COYUITO HOUSE 119 CARLOS PALANCA, JR. ST.

LEGASPI VILLAGE MAKATI CITY

P.O. BOX 3831 CPO 1099 MANILA* TEL NOS. 8104916 TO 35* FACSIMILE 8102991

CO-SIGNER’S STATEMENT

Date: October 3, 2019

I am agreeable to sign with the applicant XYZ Group Inc.

covering the bond applied for him from the PRUDENTIAL GUARANTEE AND ASSURANCE
INC. in the amount of P442,633.27 in favor of ABC Corporation.
I am aware of the responsibility which I will assume in signing with XYZ Group Inc.
I am also aware that you rely on the truth of the following statements in the consideration thereof.

I authorized you to obtain such information as you may require concerning the statements
made hereunder and I agree that this document shall remain your property whether or not the
bond is granted.

(All the following questions must be fully answered - If none. state “None”.”Not Applicable” is not an answer)
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Name Grace Dela Cruz Passport no. ***
(Please print or type full name)
Business *** .Tel.No ***

Residence B1 L24 San Isidro Heights, RHE, Makati City Provincial Address

Salary, Wages per Year .........................................................................................................................***

Income from business, etc..............................................................................…......Amount per Year (P...................................................)

Marries/Single: *** Living with husband or wife: *** Number of dependents: ***
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If employed please state: If in business for self, please state:

Name of Employer: *** Firm or trade name: Construction

Address: *** Address.......................................................Tel.No..........................

Number of years with employer: *** Kind of Business......................................How long........................

Kind of Business of employer: *** Capital Invested...........................................P..................................

Position occupied by co-maker: *** Sole owner or partner.......................................................................

Previous Employer: *** Name..............................................Address.....................................

:
Address: *** Name..............................................Address.....................................
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Bank Accounts - Where Kept -
Current........................................................ Savings......................................................
SHARE OF STOCK OWNED
NAME OF ISSUING KIND NO.OF MARKET VALUE ENCUMBRANCES
cORPORATION SHARES IF ANY

REAL PROPERTIES OWNED

DESCRIPTION LOCATION AREA OF PRESENT VALUE ENCUMBRANCES
LAND

Life Insurance (Co.)......................................................................... Amount P...............................................

Co-Signer will state whether applicant is related to him and if so in what manner..........................................
Co-signer will state how long he has known the applicant...............................................................................
Co-signer will state whether he has ever been a borrower or co-maker on a personal note at any bank or
guarantor with other companies. If so, please state particulars........................................................................
............................................................................................................................................................................
Name of references:..................................................Address............................................................................
................................................Address.............................................................................
I affirm that each of the answers given to the foregoing questions is true and correct.

.......................................................................
(Signature of Co-Signer)