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-utilizatio

n

CY 2019 Funds PhP ________________ PhP ________________ __________ %

(Cut-off: June 30, 2021)

If there are PCF grants received in CY 2018 and earlier, but have less than 100% utilization rate per
DILG-BLGD data, please specify their status as of June 30, 2021 below. (No need to fill out the table if
all earlier PCF grants have 100% utilization rate per DILG-BLGD data).

Total amount received Amount utilized Percent-utilizatio

n

CY 2015 PhP __________________ PhP ____________________ _____%

CY 2016 PhP __________________ PhP ____________________ _____ %

CY 2017 PhP __________________ PhP ____________________ _____ %

CY 2018 PhP __________________ PhP ____________________ _____ %

Remarks (e.g., CY 2018 PCF project completed and unexpended balances reverted back to National
Treasury as of June 30, 2021):

__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

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

Disadvantaged Municipalities; DILG-managed funds only) (Cut-off: December 31, 2021)

Total amount received Amount utilized Percent-utilizatio

n

CY 2020 Funds PhP ________________ PhP ________________ __________ %

(Cut-off: December 31, 2021
 If there are AM/BUB grants received in CY 2019 and earlier but have less than 100% utilization rate per
DILG-OPDS data, please specify their status as of December 31, 2021 below. (No need to fill out the
table if all earlier AM/BUB grants have 100% utilization rate per DILG-OPDS data).

Total amount received Amount utilized Percent-utilizatio

n

CY 2015 PhP __________________ PhP ____________________ _____ %

CY 2016 PhP __________________ PhP ____________________ _____ %

CY 2017 PhP __________________ PhP ____________________ _____%

CY 2018 PhP __________________ PhP ____________________ _____ %

CY 2019 PhP __________________ PhP ____________________ _____ %

Remarks (e.g., CY 2018 AM/BUB project completed and unexpended balances reverted back to
National Treasury as of December 31, 2021):

__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

● CY 2021 LDRRM Fund: Appropriation

Estimated revenue from regular sources : PhP ____________________

Amount allocated for LDRRMF CY 2021 : PhP ____________________

In percent : ___________ %

● CY 2021 LDRRM Fund: Utilization of the 70% component for Preparedness (Current Fund)
Amount allocated for LDRRMF CY 2021 : PhP ____________________
(Preparedness component)

Amount utilized (as of Dec. 31, 2021) : PhP ____________________

In percent : ____________ %

● Fund appropriated for Gender and Development, CY 2021

Amount allocated : PhP ____________________

Amount utilized (as of Dec. 31, 2021) : PhP ____________________

In percent : ___________ %

● Fund appropriated for Senior Citizens and PWDs PPAs, CY 2021

 Amount allocated : PhP ____________________

Amount utilized (as of Dec. 31, 2021) : PhP ____________________

In percent : ___________ %

● CY 2021 LCPC: Fund Appropriation

IRA amount : PhP ____________________

Amount allocated for LCPC : PhP ____________________

In percent : ___________ %

● CY 2021 LCPC: Fund Utilization

Amount utilized (as of Dec. 31, 2021) : PhP ____________________

In percent : ___________ %

● Funds appropriated for PPAs for Children, CY 2021

Amount allocated : PhP ____________________

Amount utilized (as of Dec. 31, 2021) : 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, 2021)

Total amount received Amount utilized Percent-utilizatio

n

CY 2019 PhP __________________ PhP ____________________ _____ %

CY 2020 PhP __________________ PhP ____________________ _____ %

If there are funds received for SALINTUBIG projects in CY 2018 and earlier but have less than 100%
utilization rate per DILG-OPDS data, please specify their status as of December 31, 2021 below. (No
need to fill out the table if all earlier grants have 100% utilization rate per DILG-OPDS data).

Total amount received Amount utilized Percent-utilizatio

n

CY 2015 PhP __________________ PhP ____________________ _____ %

CY 2016 PhP __________________ PhP ____________________ _____ %

CY 2017 PhP __________________ PhP ____________________ _____%

CY 2018 PhP __________________ PhP ____________________ _____ %

 Remarks (e.g., CY 2018 SALINTUBIG project completed and unexpended balances reverted back to
National Treasury as of December 31, 2021):

________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

● Utilization of fund appropriated for the conservation and preservation of cultural property,
CY 2021 (Cut-off: December 31, 2021)

Amount allocated for programs, projects and : PhP ____________________

activities related to conserving and preserving
cultural property CY 2021

Amount utilized : PhP ____________________

In percent : ___________ %

● Utilization of fund appropriated for youth development, CY 2021 (Cut-off: December 31, 2021)

Amount allocated for programs, projects and : PhP ____________________

activities related to youth development, CY 2021

Amount utilized : PhP ____________________

In percent : ___________ %

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

Issued on the _____ day of ____________, 2022.

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)
 SGLG Form CM 2B Business Permit and Licensing Office

City/Municipality of : ______________________________ Income Class : ___________

Province : ______________________________ Region : ___________

INSTRUCTIONS
For the DILG City Director or 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 20.
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 highest volume of transaction for
for business permits: _______________________ business permits: _______________________

Total number of transactions: _______________________ Total number of transactions: _______________________

Sample Transactions: Sample Transactions:

Not more than 3 working days Not more than 3 working days
Application No. from application to release? Application No. from application to release?

Yes No Yes No

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text. text.

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Notes: Application filed on Day 1 should be released not later than Day 3. Weekends not counted. Attach additional pages, if
necessary

Summary of tracked economic data:

Economic Data 2020 2021

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 Signature over Printed Name
City Director or C/MLGOO Business Permit and Licensing Officer

Attested by:

___________________________________
Signature over Printed Name
City/Municipal Mayor

Official Release of this Certification

(Please affix official LGU stamp below)
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
2022 Annual Budget and CY 2022 Annual Investment Program.

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

Issued on the _____ day of ______________, 2022.

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)

SGLG Form CM 2D DepEd Representative

CERTIFICATION

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

status of implementation (Please supply required data):

SEF Utilization/LSB Plan Completion

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

_____ % of the total amount appropriated to finance the LSB Plan (Special Education Fund) 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
☐ Implementation of the National Feeding Program for undernourished children in public day
care, kindergarten, and elementary schools
☐ Others. Please specify: ________________________

Local School Board Activities

The Local School Board met at least once in these months in CY 2021:

☐ January ☐ July

☐ February ☐ August

☐ March ☐ September

☐ April ☐ October

☐ May ☐ November

☐ June ☐ December
PPAs for CY 2022

The LGU has the following programs, projects, and activities (PPAs) in their Comprehensive Development Plan
or Investment Program that are aligned with the priority education reform areas determined by the DepEd SDO
through its Division Education Development Plan (DEDP) or School Improvement Plan (SIP) and Annual
Improvement Plan (AIP). (Please supply required data, leave blank if none)

Name of PPAs Reform Area Addressed? Contained in What Document?

(CDP, LDIP, AIP, or SEF Budget)

(Attach additional pages, if necessary.)

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

Issued on the ____ day of ____________, 2022.

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)
SGLG Form CM 2D.2 DepEd Representative (for Cities with DepEd City SDO)

CERTIFICATION

This is to certify that the City of _______________________________ has the following data (Please
supply required data based on your records):

Participation Rate / Net Enrollment Rate (in %)

● SY 2019 - 2020 ____________________

● SY 2020 - 2021 ____________________

Cohort Survival Rate (in %)

● SY 2019 - 2020 ____________________

● SY 2020 - 2021 ____________________

School Leaver Rate / Dropout Rate (in %)

● SY 2019 - 2020 ____________________

● SY 2020 - 2021 ____________________

Completion Rate (in %)

● SY 2019 - 2020 ____________________

● SY 2020 - 2021 ____________________

This Certification is issued for profiling purposes as part of the Seal of Good Local Governance and the
Local Governance Performance Management System program.
 Issued on the ____ day of ____________, 2022.

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)

SGLG Form CM 2D.3 DepEd Representative (for Cities with no DepEd City SDO, and Municipalities)
To be accomplished separately by ALL DepEd District Supervisors

CERTIFICATION

This is to certify that the DepEd District of _______________________________ has the following data
(Please supply required data based on your records):

Participation Rate / Net Enrollment Rate (in %)

● SY 2019 - 2020 ____________________

● SY 2020 - 2021 ____________________

Cohort Survival Rate (in %)

● SY 2019 - 2020 ____________________

● SY 2020 - 2021 ____________________

School Leaver Rate / Dropout Rate (in %)

● SY 2019 - 2020 ____________________

 ● SY 2020 - 2021 ____________________

Completion Rate (in %)

● SY 2019 - 2020 ____________________

● SY 2020 - 2021 ____________________

This Certification is issued for profiling purposes as part of the Seal of Good Local Governance and the
Local Governance Performance Management System program.

