Attachment 1 Fidelity Bond Application Form RerunLIC OF THE PHILIPPINES (Werislon No. 02 Date! May 30,2029) "KAGAWARAN NG PANANALAPI SR NOWBER KAWARIHAN NG INGATANG-YAMAN—[Nlosseuntinty Brno (QUREAU OF THE TREASURN) REQUEST FOR APPLICATION FOR BONDING AND/OR CANCELLATION OF FIDELITY BOND OF ACCOUNTABLE PUBLIC OFFICER armucron 7 RSSOURLEN a FORICORRESTY __awaRcADOROBRATE ROHS LoJumoneoe -7™ MAGDARAOG ANASELLA MLLANUEVA [roxTeoreRTH mann) [RPLADEOF TH 26/952 PANGANIGAN, CATANDUANES TC wae Ti smcte CI woowen — [9106785103 390072061, 5 manico [] serazaren_| anabetlamsadaraogGgmailcom fo-woxtncr NCOME (Soareralawancor busier come adie ine) [1 ESTIMATED MONTHLY ERFENSES 2365.00 10,00000 [Have you ever been separated rom te seve In ay ofthe folowing modes: reslgnstion,relremer, rapped Wom heals, asmissal rmination, end of tar, Rrished contract or phased out (abaion inthe publi oF privat sector? Cvs Gino rye, ove eats yes. ve oats (yes pve gens Date Fs: Date Filed 4. CHARACTER REFERENCE (ns! mut ot be rele upto the orth cere by consanguinity fo appar) NAME ‘ADDRESS. CONTACT NUMBER TIRS-HRDILYR V. BORROWED, TATSUPANGANIBAN CANPUS (AESTEST ‘OR. RAMON F. SAMONTE ‘CATSU PANGANIGAN CAMPUS, lszurassr02 MRS ZELOAF. REYES (GATSU PANGANIGAN CAMBUS. 027178 15 | declare tal the anwer to the foregong questions are Vue to te best of my knowledge and Bele | uly understand that any rmarepreseniaton made in the apptcalion and supportng documents shal cause te ting of axmintravesermnal case(s) agate Goverment ied 10 TWcARD, (Ditiense’PacepertNumber —» Y9ONTZ05Y—— DotarPace of save DeBOOS RAC, js amscracowosvonnnen men APR 19 2008 10 as nani above nS ae Se Papen[FAWOURT OF RCCOUNTABITY FANE OF OFFICE OR AGEHCY anne 'SUCS, CATANOUANES STATE UNIVERSITY [ACCOUNTABILITY pC a. ADDRESS OF OFFICE OR AGENCY VIRAG CATANOUANES (CAPITAL) CATANDUANES (2) Ponte Funas (1) As Cotectng Ofer (@)As Disbursing Ofer {3)A8 Sing Otionr Tine wnyay Prses [20\STanIONDISION (Pace cTassignmen) (CATANOUANES STATE UNIVERSITY- PANGANIBAN CAMPUS, (3) nvesimert Ofc (GS vestments Tire Depoos, ec) fa TTLE OF POSTTION OR DESIGNATION (6) Putte Property {i)lnvniones (ger GAAM) {2} Property Pla 8 Equant et ace Ve) [EE DATE OF DESIGNATION OR ASSUMPTION OF (oFeme and tere: a4 oO (swan sae ba rn or (Pose Same ec ———ts Glow mene SoM prwornerconmer (soe mrad aan i Ee [EJ omcnyen reenter —[7E FD wearer [1 tre years E “TS BLOCK TOBE FIED ORLY W CRS OF BOND CANCELLATION =) fa OFFICE OR AGENCY ANO STATION fas name OF OFFICERS TO BE RELIEVED Ps PRESENT POSTION OR DESIGNATION fe AMOUNT OF BOND fs Risk NUMBER AND EFFECTIVITY DATE. fs oATE OF RELIEF fo. CAUSE OF RELIEF - CI ost 13. THISIS TO CERTIFY THAT, as Head of Agency of veri he tuanuness of tbo anawers lo the questions contained on the facs GF Bis form and found them corock slat a can be ascertained and bat the ‘ppleantis a eale amd contentve risk Hance, the undersigned i recommending approval and authoring the request fr esa oe eS of ave accountable pb oe 2, AMOUNT OF BOND RECOMMENDED fs, AMOUNT OF BOND PREMIUM PAYABLE NY 750,000.00 11,250.00 This so cory that have carly evaluated th request for Jappuicarion [_] Renewar [_]canceLiaTion Felt Bond of he above-mentioned accountable puble ft PapeTeT “Name of Office: State Universities and Colleges (SUCs), Catanduanes State University, Catanduanes State University LIST OF BONDED ACCOUNTABLE PUBLIC OFFICERS PREVIOUS YEAR'S DATA REMARKS WITH PENDING. | FOUND Gun see oF DESIGNATION EFFECTIVE DATE amount 80ND UL, NAME OF PUBLIC OFFICER. kterningrootecthey RISK No. coverace | AMMstRaTve | WHATIS THE [APPLICATION fom ] Te STATUS OF THE ‘Signing ome) {ANOVOR CRIMINAL Accountasuy| sono | PREMIUM IMPLEMENTATION For renewal CASE(Yes oN) | op penaLrv? WAGOARAOG ANABELLA x (camer 200.0000] rsooonco] 1928000] tym xO Not apples VULANUEVA Totals [ Zacaseeno] —reomnono] 1128020 Prepared By: Reviewed 8 Certied and Approved By: ee retcuefl o jrempronuevo Senior Admin. Asst I ‘Signature over printed name Postion Date: _08/03/2023, af AON SAiOnTe, PH ofan charge Sihatue over ped ame Postion |=e PATRICK RLAIN T. AZANZA, PH.D, Signatbre over printed name Designation of Authorized OfficialDepartment of Finance BUREAU OF THE TREASURY Region V - Bicol Regional Office Transmittal No,__0520-2022-04-00198 120/202; ——§ “Bi 2—$ CONFIRMATION LETTER The SUC President I ‘State Universities and Colleges (SUCs) Catanduanes State Universty-08053 - 080530000000 Virac Catanduanes Sir/Madam: This is to inform you that the request for bonding and/or cancellation of bonds of the following accountable offcisis and employees of your Ofice! Agency has been approved and duly entered in the Registry of Bonded Public Officers maintained by Catanduanes Offce of this Bureau istics Prownetal Offes) Name and position of Bonded |g tign RiskNo, {APProved Amount| Effective Date Public Officers efBOND jrding | Cancelation NAGOARAOG, ANABELLAV | CATANDUANES | 0530-202 00253H 750,000.00] 0471872022 | oarTarzoz3 Bong cowrage:1 ys) UNIVERSITY.PaN Anan ‘CAMPUS, The bond shall be renewed on or before the anniversary date, otherwise bond is automatically cancelled. Please notify this Office if there are changes in accountable officers or amount of accountability within the effective period of the bond. Very truly yours, ROSALIA V. DE LEON Treasurer of the Philippines By: ROSSM BELMONTE A Resi t Rosai BE ce: COA Resident Auditor