Request for account termination and withdrawal of funds

I,........................................................................................................................with ID/Passport
number..........................., confirm that I am the sole owner and beneficiary of my Coins.ph
account, registered under the email address ......................................... @........................... To
date, I have been responsible for all transactions to and from my Coins.ph account.

With this document, I request that my account be terminated.

With this declaration, I agree to defend and indemnify Coins.ph from and against any and all
claims, charges, suits, and expenses of every kind and nature whatsoever, including
attorney’s fees and expenses, arising out of or based upon my use of the Coins.ph service
and/or my transactions with third parties. Upon the closure of my account, I agree to release
and discharge Coins.ph, its parent, employees, agents, licensees, successors and assignees
from any and all claims, demands, or causes of action in relation to my use of the Coins.ph
service and/or my account activity.

By requesting to close my account, I hereby authorize Coins.ph to withdraw any outstanding

balance, minus any applicable fees, from my account and transfer them into my possession.
For any balance in Bitcoins, I understand that Coins.ph will convert the balance to peso using
the exchange rate as advertised on the website, at the time of the processing of my request. I
confirm that I will not have any claims for funds received to my account after its termination.
After that time, no new funds will be payable to me.

I confirm that, as the sole beneficiary of the account, I will be the recipient of the balance
amount.

Withdrawal Options (please choose one):

⃣ Pick up from LBC Instant Peso Padala (up to P 50,000 only)

Regular cash out fee applies depending on the amount, up to PHP 120

Recipient Name (must be your name)....................................................................

Phone Number........................................................................................................
Address...................................................................................................................

⃣ Deposit to my Bank account (up to P400,000 only, fee is PHP 0)

Cash out fee of PHP 200 applicable to BDO accounts.

Bank Name (must be a supported bank) ..................................................................

Account Holder Name (must be your name) ........................................................
Account Number........................................................................................................
 ⃣ I confirm that I have attached a notarized or certified true copy of my Government issued ID.

Coins.ph Account holder:

Signature:
Address:
Date:
Signed in the presence of:

.........................................

Acknowledgement

Republic of the Philippines)

...........................................)SS.

BEFORE ME, a Notary Public in and in ............................................... this day of .................... ,

20__ personally appeared the following:
Name: Government Issued ID No: Date and Place of Issue

all known to me to be the same persons who executed by the foregoing instrument and they
acknowledged to me that the same is their free and voluntary act and deed.

WITNESS MY HAND AND SEAL in the place and on the date first above written.

Doc. No. ..............................................................................................;

Page No. ..............................................................................................;
Book No............................................................................................... ;
Series of ................................................................................................