Attachment 1
Fidelity Bond Application Form
RerunLIC OF THE PHILIPPINES (Werislon No. 02 Date! May 30,2029)
"KAGAWARAN NG PANANALAPI SR NOWBER
KAWARIHAN NG INGATANG-YAMAN—[Nlosseuntinty Brno
(QUREAU OF THE TREASURN)
REQUEST FOR APPLICATION FOR BONDING AND/OR CANCELLATION OF
FIDELITY BOND OF ACCOUNTABLE PUBLIC OFFICER
armucron 7 RSSOURLEN a FORICORRESTY __awaRcADOROBRATE ROHS LoJumoneoe -7™
MAGDARAOG ANASELLA MLLANUEVA
[roxTeoreRTH mann) [RPLADEOF TH
26/952 PANGANIGAN, CATANDUANES
TC wae Ti smcte CI woowen — [9106785103
390072061, 5 manico [] serazaren_| anabetlamsadaraogGgmailcom
fo-woxtncr NCOME (Soareralawancor busier come adie ine) [1 ESTIMATED MONTHLY ERFENSES
2365.00 10,00000
[Have you ever been separated rom te seve In ay ofthe folowing modes: reslgnstion,relremer, rapped Wom heals, asmissal
rmination, end of tar, Rrished contract or phased out (abaion inthe publi oF privat sector?
Cvs Gino
rye, ove eats
yes. ve oats (yes pve gens
Date Fs: Date Filed
4. CHARACTER REFERENCE (ns! mut ot be rele upto the orth cere by consanguinity fo appar)
NAME ‘ADDRESS. CONTACT NUMBER
TIRS-HRDILYR V. BORROWED, TATSUPANGANIBAN CANPUS (AESTEST
‘OR. RAMON F. SAMONTE ‘CATSU PANGANIGAN CAMPUS, lszurassr02
MRS ZELOAF. REYES (GATSU PANGANIGAN CAMBUS. 027178
15 | declare tal the anwer to the foregong questions are Vue to te best of my knowledge and Bele | uly understand that any
rmarepreseniaton made in the apptcalion and supportng documents shal cause te ting of axmintravesermnal case(s)
agate
Goverment ied 10 TWcARD,
(Ditiense’PacepertNumber —» Y9ONTZ05Y——
DotarPace of save DeBOOS RAC,
js amscracowosvonnnen men APR 19 2008
10 as nani above
nS
ae Se
Papen[FAWOURT OF RCCOUNTABITY FANE OF OFFICE OR AGEHCY
anne 'SUCS, CATANOUANES STATE UNIVERSITY
[ACCOUNTABILITY
pC
a. ADDRESS OF OFFICE OR AGENCY
VIRAG CATANOUANES (CAPITAL)
CATANDUANES
(2) Ponte Funas
(1) As Cotectng Ofer
(@)As Disbursing Ofer
{3)A8 Sing Otionr
Tine wnyay Prses
[20\STanIONDISION (Pace cTassignmen)
(CATANOUANES STATE UNIVERSITY-
PANGANIBAN CAMPUS,
(3) nvesimert Ofc (GS vestments Tire
Depoos, ec)
fa TTLE OF POSTTION OR DESIGNATION
(6) Putte Property
{i)lnvniones (ger GAAM)
{2} Property Pla 8 Equant et ace Ve)
[EE DATE OF DESIGNATION OR ASSUMPTION OF
(oFeme and tere:
a4 oO
(swan sae ba rn or
(Pose Same ec ———ts
Glow mene SoM prwornerconmer
(soe mrad aan i
Ee [EJ omcnyen
reenter —[7E FD wearer
[1 tre years
E “TS BLOCK TOBE FIED ORLY W CRS OF BOND CANCELLATION =)
fa OFFICE OR AGENCY ANO STATION
fas name OF OFFICERS TO BE RELIEVED Ps PRESENT POSTION OR DESIGNATION
fe AMOUNT OF BOND fs Risk NUMBER AND EFFECTIVITY DATE.
fs oATE OF RELIEF fo. CAUSE OF RELIEF
- CI ost
13. THISIS TO CERTIFY THAT, as Head of Agency of veri he tuanuness of
tbo anawers lo the questions contained on the facs GF Bis form and found them corock slat a can be ascertained and bat the
‘ppleantis a eale amd contentve risk Hance, the undersigned i recommending approval and authoring the request fr
esa
oe
eS
of ave accountable pb oe
2, AMOUNT OF BOND RECOMMENDED fs, AMOUNT OF BOND PREMIUM PAYABLE
NY 750,000.00 11,250.00
This so cory that have carly evaluated th request for Jappuicarion [_] Renewar [_]canceLiaTion
Felt Bond of he above-mentioned accountable puble ft
PapeTeT
“Name of Office: State Universities and Colleges (SUCs), Catanduanes State University, Catanduanes State University
LIST OF BONDED ACCOUNTABLE PUBLIC OFFICERS
PREVIOUS YEAR'S DATA REMARKS
WITH PENDING. | FOUND Gun
see oF DESIGNATION EFFECTIVE DATE amount 80ND UL,
NAME OF PUBLIC OFFICER. kterningrootecthey RISK No. coverace | AMMstRaTve | WHATIS THE
[APPLICATION fom ] Te STATUS OF THE
‘Signing ome) {ANOVOR CRIMINAL
Accountasuy| sono | PREMIUM IMPLEMENTATION
For renewal CASE(Yes oN) | op penaLrv?
WAGOARAOG ANABELLA x (camer 200.0000] rsooonco] 1928000] tym xO Not apples
VULANUEVA
Totals [ Zacaseeno] —reomnono] 1128020
Prepared By: Reviewed 8 Certied and Approved By:
ee
retcuefl o jrempronuevo
Senior Admin. Asst I
‘Signature over printed name
Postion
Date: _08/03/2023,
af
AON SAiOnTe, PH
ofan charge
Sihatue over ped ame
Postion
|=e
PATRICK RLAIN T. AZANZA, PH.D,
Signatbre over printed name
Designation of Authorized OfficialDepartment of Finance
BUREAU OF THE TREASURY
Region V - Bicol
Regional Office
Transmittal No,__0520-2022-04-00198
120/202;
——§ “Bi 2—$
CONFIRMATION LETTER
The SUC President I
‘State Universities and Colleges (SUCs)
Catanduanes State Universty-08053 - 080530000000
Virac Catanduanes
Sir/Madam:
This is to inform you that the request for bonding and/or cancellation of bonds of the following accountable
offcisis and employees of your Ofice! Agency has been approved and duly entered in the Registry of Bonded
Public Officers maintained by Catanduanes Offce of this Bureau
istics Prownetal Offes)
Name and position of Bonded |g tign RiskNo, {APProved Amount| Effective Date
Public Officers efBOND jrding | Cancelation
NAGOARAOG, ANABELLAV | CATANDUANES | 0530-202 00253H 750,000.00] 0471872022 | oarTarzoz3
Bong cowrage:1 ys) UNIVERSITY.PaN
Anan
‘CAMPUS,
The bond shall be renewed on or before the anniversary date, otherwise bond is automatically cancelled.
Please notify this Office if there are changes in accountable officers or amount of accountability within the
effective period of the bond.
Very truly yours,
ROSALIA V. DE LEON
Treasurer of the Philippines
By:
ROSSM BELMONTE A Resi t
Rosai BE ce: COA Resident Auditor