Form 3: Annex D

Fidelity Bond Application Form

REPUBLIC OF THE PHILIPPINES (Revision No. xxx Date xxxxx)
KAGAWARAN NG PANANALAPI
KAWANIHAN NG INGATANG-YAMAN RISK NUMBER
(to be accomplished by BTr Officer)
(BUREAU OF THE TREASURY)

REQUEST FOR APPLICATION FOR BONDING AND/OR CANCELLATION OF

FIDELITY BOND OF ACCOUNTABLE PUBLIC OFFICER

INSTRUCTIONS:
1. ACCOMPLISH THIS FORM CORRECTLY 3.MARK APPROPRIATE BOXES WITH CHECK "ü"
2. PRINT ENTRIES LEGIBLY IN CAPITAL LETTERS

TYPE OF NEW RENEWAL CANCELLATION, please proceed OLD RISK NUMBER:

APPLICATION:
to Item Nos. 24-32 For Renewal
1. NAME

Surname Given Name Name Ext. (e.g., Jr.) Middle Name

2. ADDRESS
BARANGAY CALABOGO SITIO AGPAYAO ROMBLON, ROMBLON 2X2 ID PHOTO
3. DATE OF BIRTH (mm/dd/yyyy) 4. PLACE OF BIRTH

5. SEX 7.CIVIL STATUS 8. CONTACT NUMBER

MALE FEMALE SINGLE WIDOWED

6. TIN 9. EMAIL ADDRESS

MARRIED SEPARATED
10. MONTHLY INCOME (Salaries,allowances,business income and the like) 11. ESTIMATED MONTHLY EXPENSES

12. Have you ever been separated from the service in any of the following modes: resignation, retirement, dropped from the rolls, dismissal,
termination, end of term, finished contract or phased out (abolition) in the public or private sector?

YES NO
If yes, give details:

13. a. Have you ever been found guilty of any administrative offense? b. Have you ever been found guilty of criminal case before any court?

YES NO YES NO
If yes, give details: If yes, give details:
Case No/s.
Date Filed:
Status of Case/s:

14. CHARACTER REFERENCE (Individual must not be related up to the fourth degree by consanguinity or affinity to applicant)
NAME ADDRESS CONTACT NUMBER

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 me.

Government Issued ID :
ID/License/Passport Number :
Date/Place of Issue : Signature over Printed Name /Date Accomplished

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

Doc. No. ;
Page No. ; Signature of Officer/Person Administering
Book No. ; Oath
Series of .

Page 1 of 2
17. AMOUNT OF ACCOUNTABILITY 18. NAME OF OFFICE OR AGENCY

AMOUNT OF
ACCOUNTABILITY

(a) Public Funds 19. ADDRESS OF OFFICE OR AGENCY

(1) As Collecting Officer P

(2) As Disbursing Officer
(3) As Signing Officer Municipality/City Province
(4) Investment Officer (GS Investments) 20. STATION/DIVISION (Place of assignment)

(b) Public Property 21. TITLE OF POSITION OR DESIGNATION

(1) Inventories (per GAAM) P
(2) Property, Plant & Equipment (Net Book Value)
22. DATE OF DESIGNATION OR ASSUMPTION OF
ACCOUNTABILITY

(c) Forms and other valuables

(1) Internal Revenue Stamps P Year Month Day

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

Two (2) years

TOTAL AMOUNT P

Three (3) years

THIS BLOCK TO BE FILLED ONLY IN CASE OF BOND CANCELLATION
24. 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

Year Month Day

31. THIS IS TO CERTIFY 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

Applicatiom for Bonding

New
Renewal

Cancellation of Bond

of the above accountable public officer.

Signature over Printed Name of Head of the Agency/Date

Accomplished

THIS BLOCK TO BE FILLED BY BTr ONLY

32. AMOUNT OF BOND RECOMMENDED 33. AMOUNT OF BOND PREMIUM PAYABLE

This is to certify that I have carefully evaluated the request for APPLICATION RENEWAL CANCELLATION
of Fidelity Bond of the above-mentioned accountable public officer.

Name & Signature of BTr Officer DATE

Page 2 of 2