Department of the Interior and Local Government

CY 2021 Seal of Good Local Governance Form CM 2A

Accounting Office
(For Field Test Purposes Only)

SGLG Form CM 2A Accounting Office

CERTIFICATION

This is to certify that the City/Municipality of _______________________________ has the

following (please supply required information; Note that utilized funds refer to disbursed funds.):

● Utilization of Performance Challenge Fund

Total amount received Amount utilized Percent-
utilization
CY 2018 PhP ________________ PhP ________________ __________ %
(Cut-off: Dec. 31, 2020)
CY 2019 PhP ________________ PhP ________________ __________ %
(Cut-off: June 30, 2021)

Remarks:
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

 Utilization of funds from Assistance to Municipalities (formerly Bottom-Up Budgeting/Assistance to

Disadvantaged Municipalities; DILG-managed funds only) (Cut-off: December 31, 2020)

Total amount received Amount utilized Percent-

utilization
CY 2017 PhP __________________ PhP ____________________ _____%
CY 2018 PhP __________________ PhP ____________________ _____ %
CY 2019 PhP __________________ PhP ____________________ _____ %

Remarks:
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

 CY 2020 LDRRM Fund: Appropriation

Estimated revenue from regular sources : PhP ___________________
Amount allocated for LDRRMF CY 2020 : PhP ___________________
In percent : _____ %

● CY 2020 LDRRM Fund: Utilization of the 70% component for Preparedness (Current Fund)
Amount allocated for LDRRMF CY 2020 : PhP ___________________
(Preparedness component)
Amount utilized (as of Dec. 31, 2020) : PhP ___________________
In percent : ______%
 Department of the Interior and Local Government
CY 2021 Seal of Good Local Governance
(For Field Test Purposes Only)

● Fund appropriated for Gender and Development, CY 2019

Amount allocated : PhP __________________
Amount utilized (as of Dec. 31, 2020) : PhP __________________
In percent : ______%

● Fund appropriated for Senior Citizens and PWDs, CY 2019

Amount allocated : PhP ___________________
Amount utilized (as of Dec. 31, 2020) : PhP ___________________
In percent : ______%

● CY 2019 LCPC: Fund Appropriation

IRA amount : PhP ___________________
Amount allocated for LCPC : PhP ___________________
In percent : ______%

● CY 2019 LCPC: Fund Utilization

Amount utilized (as of Dec. 31, 2020) : PhP ___________________
In percent : ______%

● Utilization of funds from Provision of Potable Water Supply-Sagana at Ligtas na Tubig sa Lahat
(SALINTUBIG) projects (Cut-off: December 31, 2020)

Total amount received Amount utilized Percent-

utilization
CY 2016 PhP __________________ PhP ____________________ _____%
CY 2017 PhP __________________ PhP ____________________ _____ %
CY 2018 PhP __________________ PhP ____________________ _____%
CY 2019 PhP __________________ PhP ____________________ _____ %

Remarks:
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

● Utilization of fund appropriated for the conservation and preservation of cultural property,
CY 2019 (Cut-off: December 31, 2019)

Amount allocated for programs, projects and : PhP ___________________

activities related to conserving and preserving
cultural property CY 2019
Amount utilized : PhP ___________________
In percent : ______%
 Department of the Interior and Local Government
CY 2021 Seal of Good Local Governance
(For Field Test Purposes Only)

● Utilization of fund appropriated for youth development, CY 2019 (Cut-off: December 31, 2019)

Amount allocated for programs, projects and : PhP ___________________

activities related to youth development, CY 2019
Amount utilized : PhP ___________________
In percent : ______%

This Certification is issued for the purpose of the Seal of Good Local Governance assessment.

Issued on ________th of ____________, 2021.

Certified by: Attested by:

______________________________________ ______________________________________
Signature over Printed Name Signature over Printed Name
City/Municipal Accountant City/Municipal Mayor

Official Release of this Certification

(Please affix official LGU stamp below)
 Department of the Interior and Local Government
Form CM 2B
CY 2021 Seal of Good Local Governance Business Permit and Licensing Office
(For Field Test Purposes Only) (BPLO)

Seal of Good Local Governance

Form CM 2B Business Permit and Licensing Office

City/Municipality of : Income Class :

Province : Region :
INSTRUCTIONS
For the C/MLGOO:
(1) Ask the BPLO for the month and day of CY 2021 1st quarter with the highest volume of transaction for business permits for both new and renewal.
(2) Review database, record book or copy of application forms.
(3) Get sample transactions, at least 50% each for new business and renewal. Maximum number of samples for each is 50.
(4) Record the samples and their processing time.

PROCESSING TIME IN ISSUING A BUSINESS OR MAYOR’S PERMIT

New Business Business Renewal
Date (month and day) with _______________________ Date (month and day) with _______________________
highest volume of transaction for highest volume of transaction for
business permits business permits
Total number of transactions _______________________ Total number of transactions _______________________

Sample Transactions:
Not more than 2 working days Not more than 1 working day
Application No. from application to release? Application No. from application to release?
Yes No Yes No
1. ☐ ☐ 1. ☐ ☐
2. ☐ ☐ 2. ☐ ☐
3. ☐ ☐ 3. ☐ ☐
4. ☐ ☐ 4. ☐ ☐
5. ☐ ☐ 5. ☐ ☐
6. ☐ ☐ 6. ☐ ☐
7. ☐ ☐ 7. ☐ ☐
8. ☐ ☐ 8. ☐ ☐
9. ☐ ☐ 9. ☐ ☐
10. ☐ ☐ 10. ☐ ☐
11. ☐ ☐ 11. ☐ ☐
12. ☐ ☐ 12. ☐ ☐
13. ☐ ☐ 13. ☐ ☐
14. ☐ ☐ 14. ☐ ☐
15. ☐ ☐ 15. ☐ ☐
16. ☐ ☐ 16. ☐ ☐
17. ☐ ☐ 17. ☐ ☐
18. ☐ ☐ 18. ☐ ☐
19. ☐ ☐ 19. ☐ ☐
20. ☐ ☐ 20. ☐ ☐
(Attach additional pages, if necessary.)

Notes: (1) For business renewals: If application is filed in the morning, permit is released on the same day; if application is filed in the afternoon, permit
is released on the morning of the following day. (2) For new business: Application filed on Day1 should be released not later than Day 3. (3)Weekends
not counted.
 Department of the Interior and Local Government
CY 2021 Seal of Good Local Governance
(For Field Test Purposes Only)

Summary of tracked economic data:

Economic Data 2019 2020

Total number of new businesses ________ ________
Total number of business renewals ________ ________
Capital investments derived from registered new businesses ________ ________
Employees derived from registered new businesses and business ________ ________
renewals

Collected by: Certified by:

_____________________________________________________ ______________________________________________________
Signature over Printed Name of C/MLGOO Signature over Printed Name of BPLO

Date: ______________________________ Date: ______________________________

Attested by:

______________________________________________
Signature over Printed Name
City/Municipal Mayor

Official Release of this Certification

(Please affix official LGU stamp below)
 Department of the Interior and Local Government
CY 2021 Seal of Good Local Governance Form CM 2C
(For Field Test Purposes Only) Budget Office

SGLG Form CM 2C Budget Office

CERTIFICATION

This is to certify that the City/Municipality of _______________________________ has budget

appropriation for (please tick available item(s)):

☐ Approved Local Disaster Risk Reduction and Management (LDRRM) Plan as integrated in CY
2021 Annual Budget and CY 2021 Annual Investment Program.

This Certification is issued for the purpose of the Seal of Good Local Governance assessment.

Issued on ________th of ____________, 2021.

Certified by: Attested by:

______________________________________ ______________________________________
Signature over Printed Name Signature over Printed Name
City/Municipal Budget Officer City/Municipal Mayor
Official Release of this Certification
(Please affix official LGU stamp below)
 Department of the Interior and Local Government
CY 2021 Seal of Good Local Governance Form CM 2D
(For Field Test Purposes Only) DepEd Representative

SGLG Form CM 2D DepEd Representative

CERTIFICATION

This is to certify that the Local School Board (LSB) Plan for CY 2019 of City/Municipality of
_______________________________ has the following status of implementation (Please supply required data):

_____ % of programs, project, and activities are completed; and

_____ % of the total amount appropriated to finance the LSB Plan is utilized.

Accordingly, the said Plan completed, or its fund utilized for, the following items (tick appropriate item(s)):

☐ Operation and maintenance of public schools

☐ Construction and repair of school buildings
☐ Facilities and equipment
☐ Educational research
☐ Purchase of books and periodicals
☐ Sports development
☐ Others. Please specify: ____________

Moreover, the Local School Board met at least once in:

CY 2020 CY 2021
☐ July ☐ January
☐ August ☐ February
☐ September ☐ March
☐ October
☐ November
☐ December

This Certification is issued for the purpose of the Seal of Good Local Governance assessment.

Issued on ________th of ____________, 2021.

