charged a processing fee.

Others (Specify) ______________________________________________________ Others (Specify) ______________________________________________

I hereby certify that the information stated above are true and correct. I authorize the Bank to use said information in order to fulfill my request.

Signature of Depositor Over Printed Name Date

For Lost/Stolen Card Only

This will serve as the Cardholder’s written report of such loss to the Bank.

I hereby represent and warrant that the foregoing information are true and correct based on my personal knowledge and that the IDs I have presented are genuine and authentic and I agree
to hold and agree to indemnify East West Banking Corporation (EWBC) free and harmless from any liability for the issuance of a replacement Card.

I likewise agree to hold EWBC free and harmless from any liability arising from the loss of my Card including but not limited to liability for transactions made through said Card prior to my
reporting the same to EWBC as lost.

Signature of Depositor Over Printed Name Date

MODE OF PAYMENT
Cash OR Number ___________________________________

Debit From Account Account Number _______________________________

I/We hereby authorize the Bank to debit the abovementioned account for the amount of the EastWest Card Replacement Fee/Regeneration of PIN Mailer Form. Further, I/We declare under
the penalties of perjury that my co-depositor/s, if any, is/are still living.

Signature of Accountholder Over Printed Name & Date Signature of Accountholder Over Printed Name & Date

FOR BANK USE ONLY

To be filled up upon receipt of request for card replacement/regeneration of PIN Mailer Form

Valid ID/s Presented

Type of ID ID Number Date of Issue/Expiry

Receiving/Processing Store Attending Store Personnel/Processed By Date Received/Processed Approved By Date Approved

Signature Over Printed Name Signature Over Printed Name

To be filled up upon activation of Card (For Card Replacement Request Only)

Processed by Date Processed Activated/Approved by Date Activated/Approved

Signature Over Printed Name Signature Over Printed Name

DEBIT CARD AND PIN MAILER ACKNOWLEDGEMENT RECEIPT

I hereby acknowledge having received the Debit Card and PIN Mailer on the date indicated therein.

CARD Released By Received By/Date Received Signature Verified By PIN Mailer Released By Received By/Date Received Signature Verified By

Details of ID(s) Presented by the Debit Card Holder

EW Form 18-031 11/2014 CONFIDENTIAL