; Form 3: Annex D
Fidelity Bond Application Form
sevuneeretimamme Genel
Eredar rritte so
EAVAAR A ety — ROGRNUMBER
(BUREAU OF THE TREASURY) _ 4
REQUEST FOR APPLICATION FOR BONDING AND/OR CANCELLATION OF
FIDELITY BOND OF ACCOUNTABLE PUBLIC OFFICER
WwSTRUCTIONS. 1 ACCOMPLISH THIS FORM CORRECTLY MARK APPROPRIATE BOXES] waTHeNeC "U™
rrr oF (FH wew [_] renewar CANCELLATION, please proceed [OLD mix nuMoen|
ana 10 tem Nos 24.32. For Renewal
cae |
RESURRECCION ROMEO mano
Ne — ee AB
ADDRESS |
07 TOMAS CLAUDIO ST. MAYBANCAL MORONG. RIZAL |
DATE OF BIRTH even) Ye PLAGE OF TH |
B31/1956 JMORONG RIZAL | |
sex rev aT SONTAGT MMDER |
ius (Crewe | swore Cowes fo sorssasass L —
=
8. EMAIL ADDRESS
130.382.664.000 (A nansvecl] serarareo
10. MONTHLY INCOME (Ssleriesalowances,business income and the lke) | 19, ESTIMATED MONTHLY EXPENSES
3283 60,000
12. Have you ever been sepsrated from the service In any ofthe following modes: reslgnaion, retirement, dropped fom the rll,
Sismistal. termination, end of term, irished contract oF phased out (abolition
thepubic or priate sector?
irs Ohno
tyes. ove dette: [RETIRED MATERIAL CONTROL OF SUPPERVISOR CENTRAL BANK OF THE Pit
Have yau ever Deen found guilty of criminal case balers ony
leourt?
ae
Cres pAxo
tyes, ve dota
Case Nols.
Dato Filed
1 of Casote
(CHARACTER REFERENCE (injvduol mut rot bo related upto the fourth dgroo by consanguinty or aft t appcant)
NAME ‘ADDRESS ‘CONTACT NUMBER
"MARK PHILIP F PALPALLATOC WORONG RIZAL 9357014109
PERLITAF MARCELINO [MORONG.RIZAL 9355147562
TRECHELL JOY R. PASTORPILL [MORONG.RIZAL 9353008830
1.
L
se.
| docare that the answor to the foregoing questions are tuo tothe best of my knowledge and botet. fully understand
‘that any msrepresentation made in this application and supporting dacuments shall cause the fing of
‘administratvelcnminal casa(s) against me
Government Issued 1D
{O/LicenvolPassoon Number
Date/Piace of esue
suescrasco aw snownnostwome nis LT DEC 2023 ana exronny rst
10 68 nested above
Doe. No. be;
Page No i
‘Book No, Liv;
Senes of
31, 2028
TOP
1.33 252/05-30-86
IBPLIFETINE HCNELE NOLO2322/0419-0IK4
Pago tore[AMOUNT OF ACCOUNTABTUTY Ti. NAME OF OFFICE OR AGENCY
amount o
AccoUMTAUTY [BARANGAY MAYBANCAL
(2) Pub Funds [78 ADDRESS OF OFFICE ORAGENGY |
(1) As Catectng Ofc nnn MANILA EAST ROAD MAYBANCAL
(2) As Disbursing Offcor i, ‘WORONG RIZAL
(914sSiqnng OFfcer jari.204 Tipit Frown
(6 Iovestment Offer (6S Investments) 20: STATIONIIVSION Pace of eanignment)
‘BARANGAY MAYBANCAL
(0) Public Property [1 THTLE OF POSITION OR DESIGNATION
(1) Invenores (per GRAM) P.
