REPUBLIC~OF THE PHILIPPINES Grwmma. Fora No. 67 (A)
(Revised March 24, 1976)
(ity oF Province)
REQUEST FOR BONDING AND/OR CANCELLATION OF BOND OF
ACCOUNTABLE OFFICIALS AND EMPLOYEES OF
‘THE REPUBLIC OF THE PHILIPPINES
{. NAMB OF PERSON TO BE BONDED/WHOSE BOND 1S TO | 2 DESIGNATION OR TITLE OF POSITION
BE CANCELLED
Surname Given Middle
‘& DATE INCOMING OFFIGHR ASSUMES ACCOUNTABILITY
Year Month Day
7 STATION
Municipality Provinee/City
5 AMOUNTS OF MAXIMUM ACCOUNTABILITY /CUSTODY —
(When extent or character of an Offesr's control
lover funds or property cannot be inferred from the
tle or designations given, a full and complete statement
Jof duties should be given above,
(Use additional shect if necessary).
(a) Public Fonds
() As Colleeing Officer
(2) As Disbursing Offcer
(b) Public Property
(1) Supplies & Materials
(2) Equipment.
~(8) Others
(e) Forms and other valuables
(1) Internal Rev, Stamps
(2) Internal Rev. Dec. Stamps
(3) Customs Doc, Stamps
(4) Postage and other Stamped Stock
(5) Science Stamps
(8) Cash Tickets
(1) Others
Total Amout
6. SALARY ATTACHED TO THE POSITION
(In ease of temporary appointment or designation,
Jaalary or permanent and temporay incumbent. should
be stated).
1. BOND RECOMMENDED
8. BOND FILED BY LAW OR BY THE CHAIR-
MAN, COMMISSION ON AUDIT
PERSONAL RECORD OF PERSON TO BE BONDED
(Use additional tor separate sheeta if neessary)
(A) PREVIOUS EXPERIENCE |__@) CRIMINAL OR ADMINISTRATIVE RECORD
(2HIS BLOCK TO BE FILLED ONLY IN CASH OF BOND CANCELLATION)
70, NAME OF OFFICER TO BE RELIEVED ii, PRESENT TITLE OR DESIGNATION
‘Sormame Given middle
42, AMOUNT OF BOND AND RISK NUMBER IN FORCE| 13. SALARY OF PERSON TO BE RELIEVED
i DATE OF BELIEF 35. CAUSE OF RELIEF
Year Month Day. |
16, REMARKS
Head of Agency or Office
City Mayor Of
Provincial Treasurer
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