Request For Document

Part 1 My / Our Particular

Name (as per NRIC / Passport/
Business Registration)
NRIC/ Passport No./ Business
Registration No.
Part 2 My / Our Request
1. I/ we request a copy of the following document(s) :
Account Number: Principal Credit Card Number:
1 - - - 1 - - -
2 - - - 2 - - -
3 - - - 3 - - -
4 - - - 4 - - -
5 - - - 5 - - -
6 - - - 6 - - -
Statement of Account Cheque Image
Statement of Credit Card (request by principal cardholder only)
Withdrawal Slip/ Debit Advice Clearing Cheque
Deposit Slip/ Credit Advice Image Return Document
Security Document Others

Information on the document(s) requested Information on the document(s) requested

[ e.g. statement for xx month, cheque number etc.] [ i.e. statement for xx month]

2. I / we request for certification of the document(s) requested No Yes

3. Please deliver the document(s) to me/ us as follows :- To collect at branch By Courier
Please complete the below if document to be collected by Authorised Person Name (as per
NRIC/ Passport)

NRIC/ Passport No. Contact Number:

Part 3 Payment
Account/ Credit Card Number to be Debited/ Charged:
Savings Account/ Current Account Number : - - -

Principal Credit Card Number : - - -

(only applicable for request of credit card statement)
**For Bank Use Only: TXCD: 6004 | Amount: RM_______.00
Part 4 Declaration Part 5 Acknowledged Receipt
I / We understand that the copy document is subject to the fees and I hereby acknowledge receipt of the copy of document
charges. For details of the charges, please refer to UOB Fees & Charges requested.
at our website: www.uob.com.my
Name:
ID no.:

Customer Signature Recipient's Signature

Date: D D - M M - Y Y Y Y Date: D D - M M - Y Y Y Y

Part 6 For Bank Use Only

For statement request OTC 1 Mail In 4 **For time sensitive Credit Card Statement printed and collected at branch:
Waiver Offsite (with Biometric)2 Fax
5
Branch to raise Service Request via C360/GCR.
Branch Code: Offsite (without Biometric)3 SR Type: (Branch Only) Credit Card - Fee Collection_COPC Account Services
Cost Centre: Offsite Collected By:
CHQ IMAGE REQUEST (SNV); SLA = T, latest T+1 Day
Service Fee RM Attended By Approved By REQUEST FOR FINANCIAL STATEMENT IND (SNV); SLA = T, latest T+1 Day
1006200070 REQUEST FOR FINANCIAL STATEMENT N.IND (SNV); SLA = T, latest T+1 Day
(SVC-DEP-CA)
ODS-STATEMENT (SNV); SLA = T, latest T+1 Day
1006200520
(SVC-DEP-SA) EWF Maker EWF Checker
Courier Fee Name
1007622080 Rec Date & Time Name
(RECY-COURIER)
Customer Signature Verified 1,2,3 Supporting Document, Name Name
Total Charges (RM): MyKad Biometric Verified 1,2 if any 1,2,3,4,5
Scan Date & Time QR Date & Time
Reason for copy document: Job Batch ID No. No. of Pages
For attention of Branch RIOC/ CMOC GSU T&O Others Copy made on: (ddmmyy)

[DOC-01 : Rev 07/24]

United Overseas Bank (Malaysia) Bhd. (Reg. No. 199301017069 (271809-K))