Attachment 1 Fidelity Bond Application Form ‘Rerosuic oF THe PurLippnves craton No. 02 Date May 90,3023 EAGAWARAN NG PANARALAPL “TET a [KAWANIAN NG INGATANG-YAMAN pte (BUREAU OF THE TREASURY) ramet REQUEST FOR APPLICATION FOR BONDING AND/OR CANCELLATION OF FIDELITY BOND OF ACCOUNTABLE PUBLIC OFFICER nernicTonn | ASCOT FORICERRESRY ——taaROPPRSORRTDOS GOSS BF [Brehm [Cx] sew C]evem[-] emeeaatoracerom — Paanaemaaar Seca enc susan ‘DATE OF BIRTH (mmiadiyyyy) [Js PLACE OF BRT ° erauier ROSARIO CATE Tiewe Creme [I ‘cM STATUS. sucte [J] woowes fp contact Noon 08808289 1 few aDoRESS aresi2z0 (2 waseseo ] serasaren _ | simoeeanat tomatic 'e-MONTHLY INCOME (Salar afowances. business income andthe lie) [1 ESTWUATED WONTHICT EXPENSES 30,900.00 20.0000 2: Rave you ovr boon saprnea rom ba sanon ln anya ho fohowing modes: gration, "Siemere opped on ele ama, fenoton rot, can epee eteveneona epacer eas ea Cres Biro Fp ote atte |p rar RSS PTE SOS ei Peas aero ves Ce ee move caat "gia eat suum et Cnet CHARACTER REFERENCE ni rt te a sey en ty oat) oa mone Con AcT EET [CWRYORTAWRENCE N-TREK—— | POSER TE HAPOSOROON ——~eararrg | OMRON BREE TULAY 8 WAUGONON cAviTE ——esoaeeraTae PREGITA A REGINO i sais 15 | dociare tal the answer to be foregoing quoctons ao tue wo he best of my knowode and bel fay understand bat ony ‘representation made in this application and supporing documents shall cause the fing of atminsianvlerminal caea(¢) spsinat me, ‘Sovernmant ings 10 TIvcano TDitcerserPasspor Number | S7SeTzza7—— DetePine of teaoe ‘W1RRI201S HARRGONOON m._sieschneo mo sworw oosce ron Ok waeaan oon. : oe "OR TS7pie No, 602711 / THC, Cavite F-22 {BP LIFETIME No, 0388) MCLE Comp. No, 7-0011282[FAROONT OF RECOORTREA (6) Forms another valuables (1) ena Revenue Stings (2)Pestge anc omer Std Sock (home Reet (omen Forms ane vataies (2) Puete Funds (8 Claes MARAGONDON CAVITE, CAVITE (2)As Dstersing er Somer rece cece oT (2)As Saving Oar a (lest Oe (3S veins, Tine i. STATONDNISION (ac of asigament) Depo) (0 Put Propery fF TTLE OF rosmon on pescnation (Sievers (pe ona P_ ed (Prepon Pent Saran outs vann) “Tae [Bz DATE OF DERGNATON oR REBUT F ——— [Accounsasimy [Rae oF OFRCEGR AGENT — 7 ‘SAN MIGUEL 1A (CAPUTATAN), MARAGONOON CAVITE, CAVITE {LeU-BRGY) | st0RESS oF omc OR RGEEy ————— 1 wera Tora AMUN *——aee (1 te yea ee} a ormed ox aaeneT ano STATON fs wane oromicans ouc cLeve> fs Presa rosmov on oosouaron fz amount OF BOND [2-Risk NUMBER ano EFFECTITY DATE a] fon bare Or Revie Eaten Port [esrsetaton of on fm above account pbi offen ls AMOUNT OF BOND RECOMMENDED ‘31. THIS IS TO CERTIFY THAT, as Head of Agency of. fe = erie the trhfuness of {he answers ip the quesbons contained on the ‘a off fom afd found Wm cored salar Gan be somes artuness of ‘Potcanti 3 ste and conservative ik Hence, he undersigned recommenda approval and authorenis he annie 520,900.00 ee So recipes [ss AMOUNT OF BOND PREMIUM PAYABLE 7963.50 ‘This ist cot hat have careful avalunted tho request for ‘Filly Bond of tio above-mentioned acount pubic of. APPLICATION nexewa, [Jeancenaron