Certified By:

_____________________________________________
Signature over Printed Name
DepEd Schools Division Superintendent/
designated Representative to LSB

Official Release of this Certification

(Please affix stamp of Records Section/Officer below)
 Department of the Interior and Local Government
CY 2021 Seal of Good Local Governance
(For Field Test Purposes Only) Form CM 2E
DILG Field Office

SGLG Form CM 2E DILG Field Office

CERTIFICATION

This is to certify that the City/Municipality of _______________________________ has (Please tick

available item(s)):
☐ GAD Plan and Budget for CY 2019 that has been reviewed and was found fully compliant in form
and content per PCW-DILG-DBM-NEDA JMC No.: 2016-01
☐ GAD Plan and Budget for CY 2019 that has been submitted to this Office for review

In addition, I confirm the correctness of the information/conditions contained in the attached

Documentation template.

This Certification is issued for the purpose of the Seal of Good Local Governance assessment.

Issued on ________th of ____________, 2021.

Certified by:

______________________________________
Signature over Printed Name
City/Municipal LGOO
Official Release of this Certification
(Please affix stamp of DILG RO/PO below)
 Department of the Interior and Local Government
CY 2021 Seal of Good Local Governance Form CM 2F
(For Field Test Purposes Only) DRRM Office

SGLG Form CM 2F Disaster Risk Reduction and Management Office

CERTIFICATION

This is to certify that the City/Municipality of ______________________________ has the following

(Please supply required data):

_____ % of barangays with approved Community-Based Disaster Risk Reduction and Management
(CBDRRM) Plans. Attached is the list of barangays with approved CBDRRM Plans; and

_____ % of barangays with Evacuation Guides.

This Certification is issued for the purpose of the Seal of Good Local Governance assessment.

Issued on ________th of ____________, 2021.

Certified By: Attested by:

_______________________________________ ________________________________________
Signature over Printed Name Signature over Printed Name
City/Municipal Risk Reduction City/Municipal Mayor
and Management Officer

Official Release of this Certification

(Please affix official LGU stamp below)
 Department of the Interior and Local Government
CY 2021 Seal of Good Local Governance
(For Field Test Purposes Only)

Form CM 2F (attachment)
DRRM Office

SGLG Form CM 2F Disaster Risk Reduction and Management Office (attachment)

Barangays with approved CBDRRM Plans

Period/years covered by
# Name of Barangay
CBDRRM Plan
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24

(Add rows or attach additional pages, if necessary.)

Total number of barangays: ______

Certified By: Attested by:

_______________________________________ ________________________________________
Signature over Printed Name Signature over Printed Name
City/Municipal Risk Reduction City/Municipal Mayor
and Management Officer

Official Release of this Certification

(Please affix official LGU stamp below)
 Department of the Interior and Local Government Form CM 2H
CY 2021 SGLG Assessment Planning and Dev’t Office

SGLG Form CM 2H Planning and Development Office

CERTIFICATION

This is to certify that the City/Municipality of ______________________________ has the following

(Please tick available condition(s) and/or supply required information):

A. On Presence of Illegal Dwelling Units (for cities only)

☐ Illegal dwelling units exist within LGU jurisdiction
* In case illegal dwelling units exist, reference document for housing, resettlement and relocation
programs of the LGU is:

☐ Approved City Shelter Plan

☐ Approved Resettlement and Relocation Action Plan
☐ Resettlement PPAs incorporated in CY 2019 Annual Investment Program
☐ None
Please indicate the percentage of accomplished CY 2019 targets: _______ %

B. Local tourism condition where:

☐ Income from tourism activities form part of the LGU’s main source of revenue
☐ Large segment of LGU’s population is employed in tourism activities
☐ Significant portion of the LGU’s fund is appropriated for the development of this industry

C. Report on PPAs Completion (Cut-off: December 31, 2019)

PPAs Percent Completion (in %)
CY 2019 GAD Plan’s PPAs
CY 2019 PPAs for Senior Citizens and PWDs
CY 2019 PPAs funded out of the 1% of IRA allocation for the Local
Council for the Protection of Children

This Certification is issued for the purpose of the Seal of Good Local Governance assessment.
Issued on ________th of ____________, 2021.

Certified By: Attested by:

________________________________________
__________________________________________
Signature over Printed Name Signature over Printed Name
City/Municipal Planning and Development Officer City/Municipal Mayor

Official Release of this Certification

(Please affix official LGU stamp below)
 Department of the Interior and Local Government Form CM 2I
CY 2021 SGLG Assessment Local PNP Office/Station

SGLG Form CM 2I Local PNP Office/ Station

CERTIFICATION

This is to certify that the City/Municipality of ______________________________ has undertaken the

following (Please tick applicable items only):

☐ The LGU has provided logistical support to the PNP Local Police Office/Station in CY 2020.
Accordingly, the following are the forms of support given (please tick applicable choices only):
☐ Ammunition ☐ Police station
☐ Communication ☐ Supplies
☐ Vehicle ☐ Others (please specify): _________________

☐The LGU has supported the organization of the Barangay Peacekeeping Action Teams, barangay
tanods, and/or any similar unit.
Relatively, the LGU has (please supply required data):
_____% of barangays with organized BPATs, barangay tanods and/or similar unit; and
_____% of the barangays with trained BPATs, barangay tanods and/or similar unit.

