Department of the Interior and Local Government

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

SGLG Form CM 2A Accounting Office

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

This is to certify that the City/Municipality 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:
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

 Utilization of funds from Assistance to Municipalities (formerly Bottom-Up Budgeting/Assistance to

Disadvantaged Municipalities; DILG-managed funds only) (Cut-off: December 31, 2018)

Total amount received Amount utilized Percent-

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 : ______%
 Department of the Interior and Local Government
Assessment for the Seal of Good Local Governance
CY 2019

 Utilization of funds from Provision of Potable Water Supply-Sagana at Ligtas na Tubig sa Lahat
(SALINTUBIG) projects (Cut-off: December 31, 2018)

Total amount received Amount utilized Percent-

utilization
CY 2012 PhP ____________________ PhP ____________________ _____%
CY 2013 PhP ____________________ PhP ____________________ _____ %
CY 2014 PhP ____________________ PhP ____________________ _____%
CY 2015 PhP ____________________ PhP ____________________ _____ %
CY 2016 PhP ____________________ PhP ____________________ _____ %
CY 2017 PhP ____________________ PhP ____________________ _____ %

Remarks:
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

 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
City/Municipal Accountant City/Municipal Mayor
Official Release of this Certification
(Please affix official LGU stamp below)
 Department of the Interior and Local Government Form CM 2B
Assessment for the Seal of Good Local Governance Business Permit and Licensing Office
CY 2019 (BPLO)

Seal of Good Local Governance

Form CM 2B Business Permit and Licensing Office

City/Municipality of : Income Class :

Province : Region :
INSTRUCTIONS
For the C/MLGOO:
(1) Ask the BPLO for the month and day of CY 2018 1st quarter with the highest volume of transaction for business permits for both new and
renewal.
(2) Review database, record book or copy of application forms.
(3) Get sample transactions, at least 50% each for new business and renewal. Maximum number of samples for each is 50.
(4) Record the samples and their processing time.

PROCESSING TIME IN ISSUING A BUSINESS OR MAYOR’S PERMIT

New Business Business Renewal
Date (month and day) Date (month and day)
with highest volume of with highest volume of
transaction for business transaction for business
permits _______________________ permits _______________________
Total number of Total number of
transactions _______________________ transactions _______________________

Sample Transactions:
Not more than 2 working Not more than 1
Application No. days from application to Application No. working day from
release? application to release?
Yes No Yes No
1. __________________ ☐ ☐ 1. __________________ ☐ ☐
2. __________________ ☐ ☐ 2. __________________ ☐ ☐
3. __________________ ☐ ☐ 3. __________________ ☐ ☐
4. __________________ ☐ ☐ 4. __________________ ☐ ☐
5. __________________ ☐ ☐ 5. __________________ ☐ ☐
6. __________________ ☐ ☐ 6. __________________ ☐ ☐
7. __________________ ☐ ☐ 7. __________________ ☐ ☐
8. __________________ ☐ ☐ 8. __________________ ☐ ☐
9. __________________ ☐ ☐ 9. __________________ ☐ ☐
10. __________________ ☐ ☐ 10. __________________ ☐ ☐
11. __________________ ☐ ☐ 11. __________________ ☐ ☐
12. __________________ ☐ ☐ 12. __________________ ☐ ☐
13. __________________ ☐ ☐ 13. __________________ ☐ ☐
14. __________________ ☐ ☐ 14. __________________ ☐ ☐
15. __________________ ☐ ☐ 15. __________________ ☐ ☐
16. __________________ ☐ ☐ 16. __________________ ☐ ☐
17. __________________ ☐ ☐ 17. __________________ ☐ ☐
18. __________________ ☐ ☐ 18. __________________ ☐ ☐
19. __________________ ☐ ☐ 19. __________________ ☐ ☐
20. __________________ ☐ ☐ 20. __________________ ☐ ☐
(Attach additional pages, if necessary.)
Notes: (1) For business renewals: If application is filed in the morning, permit is released on the same day; if application is filed in the afternoon,
permit is released on the morning of the following day. (2) For new business: Application filed on Day1 should be released not later than Day
3. (3)Weekends not counted.
 Department of the Interior and Local Government
Assessment for the Seal of Good Local Governance
CY 2019

Summary of tracked economic data:

Economic Data 2017 2018

Total number of new businesses ________ ________
Total number of business renewals ________ ________
Capital investments derived from registered new ________ ________
businesses

Collected by: Certified by:

_____________________________________________________________ _____________________________________________________________
Signature over Printed Name of C/MLGOO Signature over Printed Name of BPLO

Date: ______________________________ Date: ______________________________

Attested by:

