Attachment A

AGENCY LETTERHEAD

LIST OF ACCOUNTABLE PUBLIC OFFICERS

(FOR NEW APPLICANTS)

PREFERRED BOND REMARKS

AMOUNT OF
NAME OF PUBLIC OFFICER DESIGNATION COVERAGE (1, 2 or 3 (WITH/WITHOUT PENDING CASE,
ACCOUNTABILITY
YEARS) STATE NATURE OF CASE)

Prepared by: Certified and Approved by:

Signature over printed name Name & Designation of Authorized Officical