Department of the Interior and Local Government

Form P 2A
Assessment for the Seal of Good Local Governance Accounting Office
CY 2019

SGLG Form P 2A Accounting Office

C E R T I F I C A T I O N

This is to certify that the Province of _______________________________ has the following (please supply
required information; Note that utilized funds refer to disbursed funds.):

 Utilization of Performance Challenge Fund (Cut-off: December 31, 2018)

Total amount Amount utilized Percent-

received utilization
CY 2015 PhP __________________ PhP __________________ __________ %
CY 2016 PhP __________________ PhP __________________ __________ %
CY 2017 PhP __________________ PhP __________________ __________ %

Remarks:
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

 CY 2018 LDRRM Fund: Appropriation

Estimated amount of regular sources : PhP ____________________

Amount allocated for LDRRMF CY 2018 : PhP ____________________
In percent : _____ %

 CY 2018 LDRRM Fund: Utilization of the 70% component for Preparedness (Current Fund)
(Cut-off: December 31, 2018)

Amount allocated for LDRRMF CY 2018 : PhP ____________________

(Preparedness component)
Amount utilized (as of Dec. 2018) : PhP ____________________
In percent : ______%

 Utilization of funds from Conditional Matching Grant to Provinces (CMGP; formerly KALSADA
program) (Cut-off: December 31, 2018)

Total amount received Amount utilized Percent-

utilization
(Must not
exceed 100%)
CY 2016 PhP ____________________ PhP ____________________ _____ %
CY 2017 PhP ____________________ PhP ____________________ _____ %

Remarks:
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
 Department of the Interior and Local Government
Assessment for the Seal of Good Local Governance
CY 2019

 Utilization of funds for CY 2018 Peace and Order, and Public Safety Plan (Cut-off: December 31, 2018)

Amount allocated for programs, projects : PhP ____________________

and activities in POPS Plan for CY 2018
Amount utilized : PhP ____________________
In percent : ______%

 Utilization of budget appropriated for the conservation and preservation of cultural property for
CY 2018 (Cut-off: December 31, 2018)

Amount allocated for programs, projects : PhP ____________________

and activities related to conserving and
preserving cultural property CY 2018
Amount utilized : PhP ____________________
In percent : ______%

This Certification is issued for the purpose of the Seal of Good Local Governance assessment.

Issued on ________th of ____________, 2019.

Certified by: Attested by:

______________________________________ ______________________________________
Signature over Printed Name Signature over Printed Name
Provincial Accountant Provincial Governor
Official Release of this Certification
(Please affix official LGU stamp below)
 Department of the Interior and Local Government
Assessment for the Seal of Good Local Governance Form P 2C
Budget Office
CY 2019

SGLG Form P 2C Budget Office

C E R T I F I C A T I O N

This is to certify that the Province of _______________________________ has budget appropriation for
(please tick if there is):

☐ Approved Local Disaster Risk Reduction and Management (LDRRM) Plan

as integrated in CY 2019 Annual Budget and CY 2019 Annual Investment Program.

This Certification is issued for the purpose of the Seal of Good Local Governance assessment.

Issued on ________th of ____________, 2019.

Certified by: Attested by:

______________________________________ ______________________________________
Signature over Printed Name Signature over Printed Name
Provincial Budget Officer Provincial Governor
Official Release of this Certification
(Please affix official LGU stamp below)
 Department of the Interior and Local Government
Assessment for the Seal of Good Local Governance Form P 2D
CY 2019 DepEd Representative

SGLG Form P 2D DepEd Representative

C E R T I F I C A T I O N

This is to certify that the Local School Board (LSB) Plan for CY 2018 of the Province of
_______________________________ has the following status of implementation (Please supply required data):

_____% of programs, project, and activities are completed; and

_____% of the total amount appropriated to finance the LSB Plan is utilized.

Accordingly, the said Plan completed, or its fund utilized for, the following items (tick appropriate item(s)):

☐ Operation and maintenance of public schools

☐ Construction and repair of school buildings

☐ Facilities and equipment

☐ Educational research

☐ Purchase of books and periodicals

☐ Sports development

☐ Others. Please specify: ____________

This Certification is issued for the purpose of the Seal of Good Local Governance assessment.

Issued on ________th of ____________, 2019.

