17. A M O U N T O F A C C O U N TA B IL IT Y 18.

N A M E O F O F F IC E O R A G E N C Y

A MOUNT OF
A C C O U N TA B IL IT Y

(a) P u b lic F u n d s 19. A D D R E S S O F O F F IC E O R A G E N C Y

(1) As Collecting Officer P

(2) As Disbursing Officer
(3) As Signing Officer M unicipality/C ity P rovince
(4) Investment Officer (GS Investments) 20. S TA T IO N /D IV IS IO N (P lac e o f as s ig n m e n t )

Form 3: Annex D
(b ) P u b lic P r o p e r t y
Fidelity Bond Application
21. T IT L E O F P O S IT IO N O R D E S IG N A T IO N
Form
REPUBLIC OF THE PHILIPPINES (Revision No. xxx Date xxxxx)
(1) Inventories (per GAAM) P
KAGAWARAN NG PANANALAPI
R IS K N U MB E R
KAWANIHAN NG INGATANG-YAMAN
(2) Property, Plant & Equipment (Net Book Value) (to be accom plished by B Tr O fficer)
(BUREAU OF THE TREASURY)
22. D A T E O F D E S IG N A T IO N O R A S S U M P T IO N O F
A C C O U N TA B IL IT Y

(c ) F o r m s an d o t h e r REQUEST
v alu ab le s FOR APPLICATION FOR BONDING AND/OR CANCELLATION OF
FIDELITY BOND OF ACCOUNTABLE PUBLIC OFFICER
(1) Internal Revenue Stamps P Ye ar M onth D ay
(2) Postage 1.
IN S T R U C T IO N S :
and other Stamped
ACCOMPLISH THISStock
FORM CORRECTLY 3.MARK APPROPRIATE BOXES WITH CHECK " ü"
(3) Official Receipt 23. B O N D P E R IO D C O V E R A G E
2. PRINT ENTRIES LEGIBLY IN CAPITAL LETTERS
(4) Others Forms and valuables
T YP E O F NEW RENEWAL C A N C E L L A T IO N , please proceed O L D R IS K N UOne
M B E R(1)
: year
A P P L IC A T IO N :
to Item Nos. 24-32 F or Renewal
1. N A M E Two (2) years
TO TA L A M O U N T P
S urnam e G iven Nam e Nam e E xt. (e.g., Jr.) M iddle Nam Three
e (3) years
2. A D D R E S S
T H IS B L O C K TO B E F IL L E D O N L Y IN C A S E O F B O N D C A N C E L L A T IO N
24. O F F IC E O R A G E N C Y A N D S TA T IO N 2X 2 ID P HO TO
3. D A T E O F B IR T H (mm/dd/yyyy) 4. P L A C E O F B IR T H

25.5.NSAEMXE O F O F F IC E R S TO B E R E L IE V E D7.C IV IL S TA T U S 8. C O26.

N TAP C
R TE SNEUNMTBPEORS IT IO N O R D E S IG N A T IO N

MALE FEM A L E S IN G L E W ID O W E D
6. T IN 9. E M A IL A D D R E S S
S urnam e G iven Nam e M iddle Nam e
27. A M O U N T O F B O N D M A R R IE D S E PA R A T E D 28. R IS K N U M B E R A N D E F F E C T IV IT Y D A T E
10. M O N T H L Y IN C O M E (S alar ie s ,allo w an c e s ,b u s in e s s in c o m e an d th e lik e ) 11 . E S T IM A T E D M O N T H L Y E X P E N S E S

29. D A T E O F R E L IE F 30. C A U S E O F R E L IE F
12. H av e y o u e v e r b e e n s e p ar ate d fr o m th e s e r v ic e in an y o f th e fo llo w in g m o d e s : r e s ig n atio n , r e tir e m e n t, d r o p p e d fr o m th e r o lls , d is m is s al,
te r m in atio n , e n d o f te r m , fin is h e d c o n tr ac t o r p h as e d o u t (ab o litio n ) in th e p u b lic o r p r iv ate s e c to r ?
Ye ar M onth D ay
Y ES NO
31. THIS IS TOgive
If yes, CERTIFY
details: THAT, as Head of Agency of _____________ ______________________________, I verified the truthfulness
of the answers to the questions contained on the face of this form and found them correct insofar as can be ascertained and that the
applicant is a safe and conservative risk. Hence, the undersigned is recommending approval and authorizing the request for
b . H av e y o u e v e r b e e n fo u n d g u ilty o f c r im in al c as e b e fo r e an y
13. a. H av e y o u e v e r b e e n fo u n d g u ilty o f an y ad m in is tr ativ e o ff e n s e ?
c o u r t?
Y ES NApplicatiom
O for Bonding Y ES NO
If yes, give details: New If yes, give details:
Renewal C as e N o /s .
D ate F ile d :
Cancellation of Bond
S tatu s o f C as e /s :
of the above accountable public officer.
14. C H A R A C T E R R E F E R E N C E (Individual must not be related up to the fourth degree by consanguinity or affinity to applicant)
NA ME A DDRESS C O N TA C T N U M B E R
Signature over Printed Name of Head of the Agency/Date
Accomplished

T H IS B L O C K TO B E F IL L E D B Y B Tr O N L Y
32. AM O UN T O F B O ND RECO M M END ED 33. AM O UN T O F B O ND PREM IUM PAYA B L E

15. I declare that the answer to the foregoing questions are true to the best of my knowledge and belief. I fully understand that any
misrepresentation made in this application and supporting documents shall cause the filing of administrative/criminal case(s)
against
This is to me.
certify that I have carefully evaluated the request for APPLICATION RENEWAL CANCELLATION
of Fidelity Bond of the above-mentioned accountable public officer.
Government Issued ID :
ID/License/Passport Number : of BTr Officer
Name & Signature DATE
Date/Place of Issue : Signature over Printed Name /Date Accomplished
Page 2 of 2

16. SUBSCRIBED AND SWORN to before me this_________________________, affiant exhibiting his/her validly issued Government
ID as indicated above.

Doc. No. ;
Page No. ; S ignature of O fficer/P erson Administering
Book No. ; O ath
Series of .

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