☐ LGU statistics on crime are as follows:

CY 2019 CY 2020
Index _________________ _________________
Non-Index _________________ _________________
Total crime volume _________________ _________________

This Certification is issued for the purpose of the Seal of Good Local Governance assessment.

Issued on ________th of ____________, 2021.

Certified By:

__________________________________________
Signature over Printed Name
Chief, Local PNP Office/Station
Official Release of this Certification
(Please affix stamp of Records Section/Officer below)
 Department of the Interior and Local Government Form CM 2J
CY 2021 SGLG Assessment SWD Office

SGLG Form CM 2J Social Welfare and Development Office

CERTIFICATION

This is to certify that the City/Municipality of ______________________________ has (please supply the
following information):

_____ % of barangays have their respective violence against women and children (VAWC) desks

Submission of VAWC quarterly reports to the LSWDO for:

_____ % of barangays submitted for 1st Quarter CY 2020
_____ % of barangays submitted for 2nd Quarter CY 2020
_____ % of barangays submitted for 3rd Quarter CY 2020
_____ % of barangays submitted for 4th Quarter CY 2020

This Certification is issued for the purpose of the Seal of Good Local Governance assessment.

Issued on ________th of ____________, 2021.

Certified By: Attested by:

__________________________________________ ________________________________________
Signature over Printed Name Signature over Printed Name
City/Municipal Social Welfare and City/Municipal Mayor
Development Officer
Official Release of this Certification
(Please affix official LGU stamp below)
 Department of the Interior and Local Government Form CM 2K
CY 2021 SGLG Assessment Treasurer’s Office

SGLG Form CM 2K Treasurer’s Office

CERTIFICATION

This is to certify that the City/Municipality of ______________________________ has (please supply the
following information):
● Local revenue growth, CYs 2017 - 2019

Local revenue for:

CY 2017 : PhP ______________________
CY 2018 : PhP ______________________
CY 2019 : PhP ______________________
Growth rate for:
From 2017 to 2018 : _____%
From 2018 to 2019 : _____%
Ave. growth : ______%

● 20% Component of Internal Revenue Allotment (Development Fund), CY 2019

Amount of IRA : PhP _____________________

Amount allocated as Local Development Fund (LDF) : PhP _____________________
Amount utilized out of LDF (as of Dec. 31, 2020) : PhP _____________________

This Certification is issued for the purpose of the Seal of Good Local Governance assessment.

Issued on ________th of ____________, 2021.

Certified By: Attested by:

________________________________________
__________________________________________
Signature over Printed Name Signature over Printed Name
City/Municipal Treasurer City/Municipal Mayor
Official Release of this Certification
(Please affix official LGU stamp below)
 Department of the Interior and Local Government Form CM 2L
CY 2021 SGLG Assessment Environment and Natural
Resources Office

SGLG Form CM 2M Local Environment and Natural Resources Office

CERTIFICATION

This is to certify that the City/Municipality of ______________________________ has (please tick

available conditions):
☐ No operating open/controlled dumpsite
☐ Operating controlled/open dumpsite, LGU/private entity-owned, used as waste disposal facility
☐ An LGU-owned and operated Sanitary Landfill (SLF)
☐ Forged partnership with a private entity for the use of a SLF as final waste disposal facility
☐ Temporary Residual Containment Area, pending completion of LGU’s own SLF construction
☐ Other means of that is officially recognized by DENR-NSWMC as an alternative to SLF (in this case, Proof
that said technology officially recognized by DENR-NSWMC must be hereto attached)

☐ Safe Closure and Rehabilitation Plan for controlled/open dumpsite that is (please tick applicable condition):
☐ Approved; Date of approval: __________________________
With percent-completion of: __________________________ as of
__________________________
☐ Currently being drafted with DENR’s technical assistance

This Certification is issued for the purpose of the Seal of Good Local Governance assessment.

Issued on ________th of ____________, 2021.

Certified By: Attested by:

__________________________________________ ________________________________________
Signature over Printed Name Signature over Printed Name
City/Municipal Environment and Natural Resources City/Municipal Mayor
Officer
Official Release of this Certification
(Please affix official LGU stamp below)