Fidelity Bond Application Form (FBAF)

REQUEST FOR APPLICATION FOR BONDING AND/OR CANCELLATION OF FIDELITY BOND OF ACCOUNTABLE PUBLIC OFFICER
PERSONAL INFORMATION: PLEASE WRITE LEGIBLY AND CLEAR SO OTHERS COULD READ IT
MAKE SURE THAT ALL FIELDS ARE PROPERLY/CORRECTLY FILLED-UP
1. NAME OF OFFICIAL

Given Name
Name Extension JR./SR.
Middle Name
Surname
2. ADDRESS
Purok/Street/Bldg./Unit
Barangay
Province
City/Municipality

3. DATE OF BIRTH MONTH/DAY/YEAR - 09/10/1981

4. PLACE OF BIRTH

5. GENDER 6. TIN #
7. CIVIL STATUS 8. CONTACT NUMBER
9. EMAIL ADD VERY IMPORTANT: MAKE SURE THE USER COULD OPEN IT
10. MONTHLY INCOME
11. ESTIMATED MONTHLY EXPENSES
12. Have you ever been separated from YES OR NO
the service in any of the following
modes: resignation, retirement,
dropped from the rolls, dismissal, If YES, give details here
termination, end of term, finished
contract or phased out (abolition) in
the public or private sector?

13a. Have you ever been found guilty YES OR NO

of any administrative offense? If YES, give details here

13b. Have you ever been found guilty YES OR NO

of criminal case before any court? If YES, give details here

CASE Nos:
DATE FILED
STATUS OF CASE
14. THREE CHARACTER REFERENCE:
NAME ADDRESS CONTACT NUMBER

15. DECLARATION:
GOVERNMENT ISSUED ID : Passport, GSIS UMID, Drivers License, SSS, PHIC, TIN Card,
Postal ID, Voters ID, PRC Card, Senior Citizen ID,OFW ID
ID CARD NUMBER
DATE ISSUED MONTH/DAY/YEAR - 09/10/1981
PLACE ISSUED
DATE ACCOMPLISHED MONTH/DAY/YEAR - 09/10/1981

BOND PERIOD COVERAGE 1 YEAR/2 YEARS/3 YEARS - BEFORE PUTTING 2 OR 3 YEARS

THE AGENCY SHOULD ASK THEIR AGENCY AUDITOR IF OKAY
AMOUNT OF ACCOUNTABILITY:
PUBLIC FUNDS
### 1. Annual Budget/IRA 2021 Annual Budget/IRA 2021

SUMMARY:

NAME OF OFFICE OR AGENCY: ADDRESS OF OFFICE OR AGENCY:

AGENCY NAME For NGA's - indicate th
ADDRESS/LOCATION your agency and a
TITLE OF POSITION OR DESIGNATION:
POSITION DATE OF ASSUMPTION MONTH/DAY/YEAR
2ND POSITION -09/10/1981
ndicate the name of
ncy and address