REPUBLIC~OF THE PHILIPPINES Grwmma. Fora No. 67 (A) (Revised March 24, 1976) (ity oF Province) REQUEST FOR BONDING AND/OR CANCELLATION OF BOND OF ACCOUNTABLE OFFICIALS AND EMPLOYEES OF ‘THE REPUBLIC OF THE PHILIPPINES {. NAMB OF PERSON TO BE BONDED/WHOSE BOND 1S TO | 2 DESIGNATION OR TITLE OF POSITION BE CANCELLED Surname Given Middle ‘& DATE INCOMING OFFIGHR ASSUMES ACCOUNTABILITY Year Month Day 7 STATION Municipality Provinee/City 5 AMOUNTS OF MAXIMUM ACCOUNTABILITY /CUSTODY — (When extent or character of an Offesr's control lover funds or property cannot be inferred from the tle or designations given, a full and complete statement Jof duties should be given above, (Use additional shect if necessary). (a) Public Fonds () As Colleeing Officer (2) As Disbursing Offcer (b) Public Property (1) Supplies & Materials (2) Equipment. ~(8) Others (e) Forms and other valuables (1) Internal Rev, Stamps (2) Internal Rev. Dec. Stamps (3) Customs Doc, Stamps (4) Postage and other Stamped Stock (5) Science Stamps (8) Cash Tickets (1) Others Total Amout 6. SALARY ATTACHED TO THE POSITION (In ease of temporary appointment or designation, Jaalary or permanent and temporay incumbent. should be stated). 1. BOND RECOMMENDED 8. BOND FILED BY LAW OR BY THE CHAIR- MAN, COMMISSION ON AUDIT PERSONAL RECORD OF PERSON TO BE BONDED (Use additional tor separate sheeta if neessary) (A) PREVIOUS EXPERIENCE |__@) CRIMINAL OR ADMINISTRATIVE RECORD (2HIS BLOCK TO BE FILLED ONLY IN CASH OF BOND CANCELLATION) 70, NAME OF OFFICER TO BE RELIEVED ii, PRESENT TITLE OR DESIGNATION ‘Sormame Given middle 42, AMOUNT OF BOND AND RISK NUMBER IN FORCE| 13. SALARY OF PERSON TO BE RELIEVED i DATE OF BELIEF 35. CAUSE OF RELIEF Year Month Day. | 16, REMARKS Head of Agency or Office City Mayor Of Provincial Treasurer se4964‘NUIGQY NO NOISSIFENOD ‘NYREIVED oy Jo Ayzomny 4g ee —g ju Gmoue om UF pexy pre poroudde sf uomsod pauonueuruiqa em soy puog ‘eyueR ‘somrddryg ey} Jo Jernsvery, ey 0} peprwAzoy AYIN;pedsey TOaNseOL, [UOUPAOL ae somewaly, £119 rope neomng, ‘wsonbor Ung om Jo 2 wy UT pasodosd prog oT Jo peAcudde Supuoumoser ‘epue yy ‘soulddy yA ayy Jo roINswaXy, ay} O} ‘oypny 4719 20 yeouraorg ‘nuaing oy} YSnom ‘pepreMsoy Apes, ve6rr0 Curia omy 70 sernswoxy, om 44 wy POG 94 94 7G) (GALIOMAas 98 OL MLVG) (uo 40 sONTAOU ‘avaHoE) (NoILWNOISI@) SANIAArTINE AHL 20 OrTanaTH SHE. JO SITAOALA GNV STVIOISIO TIEVINNOIOV dO GXO@ JO NOLLVTTIONVD 4O/UNY DNIGNOS 205 asandaa