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
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
REPORT ON INVENTORY OF SUPPLIES AND MATERIALS
As of ___________
Barangay: ________________________ City/Municipal: ______________________
Tel. No. :________________________ Province: ___________________________
For which ______________________________________________is accountable, having assumed accountability on ______________________
(Name of Accountable Officer) (Official Designation) (Date of Assumption)
SHORTAGE/OVERAGE REMARKS
BALANCE PER CARD ON HAND PER COUNT
ARTICLE DESCRIPTION STOCK NUMBER UNIT OF MEASURE UNIT VALUE (Quantity) (Quantity) Quantity Value
Prepared by: Approved by:
________________________
Signature over Printed Name Signature over Printed Name Signature over Printed Name
Barangay Treasurer Punong Barangay or Representative Punong Barangay
Member, Inventory Committee Chairman, Inventory Committee
Date Date Date
Annex 39
REPORT ON INVENTORY OF PURCHASED PROPERTY AND EQUIPMENT
As at ______________, 20___
SK of Barangay: ________________________
City/Municipality: ______________________
Province: _____________________________
For which _______________________________, __________________ is accountable, having assumed such accountability on ___________________.
(Name of Accountable SK Official) (Official Designation ) (Date of Assumption)
Balance On Hand Shortage/Overage
Unit of Per PEC Per Count
Article Item Description Property No. Measurement Unit Cost (Quantity) (Quantity) Quantity Value Remarks
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10)
Prepared and Certified Correct by: Approved by:
_________________________ ___________________________ ___________________________ ____________________________
Signature over Printed Name Signature over Printed Name Signature over Printed Name Signature over Printed Name
Member, Inventory Committee Member, Inventory Committee Head, Inventory Committee SK Chairperson
Date:________________ Date:_________________ Date:___________________ Date:_________________
Report on Inventory of Property and Equipment
As of ________________________
Barangay: _________________________ City/Municipality: _______________________________
Tel. No.: __________________________ Province: _____________________________________
For which _________________________________ is accountable
(Name of Accountable Officer)(Official Designation)
Balance PEC On Hand per count Shortage/Overage
Article Description Property /ICS Number Unit of Measure Unit Value Remarks
(Quantity) (Quantity)
Quantity Value
Part A – Property and equipment covered by PAR
Part B – Property and equipment covered by ICS
Prepared by: Approved by:
________________________ ________________________ _____________________________
Signature over Printed Name Signature over Printed Name Signature over Printed Name
Barangay Treasurer Punong Barangay or Representative Punong Barangay
Member, Inventory Committee Chairman, Inventory Committee
____________________
Date
________________
Date
