2019 Seal of Good Local Governance Form 5

Summary of Initial Results - All LGUs in the Region

INSTRUCTIONS: PLEASE READ BEFORE PROCEEDING TO THE ITEMS.

For the RFP: (1) Consolidate and summarize findings of all LGUs in the region by filling out this Form 5. If the LGU
initially passed SGLG or has pending change request, please put "1"; otherwise, put "0". (2) Please ensure that required
signatures are affixed at the last page of this form, and initials are accordingly present at the bottom of each page. (3)
Submit this form in 2 formats: one in PDF with complete signatures; and the other one in MS Excel format.

Region: __________________

PROVINCE LGU Name INCOME LGU Passed W/ pending change

CLASS TYPE SGLG? request?

We hereby certify that the information herein are true and correct, and are accordingly supported by
required documents as reviewed by the undersigned.

(Signature over Printed Name)

Asst. Regional Director as the SGLG RAT Leader

(Signature over Printed Name)

LGMED Chief

(Signature over Printed Name)

LGPMS-SGLG RFP

(Signature over Printed Name)

CSO Representative, Name of Agency

(Signature over Printed Name)

Regional Director

Date: