Department of the Interior and Local Government

Form P 2A
CY 2021 Seal of Good Local Governance
Accounting Office
(For Field Test Purposes Only)

SGLG Form P 2A Accounting Office

CERTIFICATION
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

Total amount received Amount utilized Percent-utilization

CY 2018 PhP _____________ PhP ______________ __________ %
(Cut-off: Dec. 31, 2020)
CY 2019 PhP _____________ PhP ______________ __________ %
(Cut-off: June 30, 2021)

Remarks:
____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

● CY 2020 LDRRM Fund: Appropriation

Estimated revenue from regular sources : PhP ________________

Amount allocated for LDRRMF CY 2020 : PhP ________________
In percent : _____ %

● CY 2020 LDRRM Fund: Utilization of the 70% component for Preparedness (Current Fund)

Amount allocated for LDRRMF CY 2020 : PhP ________________

(Preparedness component)
Amount utilized (as of Dec. 31, 2020) : PhP ________________
In percent : ______%

● Fund appropriated for Gender and Development, CY 2019

Amount allocated : PhP ________________

Amount utilized (as of Dec. 31, 2019) : PhP ________________
In percent : ______%

● Fund appropriated for Senior Citizens and PWDs, CY 2019

Amount allocated : PhP ________________

Amount utilized (as of Dec. 31, 2019) : PhP ________________
In percent : ______%

● CY 2019 LCPC: Fund Appropriation

IRA amount : PhP ________________

Amount allocated for LCPC : PhP ________________
In percent : _____ %
 Department of the Interior and Local Government
CY 2021 Seal of Good Local Governance
(For Field Test Purposes Only)

● CY 2019 LCPC: Fund Utilization

Amount utilized (as of Dec. 31, 2019) : PhP __________________
In percent : ______%

● Utilization of fund appropriated for the conservation and preservation of cultural property,
CY 2019 (Cut-off: December 31, 2019)

Amount allocated for programs, projects and : PhP ________________

activities related to conserving and preserving
cultural property CY 2019
Amount utilized : PhP ________________
In percent : ______%

● Utilization of fund appropriated for youth development, CY 2019 (Cut-off: December 31, 2019)

Amount allocated for programs, projects and : PhP ________________

activities related to youth development, CY 2019
Amount utilized : PhP ________________
In percent : ______%

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

Issued on ________th of ____________, 2021.

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
CY 2021 Seal of Good Local Governance Form P 2C
Budget Office
(For Field Test Purposes Only)

SGLG Form P 2C Budget Office

CERTIFICATION

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 2021 Annual Budget and CY 2021 Annual Investment Program.

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

Issued on ________th of ____________, 2021.

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
CY 2021 Seal of Good Local Governance Form P 2D
(For Field Test Purposes Only) DepEd Representative

SGLG Form P 2D DepEd Representative

CERTIFICATION
This is to certify that the Local School Board (LSB) Plan for CY 2019 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: ____________

Moreover, the Local School Board met at least once in:

CY 2020 CY 2021
☐ July ☐ January
☐ August ☐ February
☐ September ☐ March
☐ October
☐ November
☐ December

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

Issued on ________th of ____________, 2021.

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
CY 2021 Seal of Good Local Governance
(For Field Test Purposes Only) Form P 2E
DILG Field Office

SGLG Form P 2E DILG Field Office

CERTIFICATION

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

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 ____________, 2021.

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
CY 2021 Seal of Good Local Governance Planning and Dev’t Office
(For Field Test Purposes Only)

SGLG Form P 2H Planning and Development Office

CERTIFICATION

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

A. 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

B. Report on PPAs Completion

(Cut-off: December 31, 2019)

PPAs Percent Completion (in %)

CY 2019 GAD Plan’s PPAs

CY 2019 PPAs for Senior Citizens and PWDs

CY 2019 PPAs funded out of the 1% of IRA allocation for

the Local Council for the Protection of Children

This Certification is issued for the purpose of the Seal of Good Local Governance assessment.
Issued on ________th of ____________, 2021.

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
CY 2021 Seal of Good Local Governance Form P 2I
(For Pilot-testing Purposes Only) Local PNP Office/Station

SGLG Form P 2I Local PNP Office

CERTIFICATION

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

☐ The LGU has provided logistical support to the PNP Local Police Office in CY 2020.
Accordingly, the following are the forms of support given (please tick applicable choices only):
☐ Ammunition ☐ Police station
☐ Communication ☐ Supplies
☐ Vehicle ☐ Others (please specify): ________

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

Issued on ________th of ____________, 2021.

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
CY 2021 Seal of Good Local Governance
Treasurer’s Office
(For Pilot-testing Purposes Only)

SGLG Form P 2K Treasurer’s Office

CERTIFICATION

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

● Local revenue growth, CYs 2017 - 2019

Local revenue for:

CY 2017 : PhP _________________
CY 2018 : PhP _________________
CY 2019 : PhP _________________
Growth rate for:
From 2017 to 2018 : _____%
From 2018 to 2019 : _____%
Ave. growth : ______%

● 20% Component of Internal Revenue Allotment (Development Fund), CY 2019

Amount of IRA : PhP ________________

Amount allocated as Local Development Fund (LDF) : PhP ________________

Amount utilized out of LDF (as of Dec. 31, 2020) : PhP ________________

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

Issued on ________th of ____________, 2021.

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)