Issued on the ____ day of ____________, 2022.

Certified By:

_____________________________________________
Signature over Printed Name
DepEd Schools District Supervisor
Official Release of this Certification
(Please affix stamp of Records Section/Officer below)

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 2021

 ☐ Has been reviewed and was found fully compliant in form and content per PCW-DILG-DBM-NEDA
JMC No.: 2016-01
☐ Has been submitted to DILG for review
☐ No submission

GAD Plan and Budget for CY 2022

☐ Has been reviewed and was found fully compliant in form and content per PCW-DILG-DBM-NEDA
JMC No.: 2016-01
☐ Has been submitted to DILG for review
☐ No submission

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 the ____ day of ____________, 2022.

Certified by:

______________________________________

Signature over Printed Name

City Director or City/Municipal LGOO

Official Release of this Certification

(Please affix stamp of DILG RO/PO below)

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 the ____ day of ____________, 2022.

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)

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

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(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)

SGLG Form CM 2G Engineering Office

CERTIFICATION
This is to certify that the City/Municipality of ______________________________ has the following
(Please supply required data and photo documentation. You may add remarks for each photo.):

A. Local Government Building

Complete Address: _________________________________
Photo of the Ramp with the Grab Bars
Wide Angle Shot, showing whole ramp
*if no ramps, photo showing ground level
entrance/ dropped curb/ lift

Width (in meters): _____________

Other Remarks (if any):

________________________________

Photo of the Ramp with the Gradient Finder

Test (result should be shown)

Gradient: _____________

Other Remarks (if any):

_______________________________

Photo of the Ramp Flooring

Refer to Technical Notes Annex A

Flooring Material: ____________________

Slip-Resistance (if dry and unpolished)

☐ Very Good
☐ Good
☐ Fair
☐ Poor to Fair
☐ Very Poor to Fair
Slip-Resistance (if wet)
☐ Very Good
☐ Good
☐ Fair
☐ Poor to Fair
☐ Very Poor to Fair

Other Remarks (if any):

________________________________

Photo of the PWD CR (Wide Shot)

Must show the toilet with grab bar and wheelchair
inside

Refer to Technical Notes Annex A

Floor Area of the PWD CR: (in m2): ________

Has at least 2.25 m2 turning space with a

minimum dimension of 1.50m for
wheelchairs?
☐ Yes
☐ No

Other Remarks (if any):

________________________________

Photo of the PWD CR’s entrance

Width of the entrance (in meters): _________

Other Remarks (if any):

________________________________

Photo of the Flooring of the PWD CR

Refer to Technical Notes Annex A

Flooring Material: ____________________

Slip-Resistance (if dry and unpolished)

☐ Very Good
☐ Good
☐ Fair
☐ Poor to Fair
☐ Very Poor to Fair
Slip-Resistance (if wet)
 ☐ Very Good
☐ Good
☐ Fair
☐ Poor to Fair
☐ Very Poor to Fair
Other Remarks (if any):
________________________________

Photo of the Signages

(Directional and information signs showing the
location of ramps, elevator, PWD CRs)

________________________________

Photo of the Parking Space for PWDs

________________________________

Other PWD-friendly space/facility/equipment

(If any)

________________________________
B. Main Hospital/Health Facility
Name of Facility: __________________________________
Address: _________________________________________

Photo of the Ramp with the Grab Bars

Wide Angle Shot, showing whole ramp
*if no ramps, photo showing ground level
entrance/ dropped curb/ lift

Width (in meters): _____________

Other Remarks (if any):

________________________________

Photo of the Ramp with the Gradient Finder

Test (result should be shown)

Gradient: _____________

Other Remarks (if any):

_______________________________
Photo of the Ramp Flooring

Refer to Technical Notes Annex A

Flooring Material: ____________________

Slip-Resistance (if dry and unpolished)

☐ Very Good
☐ Good
☐ Fair
☐ Poor to Fair
☐ Very Poor to Fair
Slip-Resistance (if wet)
☐ Very Good
☐ Good
☐ Fair
☐ Poor to Fair
☐ Very Poor to Fair
Other Remarks (if any):
________________________________

Photo of the PWD CR (Wide Shot)

Must show the toilet with grab bar and wheelchair
inside

Refer to Technical Notes Annex A

Floor Area of the PWD CR: (in m2): ________

Has at least 2.25 m2 turning space with a

minimum dimension of 1.50m for
wheelchairs?
☐ Yes
☐ No

Other Remarks (if any):

________________________________
Photo of the PWD CR’s entrance

Width of the entrance (in meters): _________

Other Remarks (if any):

________________________________

Photo of the Flooring of the PWD CR

Refer to Technical Notes Annex A

Flooring Material: ____________________

Slip-Resistance (if dry and unpolished)

☐ Very Good
☐ Good
☐ Fair
☐ Poor to Fair
☐ Very Poor to Fair
Slip-Resistance (if wet)
☐ Very Good
☐ Good
☐ Fair
☐ Poor to Fair
☐ Very Poor to Fair
Other Remarks (if any):
________________________________

Photo of the Signages

(Directional and information signs showing the
location of ramps, elevator, PWD CRs)

________________________________
Photo of the Parking Space for PWDs

________________________________

Other PWD-friendly space/facility/equipment

(If any)

________________________________
C. LG-managed tertiary educational facility/technical vocational education and training center
Name of Facility: __________________________________
Address: _________________________________________

Photo of the Ramp with the Grab Bars

Wide Angle Shot, showing whole ramp
*if no ramps, photo showing ground level
entrance/ dropped curb/ lift

Width (in meters): _____________

Other Remarks (if any):

________________________________

Photo of the Ramp with the Gradient Finder

Test (result should be shown)

Gradient: _____________

Other Remarks (if any):

_______________________________

Photo of the Ramp Flooring

Refer to Technical Notes Annex A

Flooring Material: ____________________

Slip-Resistance (if dry and unpolished)

☐ Very Good
☐ Good
☐ Fair
☐ Poor to Fair
☐ Very Poor to Fair
Slip-Resistance (if wet)
☐ Very Good
☐ Good
☐ Fair
☐ Poor to Fair
☐ Very Poor to Fair
Other Remarks (if any):
________________________________
Photo of the PWD CR (Wide Shot)
Must show the toilet with grab bar and wheelchair
inside

Refer to Technical Notes Annex A

Floor Area of the PWD CR: (in m2): ________

Has at least 2.25 m2 turning space with a

minimum dimension of 1.50m for
wheelchairs?
☐ Yes
☐ No

Other Remarks (if any):

________________________________

Photo of the PWD CR’s entrance

Width of the entrance (in meters): _________

Other Remarks (if any):

________________________________

Photo of the Flooring of the PWD CR

Refer to Technical Notes Annex A

Flooring Material: ____________________

Slip-Resistance (if dry and unpolished)

☐ Very Good
☐ Good
☐ Fair
☐ Poor to Fair
☐ Very Poor to Fair
Slip-Resistance (if wet)
☐ Very Good
☐ Good
☐ Fair
☐ Poor to Fair
☐ Very Poor to Fair
Other Remarks (if any):
________________________________

Photo of the Signages

(Directional and information signs showing the
location of ramps, elevator, PWD CRs)

________________________________

Photo of the Parking Space for PWDs

________________________________

Other PWD-friendly space/facility/equipment

(If any)

________________________________
Other Remarks (if any)
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________

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

Issued on the _____ day of ____________, 2022.

Certified by: Attested by:

___________________________________ ___________________________________
Signature over Printed Name Signature over Printed Name
City/Municipal Engineer City/Municipal Mayor

Official Release of this Certification

(Please affix official LGU stamp below)
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 (Indicator for Cities only, but Municipalities are encouraged to
also fill this out)

☐ 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 2021 Annual Investment Program
☐ None

Please indicate the percentage of accomplished CY 2021 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, 2021)

PPAs Percent Completion (in %)

CY 2021 GAD Plan’s PPAs ____________

CY 2021 PPAs for Senior Citizens and PWDs ____________

CY 2021 PPAs funded out of the 1% of IRA allocation for the Local
____________
Council for the Protection of Children

CY 2021 PPAs for Children ____________

D. City/Municipal Average for Pupils’ Performance Indicators

This portion is ONLY applicable to municipalities and cities with no DepEd City SDO and have
multiple DepEd District Offices. Otherwise, leave this portion blank. Based on all the Certified Form
2D.3 from DepEd District Offices in your LGU, kindly compute the city/municipal average: Sum of the
Rate Recorded in each District Office / Number of District Offices
 Participation Rate / Net Enrollment Rate (City/Mun Average)

● SY 2019 - 2020 ____________________

● SY 2020 - 2021 ____________________

Cohort Survival Rate (City/Mun Average)

● SY 2019 - 2020 ____________________

● SY 2020 - 2021 ____________________

School Leaver Rate / Dropout Rate (City/Mun Average)

● SY 2019 - 2020 ____________________

● SY 2020 - 2021 ____________________

Completion Rate (City/Mun Average)

● SY 2019 - 2020 ____________________

● SY 2020 - 2021 ____________________

Remarks:

__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

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

Issued on the ____ day of ____________, 2022.

