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 knowledge of Security Bank Corporation is prohibited and is punishable by a fine and/or imprisonment
CUSTOMER REQUEST FORM
BRANCH: DATE:

A. GENERAL INFORMATION B. PAYMENT DETAILS

MODE OF PAYMENT AMOUNT DUE:

ACCOUNT NUMBER:
Cash Amount 1

ACCOUNT NAME:
SBC Check No. Amount 2

Debit Account No. TOTAL AMOUNT

CARD NUMBER:
Please use Universal Transaction Slip to validate transaction.

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

New Address: 6. Deletion of signatory/ies

7. SMS Opt Out ATM OTC

Cellphone No.:
C. BANK FORMS REQUEST
Landline No.:
8. eSOA
Status: TIN/SSS/GSIS:
9. Replacement of Lost Passbook (Fill-out Affidavit of Loss below)
E-mail Address:
10. Others, please specify:
Nationality: Country:

3. Please update mobile number and/or e-mail address of my SB Online Account

CUSTOMER'S SIGNATURE
Please indicate SBOL User ID: By signing this form, you assume full responsibility for the correctness, genuineness and
validity of all information indicated herein. You also authorize the bank to debit your
D. CARD MAINTENANCE REQUEST account for the 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
11. New PIN Mailer
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
12. Correction of Embossed Name (Embossed Name should appear as:)
that your co-depositor/s is/are still living.

If via Authorized Representative: This is to authorize,

For Pick-up at Branch whose signature appears below, to receive my/our requested herein:

RECEIVED BY / DATE:
By signing this form, I/we hereby acknowledge receipt of my/our request above.

Signature Over Printed Name Signature Over Printed Name

Signature Over Printed Name Signature Over Printed Name

Signature Over Printed Name of Representative

ID Details of Representative:

FOR BANK'S PROCESSED BY: APPROVED BY:

BR 154-01/20
USE ONLY

under Republic Act No. 8792, otherwise known as the Electronic Commerce Act.
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
9. 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.

(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. ________;

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