Attachment 2

(AGENCY LETTERHEAD)
Form 4: Annex E

LIST OF BONDED ACCOUNTABLE PUBLIC OFFICER/S

PREVIOUS YEAR'S DATA REMARKS

TYPE OF DESIGNATION AMOUNT
(e.g. Disbursing/ EFFECTIVITY DATE BOND IF FOUND GUILTY, WHAT IS
NAME OF PUBLIC OFFICER APPLICATION RISK NO. WITH PENDING
Collecting/Signing COVERAGE THE STATUS OF THE
From To ADMINISTRATIVE AND/OR
Officer) ACCOUNTABILITY BOND PREMIUM IMPLEMENTATION OF
CRIMINAL CASE (Yes or No)
( For Renewal) PENALTY?

Prepared by: Reviewed by: Certified and Approved by:

Signature over printed name Signature over printed name Signature over printed name
Position Position Designation of Authorized Official

Date: