Please staple

a recent
CUSTOMER RECORD FORM: DBP PREPAID/CASH CARD colored
1x1 ID picture

Important: Please write legibly in ALL CAPS. Fill out all fields and do not leave any blanks. Indicate N/A if not applicable.
Requirements: Attach one (1) recent colored 1x1 ID picture and a clear photocopy of one (1) valid government-issued identification document (front and back).

FIRST NAME MIDDLE NAME LAST NAME GENDER

 MALE
 FEMALE
DATE OF BIRTH PLACE OF BIRTH NATIONALITY  FILIPINO  OTHER: ______________________________
 SINGLE  SEPARATED  WIDOW/ER
CIVIL STATUS
MM/DD/YYYY Town/Municipality/City Province and Country  MARRIED  ANNULLED
TAX IDENTIFICATION MOBILE/CELLPHONE
NUMBER (TIN) – – NUMBER/S

OTHER VALID  SSS  GSIS  PASSPORT ID NUMBER/S E-MAIL

ID/S PRESENTED  OTHER: _______________________ ADDRESS
PRESENT ADDRESS

House/Unit # Building / Street Name Barangay Municipality / City Zip Code Province Country
PERMANENT ADDRESS  Check if same as Present Address

House/Unit # Building / Street Name Barangay Municipality / City Zip Code Province Country
NATURE OF WORK GOVERNMENT  PRIVATE  SELF-EMPLOYED/BUSINESS  PRACTICING PROFESSIONAL  STUDENT  RETIRED
NAME OF  EMPLOYER  BUSINESS  SCHOOL SOURCE OF FUND
 EMPLOYMENT
 PERSONAL INCOME
ADDRESS OF  EMPLOYER  BUSINESS  SCHOOL
 BUSINESS
 ALLOWANCE
DBP PREPAID CARD TERMS AND CONDITIONS
1. ACCEPTANCE OF TERMS AND CONDITIONS – By accepting, activating or using this DBP Prepaid Card (hereinafter referred to as “Card”), you are deemed
to have accepted these Terms and Conditions, including the contents of the welcome letter/card carrier and any attachments.
2. CARD USAGE – Load credited to the Card may be withdrawn as cash through any BancNet-accredited automated teller machine (ATM) unit nationwide.
Card credits can also be used to pay for goods and services through any BancNet-accredited point-of-sale (POS) terminal. You authorize the Bank to
deduct all fees and charges due to us or due to third parties from your Card balance.
3. CARD BALANCE – You may not add to the Card balance or otherwise reload your Card. Card fund balance is not entitled to earn interest. The amount
loaded in the Card is not considered a deposit and may only be redeemed at face value.
4. EXPIRATION – The Card is valid from the date of issuance until the last day of the month indicated on the face of the Card (Valid Thru MM/YY).
5. CARDHOLDER LIABILITY – You shall hold DBP free and harmless from any and all losses, damages or liability you shall suffer a consequence or result
of your disclosure of your PIN or unauthorized use of your Card. You are absolutely and unconditionally liable for the full amount of all activity/ies on
your Card account completed through the different channels.
6. CLAIMS AGAINST ERRONEOUS ENTRY – Special effort is exerted to ensure proper and correct entry/ies. However, the Bank shall investigate any
cardholder claim, without the Bank incurring liability as a consequence thereof, concerning suspected erroneous entry related to your Card.
7. CARD MAINTENANCE
a. The Card should be safeguarded by the cardholder. In case of loss or theft, the fact should be reported at once by contacting the DBP e-Channels
Operations Department for blocking of the Card Account.
b. The cardholder must notify the Bank of any error in Card transactions immediately.
8. CARD REPLACEMENT – For a lost or stolen Card, a new Card may be issued by submitting a request for Card replacement at the nearest COMELEC
Office, subject to prevailing card replacement charges. The remaining fund in the lost/stolen Card, if any, shall be transferred/credited to the new Card
which shall bear a new and different Card number.
9. CLOSING OF ACCOUNT – Should the Cardholder wish to close his/her Prepaid Card account, a Manager’s Check may be issued (subject to payment of
applicable fees) with the unused Card load.
10. The Bank reserves the right to amend any of the foregoing terms and conditions with prior notice to Cardholders.
11. To the extent possible, these Terms and Conditions shall be subject to BSP Circular No. 649 Series of 2009 (Guidelines Governing the Issuance of
Electronic Money) which is deemed incorporated herein by reference.

WAIVER OF RIGHTS
The undersigned Cardholder acknowledges that the DBP Prepaid/Cash Card with Package Unit Identification (PUID) Number indicated below is
opened and/or maintained in accordance with the Memorandum of Agreement between the Commission on Elections (COMELEC) and the Development
Bank of the Philippines (DBP) and thus, holds DBP free and harmless from any liability and/or damage arising from the said ATM Card Account, including
instructions to: (a) Affect any adjustment/correction including crediting/debiting on the said ATM account; (b) Dishonor/disallow any withdrawal; (c)
Stop/hold from making any payment on the said ATM account. The undersigned Cardholder hereby: (a) waives any right or benefit accorder by Republic Act
No. 1405, or any similar laws, rules and regulation to said notice, advice or instruction; and (b) consents to the disclosure by Comelec and/or DBP to any
third party of any information pertaining to the said ATM Card Account.

COMELEC–DBP Cash Card Package Unit Identification (PUID) No.

personally issued by the undersigned COMELEC Election Officer
SPECIMEN SIGNATURE OF CUSTOMER
I hereby signify my intention to avail of the DBP Prepaid / Cash Card.
Affixing my signature below signifies that I agree to be governed by the
Prepaid Card Terms and Conditions.
0 0 0 0 0 1
AUTHENTICATED BY COMELEC ELECTION OFFCIER
I hereby certify that I personally conducted the necessary interview and
review of identification documents per the AMLA policy on Know Your
Customer and authenticated the signature of the client.

__________________________________________________ _____________________ __________________________________________________ _____________________

Signature over Printed Name of Customer Date Signature over Printed Name of Election Officer Date
DO NOT WRITE BELOW THIS PORTION.
ENCODED BY (COMELEC) REVIEWED / CHECKED BY APPROVED BY RECEIVED BY DBP

DATE: DATE: DATE: DATE:

revised 03.26.2018