______________________________________________
Signature over Printed Name
City/Municipal Mayor

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 CM 2C
Budget Office
CY 2019

SGLG Form CM 2C Budget Office

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

This is to certify that the City/Municipality of _______________________________ has budget

appropriation for (please tick available item(s)):

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

☐ Implementation of Community-Based Disaster Risk Reduction and Management (CBDRRM) 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
City/Municipal Budget Officer City/Municipal Mayor
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 CM 2D
CY 2019 DepEd Representative

SGLG Form CM 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 City/Municipality 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 CM 2E
DILG Field Office
CY 2019

SGLG Form CM 2E DILG Field Office

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

This is to certify that the City/Municipality 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
City/Municipal LGOO
Official Release of this Certification
(Please affix stamp of DILG RO/PO below)
 Department of the Interior and Local Government
Assessment for the Seal of Good Local Governance Form CM 2F
DRRM Office
CY 2019

SGLG Form CM 2F Disaster Risk Reduction and Management Office

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

This is to certify that the City/Municipality of ______________________________ has the following (Please
supply required data):

_____% of barangays with approved Community-Based Disaster Risk Reduction and Management
(CBDRRM) Plans. Attached is the list of barangays with approved CBDRRM Plans; and

_____% of barangays with Evacuation Guides.

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
City/Municipal Risk Reduction City/Municipal Mayor
and Management Officer

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
CY 2019 Form CM 2F (attachment)
DRRM Office

SGLG Form CM 2F Disaster Risk Reduction and Management Office (attachment)

Barangays with approved CBDRRM Plans

Period/years covered by
# Name of Barangay
CBDRRM Plan
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
(Add rows or attach additional pages, if necessary.)

Total number of barangays: ______

 Department of the Interior and Local Government Form CM 2H
Assessment for the Seal of Good Local Governance Planning and Dev’t Office
CY 2019

SGLG Form CM 2H Planning and Development Office

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

This is to certify that the City/Municipality of ______________________________ has the following (Please tick
available condition(s) and/or supply required information):

A. On Presence of Illegal Dwelling Units (for cities only)

☐ Illegal dwelling units exist within LGU jurisdiction
* In case illegal dwelling units exist, reference document for housing, resettlement and relocation
programs of the LGU is:

☐ Approved City Shelter Plan

☐ Approved Resettlement and Relocation Action Plan
☐ Resettlement PPAs incorporated in CY 2018 Annual Investment Program
☐ None
Please indicate the percentage of accomplished CY 2018 targets: ________%

B. 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
City/Municipal Planning and Development Officer City/Municipal Mayor

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 CM 2I
CY 2019 Local PNP Office/Station

SGLG Form CM 2I Local PNP Office/ Station

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

This is to certify that the City/Municipality of ______________________________ has undertaken the

following (Please tick applicable items only):

☐ The City/Municipal Mayor 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

☐ 2nd quarter CY 2018

☐ 3rd quarter CY 2018

☐ 4th quarter CY 2018

☐ The LGU has provided logistical support to the PNP Local Police Office/Station 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 LGU has supported the organization of the Barangay Peacekeeping Action Teams, barangay
tanods, and/or any similar unit.

Relatively, the LGU has (please supply required data):

_____% of barangays with organized BPATs, barangay tanods and/or similar unit; and
_____% of the barangays with trained BPATs, barangay tanods and/or similar unit.
Department of the Interior and Local Government
Form CM 2I
Assessment for the Seal of Good Local Governance Local PNP Office/Station
CY 2019

☐ 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

☐ 2nd quarter CY 2018

☐ 3rd 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, Local PNP Office/Station

Official Release of this Certification

(Please affix stamp of Records Section/Officer below)
 Department of the Interior and Local Government
Form CM 2J
Assessment for the Seal of Good Local Governance SWD Office
CY 2019

SGLG Form CM 2J Social Welfare and Development Office

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

This is to certify that the City/Municipality of ______________________________ has (please supply the following
information):

____ % of barangays have their respective violence against women and children (VAWC) desks

Submission of VAWC quarterly reports to the LSWDO for:

____ % of barangays submitted for 1st Quarter CY 2018
____ % of barangays submitted for 2nd Quarter CY 2018
____ % of barangays submitted for 3rd Quarter CY 2018
____ % of barangays submitted for 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: Attested by:

__________________________________________ ________________________________________
Signature over Printed Name Signature over Printed Name
City/Municipal Social Welfare and City/Municipal Mayor
Development Officer
Official Release of this Certification
(Please affix official LGU stamp below)
 Department of the Interior and Local Government
Form CM 2K
Assessment for the Seal of Good Local Governance Treasurer’s Office
CY 2019

