Re: [Name of the defaulting bank ] ("the defaulting bank")

This is to confirm that:

The balance on Account No. [ ], or
The combined balance on the following Account Nos.
Account No. [ ]
Account No. [ ]
Account No. [ ]
Account No. [ ]

in the name of [ ], with the last recorded address on the files of the defaulting bank being [ ], is:

Amount in Numbers: BD (or BD equivalent) [ ]
Amount in Words: Bahraini Dinars (or Bahraini Dinars equivalent) [ ]

That the above named person is an Eligible Depositor and/or Investor and is entitled to the following amount under the Regulation Protecting the Deposits and Unrestricted Investment Accounts in the Kingdom of Bahrain, issued by Resolution of the Board of Directors of the Central Bank of Bahrain No. [34] of [2010] :

Amount in Numbers: BD [ ]
Amount in Words: Bahraini Dinars [ ]

This amount will be reimbursed to the above named Eligible Depositor and/or Investor by [name and address of mandated bank] ("the lead mandated bank") between [ ] and [ ], during normal business hours, upon the presentation and execution of the appended assignment.

Signed: _____________________________________________
[Name of Chairman of the Deposits and Unrestricted Investment Accounts Protection Board or other Member of the Deposits and Unrestricted Investment Accounts Protection Board]
for and on behalf of the Deposits and Unrestricted Investment Accounts Protection Board