Attachment 3: Annex D

Fidelity Bond Application Form

REPUBLIC OF THE PHILIPPINES (Revision No._____________)
KAGAWARAN NG PANANALAPI
KAWANIHAN NG INGATANG YAMAN RISK NUMBER
(BUREAU OF THE TREASURY) (to accomplished by BTr Officer)

REQUEST FOR APPLICATION FOR BONDING AND/OR CANCELLATION OF FIDELITY BOND OF ACCOUNTABLE PUBLIC
OFFICER

1. ACCOMPLISH THIS FORM CORRECTLY 3. MARK APPROPRIATE BOXES £ WITH CHECK "P"
INSTRUCTIONS:
2. PRINT ENTRIES LEGIBLY IN CAPITAL LETTERS
OLD RISK NUMBER:
TYPE OF ✘ NEW RENEWAL CANCELLATION, please proceed to item
APPLICATION: Nos. 24-32 For Renewal

1. NAME

BUENAFLOR PRAISE CABALUM

Surname Given Name Name Ext. (e.g. Jr.) Middle Name

2. ADDRESS

PUROK DAHLIA, BRGY. BUENAFLOR, TACURONG CITY

2X2 ID PHOTO
3. DATE OF BIRTH (mm/dd/yyyy) 4. PLACE OF BIRTH

APRIL 15,1997 TACURONG CITY, SULTAN KUDARAT

5. SEX 7. CIVIL STATUS 8. CONTACT NUMBER
MALE ✘ FEMALE
✘ SINGLE WIDOWED
09190918856
6. TIN 9. EMAIL ADDRESS
MARRIED SEPARATED
715-101-921-000 buenaflorpraise1129@gmail.com
10. MONTHLY INCOME (Salaries, allowances, business income and the like) 11. ESTIMATED MONTHLY EXPENSES
37,628.00 18,600.00
12. Have you ever been separated from the service in any of the following modes: resignation, retirement, dropped from the rolls, dismissal, termination, end of
term, finished contract or phased out (abolition) in the public or private sector?

YES ✘ NO
If yes, give details:

13. a. Have you ever been found guilty of any administrative offense? b. Have your ever been found guilty of criminal case before any court?

YES ✘ NO YES ✘ NO
If yes, give details: If yes, give details:
Case No/s.
Date Filed:
Status of Case/s:

14. CHARACTER REFERRENCE (Individual must not be related up to the fourth degree by consanguinity or affinity to applicant)
NAME ADDRESS CONTACT NUMBER

EMALYN CONCON KORONADAL CITY 09085017365

NORHUDA KAMANSA COTABATO CITY 09190937472
ATTY. JOHN PAUL MACABABBAD SURALLAH 09222066072

15. I declare that the answer to the foregoing questions are true to the best of my knowledge and belief. I fully understand that any misrepresentation made in this
application and supporting documents shall cause the filing of administrative/criminal case(s) against me.

Government Issued ID : PRC ID

ID/License/Passport Number : 0188514 PRAISE C. BUENAFLOR
Date/Place of Issue : JULY 6, 2018-GENERAL SANTOS Signature over Printed Name/Date Accomplished

16. SUBSCRIBED AND SWORN to before me this , affiant exhibiting his/her validly issued Government ID as indicated above.

Doc. No. ;
Page No. ;
Book No. ;
Series of . Signature of Officer/Person Administering Oath

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AMOUNT OF ACCOUNTABILITY 18. NAME OF OFFICE OR AGENCY
AMOUNT OF
ACCOUNTABILITY
LAND TRANSPORTATION FRANCHISING AND
REGULATORY BOARD REGION 12
19. ADDRESS OF OFFICE OR AGENCY
(a) Public Funds
KORONADAL CITY SOUTH COTABATO
(1) As Collecting Officer P Municipality/City Province
(2) As Disbursing Officer 20. STATION/DIVISION (Place of assignment)
(3) As Signing Officer 10,000,000.00
(4) Investment Officer (GS Investments)
KORONADAL CITY
21. TITLE OF POSITION OR DESIGNATION

(b) Public Property REGIONAL ACCOUNTANT

(1) Inventories (per GAAM) P 22. DATE OF DESIGNATION OR ASSUMPTION OF

ACCOUNTABILITY
(2) Property, Plant & Equipment (Net Book Value)

2019 JANUARY 16
(c) Forms and other valuables Year Month Day

(1) Internal Revenue Stamps P 23. BOND PERIOD COVERAGE

(2) Postage and other Stamped Stock
(3) Official Receipt ✘ One (1) year
(4) Other Forms and valuables
✘ Two (2) years

TOTAL AMOUNT P 10,000,000.00 Three (3) years

THIS BLOCK TO BE FILLED ONLY IN CASE OF BOND CANCELLATION

24. OFFICE OR AGENCY AND STATION

25. NAME OF OFFICER TO BE RELIEVED 26. PRESENT POSITION OR DESIGNATION

Surname Given Name Middle Name

27. AMOUNT OF BOND 28. RISK NUMBER AND EFFECTIVITY DATE

29. DATE OF RELIEF 30. CAUSE OF RELIEF

Year Month Day

31. THIS IS TO CERTIFY THAT, as Head of Agency of LAND TRANSPORTATION FRANCHISING AND REGULATORY BOARD REGION 12 ,
I verified the truthfulness of the answers to the questions contained on the face of this form and found them correct insofar as can be ascertained and that the applicant is a
safe and conservative risk. Hence, the undersigned is recommending approval and authorizing the request for

✘ Application for Bonding

✘ New
Renewal
Cancellation of Bond

of the accountable public officer.

PATERNO REYNATO C. PADUA
Signature over Printed Name of Head of the Agency/ Date
Accomplished

THIS BLOCK TO BE FILLED BY BTr ONLY

32. AMOUNT OF BOND RECOMMENDED 33. AMOUNT OF BOND PREMIUM PAYABLE

3,500,000.00 52,500.00

This is to certify that I have carefully evaluated the request for ✘ APPLICATION RENEWAL CANCELLATION
of Fidelity Bond of the above-mentioned accountable public officer.

MAY 25, 2021

Name & Signature of BTr Officer Date
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