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Attachment B

AGENCY LETTERHEAD

LIST OF BONDED PUBLIC OFFICERS (FOR RENEWAL)


PREVIOUS YEAR'S DATA
NAME OF PUBLIC OFFICER DESIGNATION EFFECTIVE DATE RISK NO. AMOUNT BOND PREMIUM REMARKS (WITH/WITHOUT PENDING CASE, STATE NATURE OF CASE, if any)

From

To

Prepared by:

Certified and Approved by:

Signature over printed name

Name & Designation of Authorized Officical

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