CLASS D
Land Bank of the Philippines
CLIENT REQUEST FORM
Date: _____________________
Account Name Account Number/s
Request for (Please Specify) Date/Period Covered Purpose
Bank Statement Bank Certificate Snapshot Others_______
Change of Account Details To______________________________________
Mode of Payment
Debit from Account ______________________________ Cash _____________
Authorized Representative Authorized Signatory Authorized Signatory
FOR BANK USE ONLY
Signature Verified by Checked/Approved by Released by Received by
__________________________
Signature Over Printed Name
Payment Validation
Original copy – LBP Duplicate copy – Client/Depositor
CLASS D
Land Bank of the Philippines
CLIENT REQUEST FORM
Date: _____________________
Account Name Account Number/s
Request for (Please Specify) Date/Period Covered Purpose
Bank Statement Bank Certificate Snapshot Others_______
Change of Account Details To______________________________________
Mode of Payment
Debit from Account ______________________________ Cash _____________
Authorized Representative Authorized Signatory Authorized Signatory
FOR BANK USE ONLY
Signature Verified by Checked/Approved by Released by Received by
__________________________
Signature Over Printed Name
Payment Validation