Republic of the Philippines Republic of the Philippines

Office of the President Office of the President

Cooperative Development Authority Cooperative Development Authority
BJMP MULTI-PURPOSE COOPERATIVE BJMP MULTI-PURPOSE COOPERATIVE
BJMP MPC Building, Mindanao Avenue, Quezon City BJMP MPC Building, Mindanao Avenue, Quezon City

WITHDRAWAL SLIP WITHDRAWAL SLIP

DATE: DATE:
Please Check: Please Check:
DIVIDEND/PATRONAGE REFUND DIVIDEND/PATRONAGE REFUND
IF THE MEMBER CHOOSES TO: IF THE MEMBER CHOOSES TO:
withdraw the whole balance of DIV/PR for the semester withdraw the whole balance of DIV/PR for the semester
withdraw a certain amount only, withdraw a certain amount only,
(please specify the amount) P________________ (please specify the amount) P________________
SAVINGS WITHDRAWAL (for members with Savings Account SAVINGS WITHDRAWAL (for members with Savings Account
please specify the amount) P_________________ please specify the amount) P_________________

PASSBOOK NO.: PASSBOOK NO.:

Received from BJMP MULTI-PURPOSE COOPERATIVE the sum Received from BJMP MULTI-PURPOSE COOPERATIVE the sum
of Pesos_____________________________ of Pesos_____________________________
P P
____________________________________ ____________________________________
____________________________________________________ ____________________________________________________

____________________________________________________ ____________________________________________________
SIGNATURE OF DEPOSITOR SIGNATURE OF DEPOSITOR

____________________________________________________ ____________________________________________________
PRINTED NAME PRINTED NAME
Unit Assignment/Region Unit Assignment/Region
Mobile No. ___________________________ Mobile No. ___________________________

NOTE: NAME OF AUTHORIZED REPRESENTATIVE MUST BE WRITTEN BY NOTE: NAME OF AUTHORIZED REPRESENTATIVE MUST BE WRITTEN BY
THE DEPOSITOR HIMSELF THE DEPOSITOR HIMSELF

I HEREBY AUTHORIZE___________________________________ I HEREBY AUTHORIZE___________________________________

(NAME OF REPRESENTATIVE) (NAME OF REPRESENTATIVE)

WHOSE SIGNATURE APPEARS BELOW TO MAKE THIS WITHDRAWAL WHOSE SIGNATURE APPEARS BELOW TO MAKE THIS WITHDRAWAL
FOR ME FOR ME

________________________ ___ ______________________________ ___________________________ ______________________________

SIGNATURE OF AUTHORIZED SIGNATURE OF DEPOSITOR SIGNATURE OF AUTHORIZED SIGNATURE OF DEPOSITOR
REPRESENTATIVE REPRESENTATIVE

NOTE: AUTHORIZED REPRESENTATIVE MUST PRESENT HIS AND NOTE: AUTHORIZED REPRESENTATIVE MUST PRESENT HIS AND
DEPOSITOR’S BJMP MPC PASSBOOK AND I.D. DEPOSITOR’S BJMP MPC PASSBOOK AND I.D.

_____________________________________________ _____________________________________________
SIGNATURE OF RECEPIENT SIGNATURE OF RECEPIENT
Remarks Posted by: Verified by: Approved by: Remarks Posted by: Verified by: Approved by:

LBP ACCOUNT No.________________________________________ LBP ACCOUNT No.________________________________________