(2) Property, lant & Equirent Nat Book ae) BARANGAY CAPTAIN
|22, DATE OF DESIGNATION OR ASSUNPTIONOF |
|ACCOUNTABILITY
(6) Forms and other valuables
2023 NOVEMBER. 20
(1) rtemat Revenve Stamas e voor Ment ey
(2) Postage and otter Stamped Stock
(@) Oficial Recoint
(4) mers Fos and valuables
ras, BOND PERIOD COVERAGE
JZ] One (1) year
TOTAL AMOUNT Laas (2) woeyears
Thee 2) youre
THIS BLOCK TO BE FILLED ONLY IN CASE OF BOND CANCELLATION S59)
24. OFFICE OR AGENCY AND STATION
25, NAME OF OFFICERS TO BE RELIEVED 2. PRESENT POSITION OR DESIGNATION
Sarena Given ame uae Hane
[27 AMOUNT OF BOND 26, RISK NUMBER AND EFFEGTIITY DATE
2s, DATE OF RELIEF 30. CAUSE OF RELIEF
Yes Te ey
Fu ISIS TOCEN HET Innis rewa oF Ae OF Teoma ue
truthiuiness of te answers tothe questions contained on the Tave of his Torn and found tiem correct insofar as can be
ascertained and t 12 safe and conservative risk. Hence, the undersigned is recommending approval and
-Appicatiom fe Bonding
Ci new
Ey Renew
J cancataion of ond
ofthe stove accountable pubic coe.
Signglre over Prints Nome of Waa of tn
‘Roencyate Accomplished
THIS BLOCK TO BE FLLED BY BT OMY
'32, AMOUNT OF BOND RECOMMENDED [53, AMOUNT OF BOND PREMIUM PAYABLE
“This sto certly that Ihave carefully evaluated the request for appucarion [_] renewat. [_] CANCELLATION
‘of Fidolty Bond of the above-mentioned accountable public ofceF
Tae Spare BT Oar aForm 4: Annex €
| nae oF pusuc orncen
TYPE OF
Accounramusry
ROMEGH RESURRECOON
abe
Contedand Arpoved by:
eee
aria & Deagialon of Ravarass OaAnnex €
REVISED SCHEDULE OF PREMIUM RATES
1 CASH ACCOUNTABILITY
THINTAUM CASH MAXIMUM CASH
accountasiTy | accountaaity | AMOUNTOF BOND | BOND il
Zof their Tolal Gash | Bond Premium a
5,001.00 8,000.00 |" xseounabity | nore lose than PYG
3,007.00 42,000.00 9,000.00, 150.00
42,001.00 715,000.00 71,250.00 168.75
75,001.00 "18,000.00 13,500.00 202.50
18,001.00 21,000.00 16.750.00 251.25
21,001.00. 25,000.00 78,900.00 283.50
25,001.00. ‘30,000.00 22,500.00 337.60
'30,001.00. ‘35,000.00 26,250.00 393.75
35,001.00 40,000.00 30,000.00 450.00
40,001.00. 50,000.00) 37,500.00 562.50
50,001.00 (60,000.00 ‘45,000.00. 675.00
60,001.00 ‘80,000.00 {60,000.00 900.00
80,001.00 100,000.00 "75,000.00 7,125.00,
100,001.00 250,000.00 700,000.00 41,500.00
250,001.00 ‘500,000.00 225,000.00 3,375.00
'500,001.00 "750,000.00 360,250.00 5,253.75
750,001.00 77,000,000.00) ‘500,000.00 7,500.00
7,000,001.00 2,500,000.00 "750,000.00 71,250.00
2,500,001.00 5,000,000.00. 7,500,000.00 22,500.00
'5,000,001.00 25,000,000.00 3,500,000.00 500.00
25,000,001.00 "75,000,000.00 4,000,000.00 {60,000.00
75,000,001.00 100,000,000.00 ,000,000.00 "75,000.00
7100,000,001.00 '500,000,000.00 '8,000,000.00 120,000.00
'500,000,00.00 | 7,000,000,000.00 77,000,000.00
I! PROPERTY ACCOUNTABILITY
1. Property, Plant & Equipment (Net Book Value) 20% of ter Total Vlue | “age x 1.5% = Premium
2 iments ier GAS) otrarteavnee | 22 noi = Promum
Il FOR ACCOUNTABLE FORMS
a) Internal Revenue Stamp
'b) Postage and other Standard Stamped Stock | 10% of their Total Value
) Official Receipt Value Rounded Of =x 1.5% = Premium
4) Other Accountable Forms and Valuables to the nearest hundred