Attachment 1

Fidelity Bond Application Form

REPUBILIC OF THR PHILIPPINES (Reviaion No. 02 Date: May 30,2022)
KAOAWARAN NO PANANALAPI
KAWANIHAN NG INGATANO-YAMAN
RISK NUMBER
he ac tomplahed by AT ( e r
6 (BUREAU OF THR TRRAAURY)

REQUEST FOR APPLICATION FOR RONDING AND/OR CANCELLATION OF

FIDELITY BOND OF ACcOUNTABLE PUBLIC OF FICER
1 ACCOMPL ISH THIS FORM CORRFCNY
INSTRUCTIONS 3 MARK APROPRIAF ROXE
SITHCHFCK
pRINT NTRIES LFCIRLY IN CAPITAL LEITE RS
TYPE OF
APPLICATION:
|XNEW RENEWAL CANCELLATION, plea sepceed LDRRK NUMAER
o Item Nos. 2432 For Penawn
1. NAME
CARANATAN RICK PACLA
Suname Gen Ame NaneL(9. J
2. ADDRESS PUROK1 VLLABUENA SANTA MARIA ISARELA ISARELA

3. DATE OF BIRTH (mm'ddy) . PLACE OF BIRTH

11/20/2002 SANTAMARIA, ISABELA
Is. SEX 7.CIVIL STATUS 8. cONTACT NUMBER
XMALE FEMALE X SINGLE WIDOWED 9923773922
6. TIN 9. EMAIL ADDRESS
642522108
MARRED
10. MONTHLY INCOME (Salaries, allowances,business income and the like)
SEPARATED rlckcaranatan49Mgmail.com
11. ESTIMATED MONTHLY EXPENSES
6,000.00 6,000.00
12. Have you ever been separated from the service in any of the following modes: rosignation, retirement, dropped from the rolis, dismissal,
termination,end of term, finished contract or phased out (abolition) in the pubiic or private sector?
YES NO
Wyes give details

13. a. Have you ever been charged ol any administrative and/or criminal b. Have you over been found gully ol any administrative andior
offense? criminal case beforee aany administrative body, tribunal or court?
YES NO YES XNO
Myes, give details If yes, give details.:
Case Nols. Case Nols.
Date Filed: Date Filed:
Status of Case/s : Status of Casels:

14. CHARACTER REFERENCE (Ind1vidual must not be related up to the fourth degree by consanguinity or attinity ta applicant)
NAME ADDRESS CONTACT NUMBER
ANNALIZA C. FLORIDA BANGAD, SANTA MARIA 9953396583
JINKY M. FONTILLAS CALAMAGUIWEST, SANTA MARIA 9668625716
JUNAR L. LAGGUI VILLABUENA, SANTA MARIA 9664822899
15. Ideclare that the answer to the foregoing questions are true to the best of my knowiedge 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 me

Governent Issued ID TIN CARD

IDILicense/Passport Number 542-522-T08 RICK PACA CARANATAN /05/13/2024
Date/Place of Issue 02/08/2024 NAGUILI¤N Signalure over Prntud Name /Daw Accomplshed

16 SUBSCRIBED AND SwORN tO before me this ,affiant exhibiting his/her validiNssued Government
ID as indicated above.

Doc. No,
Page No. Signature of cer Per son Administeng
Book No
Series of
Page ol2
YESSALL"O
UNTIL DECEMBER 31,2024
RollNa d30
EPNa. 339192
PIRNo l4166303
MCLE Coinpliancu Nowiy Admittnd
17. AMOUNT OF ACCOUNTABILITY 18. NAME OF OFFIKCE OR AGENCY
VILLABUENA,SANTA MARIAISABELA, ISABELA
AMOUNT OF
ACCOUNTABILITY
(LGU BRGY)
19. ADDRE9S OF OFFICE OR AGENGY
(a) Public Funds
SANTA MARIAISABELA. ISABELA
(1) As Collecting Ofioer 0 00..
(2) As Disbursing Oficer 0 00 Prrvnra
(3) As Signing Officer 26,333.33 Mnicpaty ty
(4) Investment Oficer (GS Investments, Time
20.9TATION/DVISION (Place of assignment)
BARANGAY VILLABUENA
Deposits, etc ) 0.00..

21. TITLE OF POSTION OR CDESIGNATION

(b) Publie Property SANGGNIANG KABATAAN (K) CHAIRMAN
(1)Inventories (per GAAM) p
(2) Property, Plant &Equipment (Net Book Value)
000...
0 00
22 0ATE OF DESIKGNATION OR ASSUMPTION OF
ACCOUNTABILITY
(c) Forms and other valuables
2023 11 10

(1) Internal Revenue Slamps 000 Year Month Day

(2)Postage and other Stamped Stock 0 00
(3) Official Receipt 0.00 23. BOND PERIOD COVERAGE
0 00
(4)Others Forms and valuables
One (1) year

X| Two (2) years

TOTAL AMOUNT 26,333.33
Three (3) years
THIS BLOCK TO BE FILLED ONLY IN CASE OF BOND CANCELLATION
l24. OFFICE OR AGENCY AND STATION

25. NAME OF OFFICERS TO BE RELIEVED 26. PRESENT POSITION OR DESIGNATION

Surname Given Name MIddle Name

27. AMOUNT OF BOND 28. RISK NUMBER AND EFFECTIVITY DATE

29. DATE OF RELIEF 30. CAUSE OF RELIEF

Yea Month Day

VILUABUENA. SANTA MARIASABELA, ISABELAILGU-BRGY
31. THIS IS TO CERTIFY THAT, as Head of Agency of Iverified the truthfuiness 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

|XApplicatiom for Bonding

X New
Renewal

DCancelation of Bond
of the above accountable public officer. J¯NARLAGSt. D5/13/2024
AGENCY APPROVER
Signature over Printed Name of Head of the Agency.Dale
Accompl1shed
THIS BLOCK TO BE FILLEO BYBir ONY
32. AMOUNT OF BOND RECOMMENDED 33. AMOUNT OF BOND PREMIUM PAYABLE
22,500,00 675.00

This is to certify that ihave carefully evaluated the request for

of Fidelity Bond of the above-mentioned accountable public officer.
APPLICATION RENEWAL
cANCELuATION
Narne &Sgnaure of BTrOtfhcer DAIE

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