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)

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 2021.
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 2020 CY 2021

Index _________________ _________________

 Non-Index _________________ _________________

Total crime volume _________________ _________________

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

Issued on the ____ day of ____________, 2022.

Certified By:

__________________________________________
Signature over Printed Name
Chief, Local PNP Office/Station
Official Release of this Certification
Please affix stamp of Records Section/Officer below
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 (VAW) desks

Percentage of barangays with VAWC reports submitted to the LSWDO in CY 2021

Quarter % of Barangays with Submitted Report*

1st Quarter _____________

2nd Quarter _____________

3rd Quarter _____________

4th Quarter _____________

*In case the LGU adopted a monthly reporting system, the barangay should have
submitted reports for all the months in a quarter.

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

Issued on the _____ day of ____________, 2022.

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)
SGLG Form CM 2JA Social Welfare and Development Office
This must be submitted to the DSWD Field Office.

CERTIFICATION

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

Data on ECCD Service Providers (SP)

(Child Development Worker/Day Care Worker)

With Expired
Total Number of SP Accredited Not Accredited
Accreditation

___________ ___________ ___________ ___________

Data on ECCD Facilities

(Child Development Center/Day Care Center)

Total Number of With Expired

Accredited Not Accredited
Facilities Accreditation

___________ ___________ ___________ ___________

Issued on the _____ day of ____________, 2022.

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)
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 2018 - 2020

Local revenue for:

CY 2018 : PhP ______________________

CY 2019 : PhP ______________________

CY 2020 : PhP ______________________

Growth rate for:

From 2018 to 2019 : _____%

From 2019 to 2020 : _____%

Ave. growth : ______%

● 20% Component of Internal Revenue Allotment (Development Fund), CY 2020

Amount of IRA : PhP _____________________

Amount allocated as Local Development Fund (LDF) : PhP _____________________

% LDF Allocation out of the IRA : _______%

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 the ____ day of ____________, 2022.

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)

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):

Open/Controlled Dumpsite (if applicable)

☐ No operating open/controlled dumpsite
☐ Operates a controlled/open dumpsite, LGU/private entity-owned, used as waste disposal facility
☐ Has a 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

Access to Sanitary Landfill (SLF)

☐ Has an LGU-owned and operated Sanitary Landfill (SLF) (completed and operational)
☐ Has an LGU-owned Sanitary Landfill (SLF) being constructed
☐ Forged partnership with a government/private entity for the use of an SLF as final waste disposal facility
Name of Partner Entity/Facility: __________________________
☐ Operates a Temporary Residual Containment Area
☐ With proposed construction of an SLF, budgeted under the LGU’s Approved 10-Year SWM Plan
☐ Employs technology that addresses residual wastes that is officially recognized by DENR as an alternative to
SLF (In this case, Proof that said technology officially recognized by DENR must be hereto attached)

☐ Other initiatives to access an authorized SLF. Please specify: __________________________

Access to Materials Recovery Facility

_____ % of barangays have access to a Materials Recovery Facility (MRF)

☐ Has planned programs on increasing operational MRFs

☐ Has planned programs on expanding its operation of a single MRF servicing multiple Barangays
☐ Other initiatives to expand access to MRF. Please specify: __________________________
 This Certification is issued for the purpose of the Seal of Good Local Governance assessment.

Issued on the ______ day of ____________, 2022.

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)
 SGLG Form CM 2N Designated Tourism Officer

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

Has tracking system of tourism data

☐ Yes, manual (e.g., record book)
☐ Yes, Computer-aided
☐ Yes, Others: _____________________________________________________
☐ No

Has the following tourism data derived from the tracking system

Tourism Statistics in CY 2021

Number of Tourist Arrivals : ______________________

Number of Registered Tourism Enterprise : ______________________

Other Tourism Data (if any)

: ______________________

: ______________________

: ______________________

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

Issued on the ______ day of ____________, 2022.

Certified By: Attested by:

__________________________________________ ______________________________________
Signature over Printed Name Signature over Printed Name
City/Municipal Tourism Officer City/Municipal Mayor

Official Release of this Certification

(Please affix official LGU stamp below)