Certified By:

_____________________________________________
Signature over Printed Name
DepEd Schools Division Superintendent/
designated Representative to LSB

Official Release of this Certification

(Please affix stamp of Records Section/Officer below)
 Department of the Interior and Local Government
Assessment for the Seal of Good Local Governance Form P 2E
DILG Field Office
CY 2019

SGLG Form P 2E DILG Field Office

C E R T I F I C A T I O N

This is to certify that the Province of _______________________________ has (Please tick available item(s)):
☐ GAD Plan and Budget for CY 2019 that has been reviewed and was found fully compliant in form and
content per PCW-DILG-DBM-NEDA JMC No.: 2016-01
☐ GAD Plan and Budget for CY 2019 that has been submitted to this Office for review
☐ Approved Peace and Order, and Public Safety Plan that covers CY 2018 (If there is an approved Plan, please
supply information below)
_____% of programs, projects and activities for CY 2018 indicated in the approved Plan
accomplished by December 31, 2018

In addition, I confirm the correctness of the information/conditions contained in the attached

Documentation template.

This Certification is issued for the purpose of the Seal of Good Local Governance assessment.

Issued on ________th of ____________, 2019.

Certified by:

______________________________________
Signature over Printed Name
DILG Provincial Director

Official Release of this Certification

(Please affix stamp of DILG RO/PO below)
 Department of the Interior and Local Government Form P 2H
Assessment for the Seal of Good Local Governance Planning and Dev’t Office
CY 2019

SGLG Form P 2H Planning and Development Office

C E R T I F I C A T I O N

This is to certify that the Province of ______________________________ has the following (Please tick available
condition(s)):

Local tourism condition where:

☐ Income from tourism activities form part of the LGU’s main source of revenue

☐ Large segment of LGU’s population is employed in tourism activities

☐ Significant portion of the LGU’s fund is appropriated for the development of this industry

This Certification is issued for the purpose of the Seal of Good Local Governance assessment.

Issued on ________th of ____________, 2019.

Certified By: Attested by:

__________________________________________ ________________________________________
Signature over Printed Name Signature over Printed Name
Provincial Planning and Development Officer Provincial Governor

Official Release of this Certification

(Please affix official LGU stamp below)
 Department of the Interior and Local Government
Assessment for the Seal of Good Local Governance Form P 2I
CY 2019 Local PNP Office/Station

SGLG Form P 2I Local PNP Office

C E R T I F I C A T I O N

This is to certify that the Province of ______________________________ has undertaken the following (Please
tick applicable items only):

☐ The Provincial Governor convened the Local Peace and Order Council (LPOC).
In particular, the LPOC met at least once in (please tick applicable choice(s)):
☐ 1st quarter CY 2018 ☐ 3rd quarter CY 2018
☐ 2nd quarter CY 2018 ☐ 4th quarter CY 2018

☐ The LGU has provided logistical support to the PNP Local Police Office in CY 2018.
Accordingly, the following are the forms of support given (please tick applicable choices only):
☐ Ammunition ☐ Police station
☐ Communication ☐ Supplies
☐ Vehicle ☐ Others (please specify): _________________

☐ The City/Municipal Mayor activated its Anti-Drug Abuse Council (ADAC)

In particular, the ADAC met at least once in the (please tick applicable choice(s)):
☐ 1st quarter CY 2018 ☐ 3rd quarter CY 2018
☐ 2nd quarter CY 2018 ☐ 4th quarter CY 2018

This Certification is issued for the purpose of the Seal of Good Local Governance assessment.

Issued on ________th of ____________, 2019.

Certified By:

__________________________________________
Signature over Printed Name
Chief, Provincial Police Office
Official Release of this Certification
(Please affix stamp of Records Section/Officer below)
 Department of the Interior and Local Government
Form P 2K
Assessment for the Seal of Good Local Governance Treasurer’s Office
CY 2019

SGLG Form P 2K Treasurer’s Office

C E R T I F I C A T I O N

This is to certify that the Province of ______________________________ has (please supply the following information):
 Local revenue growth, CYs 2015 - 2017

Local revenue for:

CY 2015 : PhP ________________________
CY 2016 : PhP ________________________
CY 2017 : PhP ________________________
Growth rate for:
From 2015 to 2016 : _____%
From 2016 to 2017 : _____%
Ave. growth : ______%

 20% Component of Internal Revenue Allotment for CY 2017

Total amount of 2017 Internal Revenue Allotment : PhP _______________________

Amount allocated as Local Development Fund : PhP _______________________
(LDF)
Amount utilized out of LDF (as of Dec. 2018) : PhP _______________________

This Certification is issued for the purpose of the Seal of Good Local Governance assessment.

Issued on ________th of ____________, 2019.

Certified By: Attested by:

__________________________________________ ________________________________________
Signature over Printed Name Signature over Printed Name
Provincial Treasurer Provincial Governor

Official Release of this Certification

(Please affix official LGU stamp below)