TMP-DA-65-11-21

REQUEST FOR BANK CERTIFICATION

This is to request for the issuance of a Certification of Account(s) maintained under VALIDATION
the name of the undersigned depositors.

ACCOUNT
NUMBERS

INSTRUCTIONS

Statement as of

If more than one account

PURPOSE

MODE OF
PAYMENT

This shall serve as an authority to the Bank to debit directly from my account the
amount specified as payment for the Bank Certification requested.

FOR AUTHORIZED REPRESENTATIVES CLIENT'S SIGNATURE / CONFORME

This certification will be claimed by my authorized representative whose name
and signature appears below.

Signature over Printed Name of Authorized Representative

I shall indemnify and hold UnionBank of the Philippines, its officers, employees Signature over Printed Name of Client
or representatives free and harmless from and against any and all liabilities,
losses, damages, demands or causes of action arising from or in connection with
this Request for Bank Certification to be claimed by the above-assigned
representative.

Signature over Printed Name of Client

FOR BANK USE RECEIVED BY

ONLY
PROCESSED BY DATE AND TIME REQUESTED SEQUENCE NO

Signature over Printed Name Signature over Printed Name