CO-SIGNER’S STATEMENT (2)

TO: STRONGHOLD INSURANCE CO., INC.

17th Floor Security Bank Centre
6776 Ayala Avenue, Makati City

PLEASE PRINT AND/OR TYPE ANSWER:

The undersigned hereby agrees to act as co-signer to __________________________________
in the amount of Ps.__________________________applied by _________________________________
in favor of ____________________________________________________________________________
NAME: _______________________________________AGE: ________NATIONALITY ________________
ADDRESS: (Res.) _______________________________________________Tel. No. __________________
(Office) ______________________________________________Tel. No. _________________
CIVIL STATUS: ____________________________ NAME OF SPOUSE: _____________________________
OCCUPATION: ____________________________INCOME:__________ANNUALLY/MONTHLY _________

IF EMPLOYED, PLEASE STATE:

NAME OF EMPLOYER: ____________________________TRADE NAME: ___________________________
ADDRESS: ______________________________________ ADDRESS:______________________________
TEL. NO. ________________NO. OF YEARS ________TEL. NO. ____________NO. OF YEARS __________
KIND OF BUSINESS: ____________________________KIND OF BUSINESS: _________________________
POSITION OCCUPIED: __________________________CAPITAL INVESTED: _________________________
NAME & DESIGNATION OF SUPERIOR: ______________TRADE REFERENCE: _______________________

(IF THE SPACE PROVIDED IS NOT ENOUGH, USE BACK HEREOF)

BANK ACCOUNTS:
CURRENT ACCOUNT: _____________________________________________________________
TIME AND/OR SAVINGS DEPOSITS: __________________________________________________

REAL ESTATE AND/OR PERSONAL PROPERTIES OWNED:

DATE AREA ASSESSED VALUE INCUMBRANCE
ACQUIRED LOCATION OF DESCRIPTION OF LAND LAND IMPROVEMENT AMOUNT PAID
________ _____________________ ________ _________________ _____________
________ _____________________ ________ _________________ _____________
LIFE INSURANCE: _________________________________AMOUNT______________________________
RELATIONSHIP WITH APPLICANT: __________________________________________________________
HOW LONG HAVE YOU KNOWN THE APPLICANT? _____________________________________________
HAVE YOU EVER BEEN A BORROWER OR CO-MAKER ON A PROMISSORY NOTE WITH ANY LENDING
INSTITUTION? (PLEASE EXCLUDED RELATIVE) ________________________________________________
NAME OCCUPATION ADDRESS
___________________________ ____________________ __________________________
___________________________ ____________________ __________________________
___________________________ ____________________ __________________________

The foregoing statement and representation are true and correct and made for the purpose of
including the STRONGHOLD INSURANCE CO., INC., to issue the bond applied for. This will also serve as
an authority for the said company to verify from the above-mentioned persons, bank and entities the
veracity of the above information I have declared.

__________________________
(Signature)

SIGNED IN THE PRESENCE OF:

___________________________________ ________________________________

REPUBLIC OF THE PHILIPPINES)

) S.S

SUBSCRIBED AND SWORN to before me this _________day of _____________________201_____ at the

__________________________________Affiant exhibiting to me his/her Community Tax Certificate No.
__________________________issued at _________________________on _______________________.

Doc. No. _______

Page No._______
Book No._______
Series of 2020.