SGLG Form CM 2K Treasurer’s Office

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

This is to certify that the City/Municipality 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 :
(LDF) PhP _______________________
Amount utilized out of LDF (as of Dec. 31, 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
City/Municipal Treasurer City/Municipal Mayor
Official Release of this Certification
(Please affix official LGU stamp below)
 Department of the Interior and Local Government
Form HUC 2L
Assessment for the Seal of Good Local Governance City Health Office
CY 2019

SGLG Form HUC 2L City Health Office

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

This is to certify that the City of ______________________________ has (please supply the following information):

No. of LGU-run hospitals ___________

No. of main health center ___________
-AND-
No. of CY 2018/2019 Philhealth-accredited
facilities (hospitals + main health centers):
(a) Maternal Care Package (MCP) ___________
(b) Primary Care Benefits (PCB) ___________
(c) TB-directly observed treatment short-
course (TB-DOTS) ___________

Attached is the list of LGU-run health facilities and their corresponding PhilHealth accreditation.

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
City Health Officer City Mayor

Official Release of this Certification

(Please affix official LGU stamp below)
 Department of the Interior and Local Government Form HUC 2L (attachment)
Assessment for the Seal of Good Local Governance City Health Office
CY 2019

Instruction: (1) List down all LGU-run health centers.

(2) Tick appropriate boxes corresponding to the accreditation vested by PhilHealth to the health center.
(3) Compute and supply the needed information in the summary table.
(4) Add rows or attach additional pages, if necessary.

LGU-RUN HEALTH FACILITIES

PhilHealth Accreditation for

# Name of Hospital or Main Health Center MCP PCB TB-DOTS
2018 2019 2018 2019 2018 2019
1 ☐ ☐ ☐ ☐ ☐ ☐
2 ☐ ☐ ☐ ☐ ☐ ☐
3 ☐ ☐ ☐ ☐ ☐ ☐
4 ☐ ☐ ☐ ☐ ☐ ☐
5 ☐ ☐ ☐ ☐ ☐ ☐
6 ☐ ☐ ☐ ☐ ☐ ☐
7 ☐ ☐ ☐ ☐ ☐ ☐
8 ☐ ☐ ☐ ☐ ☐ ☐
9 ☐ ☐ ☐ ☐ ☐ ☐
10 ☐ ☐ ☐ ☐ ☐ ☐
11 ☐ ☐ ☐ ☐ ☐ ☐
12 ☐ ☐ ☐ ☐ ☐ ☐
13 ☐ ☐ ☐ ☐ ☐ ☐
14 ☐ ☐ ☐ ☐ ☐ ☐
15 ☐ ☐ ☐ ☐ ☐ ☐
16 ☐ ☐ ☐ ☐ ☐ ☐
17 ☐ ☐ ☐ ☐ ☐ ☐
18 ☐ ☐ ☐ ☐ ☐ ☐
19 ☐ ☐ ☐ ☐ ☐ ☐
20 ☐ ☐ ☐ ☐ ☐ ☐

Summary:
No. of hospitals + main health centers with accreditation either in 2018 or 2019 for:
(a) Maternal Care Package (MCP) _____
(b) Primary Care Benefits (PCB) _____
(c) TB-directly observed treatment short-course (TB-DOTS) _____
 Department of the Interior and Local Government
Assessment for the Seal of Good Local Governance
CY 2019
Form CM 2M
Environment and Natural
Resources Office

SGLG Form CM 2M Local Environment and Natural Resources Office

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

This is to certify that the City/Municipality of ______________________________ has (please tick available
conditions):
☐ No operating open/controlled dumpsite

☐ Operating controlled/open dumpsite, LGU/private entity-owned, used as waste disposal facility

☐ An LGU-owned and operated Sanitary Landfill (SLF)

☐ Forged partnership with a private entity for the use of a SLF as final waste disposal facility
☐ Temporary Residual Containment Area, pending completion of LGU’s own SLF construction
☐ Other means of that is officially recognized by DENR-NSWMC as an alternative to SLF (in this case, Proof that
said technology officially recognized by DENR-NSWMC must be hereto attached)

☐ Safe Closure and Rehabilitation Plan for controlled/open dumpsite that is (please tick applicable condition):
☐ Approved; Date of approval: __________________________
With percent-completion of: __________________________ as of __________________________
☐ Currently being drafted with DENR’s technical assistance

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
City/Municipal Environment and Natural City/Municipal Mayor
Resources Officer
Official Release of this Certification
(Please affix official LGU stamp below)