(DILG FORM)

ANNEX A.1.1
DOCUMENTARY REQUIREMENTS CHECKLIST
FALGU (Construction, Concreting, Rehabilitation, Repair, or
Improvement of Local Infrastructure)
REGION :
______________________________________________________
PROVINCE :
______________________________________________________
NAME OF LGU :
______________________________________________________

PROGRAM / PROJECT
Construction, concreting, rehabilitation, repair or improvement of any of the
following:
a. Local Roads and / or Bridges 🖵
b. Public Market 🖵
c. Slaughterhouse 🖵
d. Multi – purpose Buildings / Halls 🖵
e. Multi – purpose Pavements 🖵
f. Drainage Canals 🖵
g. Sea Wall / Rivel Wall 🖵
h. Water System including Level 1 stand alone water points 🖵
i. Evacuation Center 🖵
j. Public Park 🖵
k. Fish Port 🖵
l. Post-Harvest Facilities composed of Ice Plant and Cold Storage Facility 🖵

Project Title :
_____________________________________________________
Project Location :
______________________________________________________
Amount Requested :
______________________________________________________
Target Beneficiary :
______________________________________________________

FOR FUND RELEASE (Based on LBC 131):

 AVAILABILITY
DOCUMENTARY REQUIREMENTS REMARKS
YES NO
A. Signed request letter by the LCE stating the
following:
1. Program / Project Title;
2. Project Location, and
3. Amount 🖵 🖵

Note: If the request covers two (2) or more programs or projects,

list of programs/ projects in order or priorities shall be attached.
B. Duly notarized Omnibus Sworn Statement (OSS) –
Annex B1 🖵 🖵
C. Signed LGU Contact Details by the LCE – Annex
B2 🖵 🖵
D. Report on Fund Utilization and Status of Program /
Project Implementation – Annex C
🖵 🖵
Note: Applicable only if LGU is a recipient of FYs 2016 – 2020
LGSF – FA.
E. Certification attesting that the balances from FYs
2016 – 2019 LGSF – FA have already been
returned to the National Treasury.
🖵 🖵
Note: Applicable only if LGU is a recipient of FYs 2016 – 2019
LGSF – FA and has an unobligated balances.
F. Proof of reversion of unobligated balances (e.g.,
disbursement voucher / check, deposit slip, or
official receipt from BTr).
🖵 🖵
Note: Applicable only if LGU is a recipient of FYs 2016 – 2019
LGSF – FA and has an unobligated balances.

PROJECT IMPLEMENTATION (Based on LBC 131):

AVAILABILITY /
DOCUMENTARY REQUIREMENTS APPLICABILITY REMARKS
YES NO
A. Sanggunian Resolution endorsing the following 🖵 🖵
projects:
1. ______________________
2. ______________________
3. ______________________
 B. Approved Local Development Investment
Program highlighting the inclusion of the 🖵 🖵
proposed programs / projects.
C. Approved Annual Investment Program
highlighting the inclusion of the proposed 🖵 🖵
programs / projects.
D. Approved Detailed Engineering Design (DED)
with POW and Detailed Estimates.
🖵 🖵
Note: DED shall be in accordance with the design plan,
specifications and such other standards and policies of the
National Government.
E. Certification on Capability to Implement the
Program / Project issued by DPWH in case to
be implemented by Administration.
🖵 🖵
Note: As stipulated in Section 3 of Appendix 1 of R.A 9184
(Procurement Law)
F. No right-of-way issue
🖵 🖵
Note: Proof that there is no right-of-way issue shall be
attached.
G. Proof that the LGU has secured all the
necessary clearance or certification from
various National Agencies as prescribed by law 🖵 🖵
(e.g., ECC, CNC, Water Permit, NIPAS etc)
H. Project is not located in the following:
1. Privately-owned land;
2. Not in the critical geo-hazard areas or no-
build zones identified and/or certified by
MGB hazard map; 🖵 🖵
3. Within the territorial jurisdiction of the LGU.

Note: Proof that the project is not located in the above-

mentioned shall be provided by the LGU.

PROJECT EXECUTION:
Documentary Completeness and Accuracy (DCA) and Timeliness (T)

AVAILABILITY /
DOCUMENTARY REQUIREMENTS APPLICABILITY REMARKS
YES NO Actual Date
PRE-PROCUREMENT
 A. Notice of Authority to Debit
Account Issued (NADAI) 🖵 🖵
Note: Include NADAI No. in the Remarks.
B. Confirmation on the Receipt of
Fund. 🖵 🖵
C. Proof on the transfer of Fund to
LGU Trust Fund 🖵 🖵
Note: Per Section 3.17 of LBC 131
PROCUREMENT STAGE
YES NO TARGET ACTUAL
A. ITB Posting in PHILGEPS 🖵 🖵
B. Opening of Bids 🖵 🖵
C. Issuance of Notice of Award
(NOA) 🖵 🖵
D. Issuance of Notice to Proceed
(NTP) 🖵 🖵
PROJECT IMPLEMENTATION
A. Project Signboard per COA
Circular 2013-004 🖵 🖵
B. Request for Work Inspection. 🖵 🖵
C. Concrete Pouring Permit 🖵 🖵
D. Site Instruction 🖵 🖵
E. For Water Supply Projects, Water
Source Validation Certification
issued by the Municipal Engineer
indicating that the water source/s 🖵 🖵 N/A N/A
is/are feasible for supplying water
to the intended beneficiaries
F. Notice of Defects or Deficiencies 🖵 🖵
G. Certificate of Completion 🖵 🖵
AFTER DEFECTS AND LIABILITY PERIOD (DLP)
A. Certificate of Final Acceptance 🖵 🖵
B. Approved Annual Investment
Program highlighting the inclusion
of maintenance or repair cost as 🖵 🖵 N/A N/A
stated in the Omnibus Sworn
Statement of the LGU.
PROJECT EXECUTION:
Quality

 For this part, the Quality Assurance and Assessment Report (QAAR)
Tools shall be used in ensuring that the quality of the projects has been
monitored and compliance to National Government Standards as stated
in the Omnibus Sworn Statement of the LGU.

MONITORED BY:
_____________________________
MLGOO

_____________________________
PROVINCIAL ENGINEER

ACKNOWLEDGED BY:

_____________________________
LOCAL CHIEF EXECUTIVE / LGU REPRESENTATIVE