Attachment 1
Fidelity Bond Application Form
‘Rerosuic oF THe PurLippnves craton No. 02 Date May 90,3023
EAGAWARAN NG PANARALAPL “TET a
[KAWANIAN NG INGATANG-YAMAN pte
(BUREAU OF THE TREASURY) ramet
REQUEST FOR APPLICATION FOR BONDING AND/OR CANCELLATION OF
FIDELITY BOND OF ACCOUNTABLE PUBLIC OFFICER
nernicTonn | ASCOT FORICERRESRY ——taaROPPRSORRTDOS GOSS BF
[Brehm [Cx] sew C]evem[-] emeeaatoracerom — Paanaemaaar
Seca enc susan
‘DATE OF BIRTH (mmiadiyyyy) [Js PLACE OF BRT °
erauier ROSARIO CATE
Tiewe Creme [I
‘cM STATUS.
sucte [J] woowes
fp contact Noon
08808289
1
few aDoRESS
aresi2z0 (2 waseseo ] serasaren _ | simoeeanat tomatic
'e-MONTHLY INCOME (Salar afowances. business income andthe lie) [1 ESTWUATED WONTHICT EXPENSES
30,900.00 20.0000
2: Rave you ovr boon saprnea rom ba sanon ln anya ho fohowing modes: gration,
"Siemere opped on ele ama,
fenoton rot, can epee eteveneona epacer eas ea
Cres Biro
Fp ote atte
|p rar RSS PTE SOS
ei Peas aero
ves Ce ee
move caat "gia
eat
suum et Cnet
CHARACTER REFERENCE ni rt te a sey en ty oat)
oa mone Con AcT EET
[CWRYORTAWRENCE N-TREK—— | POSER TE HAPOSOROON ——~eararrg |
OMRON BREE TULAY 8 WAUGONON cAviTE ——esoaeeraTae
PREGITA A REGINO i sais
15 | dociare tal the answer to be foregoing quoctons ao tue wo he best of my knowode and bel fay understand bat ony
‘representation made in this application and supporing documents shall cause the fing of atminsianvlerminal caea(¢)
spsinat me,
‘Sovernmant ings 10 TIvcano
TDitcerserPasspor Number | S7SeTzza7——
DetePine of teaoe ‘W1RRI201S HARRGONOON
m._sieschneo mo sworw oosce ron Ok
waeaan
oon. :
oe
"OR TS7pie No, 602711 / THC, Cavite F-22
{BP LIFETIME No, 0388)
MCLE Comp. No, 7-0011282[FAROONT OF RECOORTREA
(6) Forms another valuables
(1) ena Revenue Stings
(2)Pestge anc omer Std Sock
(home Reet
(omen Forms ane vataies
(2) Puete Funds
(8 Claes MARAGONDON CAVITE, CAVITE
(2)As Dstersing er Somer rece cece oT
(2)As Saving Oar a
(lest Oe (3S veins, Tine i. STATONDNISION (ac of asigament)
Depo)
(0 Put Propery fF TTLE OF rosmon on pescnation
(Sievers (pe ona P_ ed
(Prepon Pent Saran outs vann) “Tae
[Bz DATE OF DERGNATON oR REBUT F ———
[Accounsasimy
[Rae oF OFRCEGR AGENT — 7
‘SAN MIGUEL 1A (CAPUTATAN), MARAGONOON
CAVITE, CAVITE {LeU-BRGY)
| st0RESS oF omc OR RGEEy —————
1 wera
Tora AMUN *——aee
(1 te yea
ee}
a ormed ox aaeneT ano STATON
fs wane oromicans ouc cLeve> fs Presa rosmov on oosouaron
fz amount OF BOND
[2-Risk NUMBER ano EFFECTITY DATE
a]
fon bare Or Revie
Eaten
Port
[esrsetaton of on
fm above account pbi offen
ls AMOUNT OF BOND RECOMMENDED
‘31. THIS IS TO CERTIFY THAT, as Head of Agency of. fe = erie the trhfuness of
{he answers ip the quesbons contained on the ‘a off fom afd found Wm cored salar Gan be somes artuness of
‘Potcanti 3 ste and conservative ik Hence, he undersigned recommenda approval and authorenis he annie
520,900.00
ee So
recipes
[ss AMOUNT OF BOND PREMIUM PAYABLE
7963.50
‘This ist cot hat have careful avalunted tho request for
‘Filly Bond of tio above-mentioned acount pubic of.
APPLICATION
nexewa, [Jeancenaron