Form 3: Annex D Rerusuic oF THE PHILirrines eee Heaton Form KAGAWARAN NG PARANALAPL a : AWANTHAN NG INGATANG-VAMAN 3 (BUREAU OF THE TREASURY) pees - REQUEST FOR APPLICATION FOR BONDING AND/OR CANCELLATION OF FIDELITY BOND OF ACCOUNTABLE PUBLIC OFFICER ImetmucTins: ACCOMPUGHTHS;FORu ComECTY | sMARNAPPROPRATEONES LN °V™ [oithew [CIs Mmmm [-]enceanctammenr Panmmomes EG -Di9 VS — tomerren 2432 | fortune Toul AEN een JAGALA_ Fz abonees AG\, PoBUuD 4, +E AWINAVOg , (AUNTE FFOATE OF aiitmmtaaym e-PUxcEOF emt Mol ia G5). AGU/ AWOKE, CONTACT GER Frew sravus danas (S3 (hn Creme |Lefsnove (1 woowen lm f-ewax anoress AMY 144-140, [Cann essa [alinidnabrhue D4 ai). cm | 0: MONTHLY MCOME aris afowances.busness income andthe ke) —[1.ESTINATED MONTHLY EPE! £000. 94 £5, 000-00 | Have you eer Deen separated fem th svi many of We oloning mode resignation, remark dropped om fe rolls Semel |=rminaon, en of erm, fished contact or phased ot abot) In the pub or pte secor? Os fo Ives. give deta: favre yo vr bea oun uty of any aa ma? [se nD ad iy tcl case las ay Os — Tato Ove pare Tye ce ds Feageaaee omen Date Fed Stas of Cat +4. CHARACTER REFERENCE nua mt nb ated up oh fth dere by consangunty or any ap NAME ‘ADDRESS. (CONTACT NUMBER r 1. | declare tet the anew ote foregning quostons are tu ote Bot of my krowladge an bait. | fly understand tat any |] © msrepresntaton made ints appeaton and supporing documents shal cause, fing of adminsatvelrminalcaze(e) agaist. Government sued 1D [DiLeense/Passport Number Daterace of issue is. suascrsep ano swore ete eis 2 DUN OEE sa od a \ossinesed stove saa era VraRt PUBLIC NIL 3OWUNERU22 - etme Ne ere Pte et et ed see anny eran i Mire rcavte Seieset a sete usin? "GE TA grater oPFF ATOORT OF RESORT Ti TATE OF OFT ON ROTTET AMOUNT OF SANGQUNIANG KROATAAN accounranury — | POBALION Oh GAL CANE (4) mesmert fet (05 testers) Bo STaTIONNISION ace asigrenty GRY. E. AGU) ALO » (AVITE SK WHA PERS Ov RE DATE OF DESIGNATION OR SSUMPTON OF (1) a Cotectng text P _ BADAN, IBVACI DAL ee coy gorcay | eA hate ae —— (2) Pubic Property (a) vertanesp GAA {2}Prpery, Pant &Eabpent et Bok ae fsscouvtaauiry (Form ana ote vatstoe um 2-4 ob ls (2) Postage an ter Stamped Stock (orf Recee (@).mers Forma and vaibles BORD PERO COVERT [A ore year 1 woe yeass [1 tee years fa OFFGE OR AGENGY AND STA Tora anounT fs NANE OF OFFIGERS TO BE RELEVED fs. PRESENT POSITION OR DESIGNATION [zr awouur oF Bono fs REX NONBER AND EFFECTIITY DATE fo oste oF REL CAUSE OF RELE = ee er 31. THIS (STO CERTIFY THAT, as Head of Agancy of EAC. AGUTNALD G. (AVIS. vesies to wartunoss fhe answers othe queslons contained on the fae of ts frm and found them caret insofar as canbe ascanane and! ha the ‘pplcant ea sate and conservative ik. Hence, the undrsignedis recommending approval and ahorzing the request for [rotten tr Bon ie = Lifereat corcelain font othe above accountable pub ote. Neu BE ANDRES a tu Myo | Satire over Pinta Nan Agere 2, AMOUNT OF BOND RECOMMENDED ss. AMOUNT OF BOND PREMIUM PAYABLE “Ths isto cert nat | have carefully evaluated the request for |APPLICATION RENEWAL [__] CANCELLATION ‘ot Fidelly Bond of he abovementioned accountable pubic fcr. Sania —=— FaeForm 3: Annex D Fidelity Bond Application Form REFUBLIC OF THE PHILIPPINES (hevision No. rx Die Kees) TKAGAWARAN NG PANANALAPT KAWANIHAN NG INGATANG-YAMAN (BUREAU OF THE TREASURY) Pee aconssed by 7 nen) REQUEST FOR APPLICATION FOR BONDING AND/OR CANCELLATION OF FIDELITY BOND OF ACCOUNTABLE PUBLIC OFFICER Pricines [Lise etre [_Jowsnvmncnn, [erm |HA-200Le ra Men ah ye a A ee Se Pe AOORESS G6. wun AB, 66K NSUAALDE, Cour FORTE oF aiari Gamcayym —[NPLACE OF RT ot] facon ALOIS, RULACAN eam Tana STATUS Je conracrnowaeR Co wae 1 smote [] mooweo of oswoued Th [rena aDoRESS T6100 armneo CJesrunmen | metiennine is8 nets ph fe YRC ORE SISTERS arsed SNES MONT EEE F.0d 20 2,000.8 Fz ave you aver boon sopastod Wom ba zavico aap odes eignaten,retrement dropped fom te lls, dismissah rmination of em, ished contrac or pared aut bolton) nthe public opiate sector”? Cives yes, gue ote T Have you sve bon found gly of criminal cas Bator ay coun? Hove you ever been found gully ofan edmbistratv fons? Oves 1 CHARACTER REFERENCE (nov mt na! ered up fo fhe sth eee by cnsanguintyor aff poco) NAME "ADDRESS (CONTACT NUMBER ROEM wT BENGISD TES GER, CAE Taso O WA —FLGe Beran Ct A tpn ITE a 1 EDI -BAGENGR TR. RANTES Tm oat. 18 | decare hat the answer to be foregoing questions ar tue to the Best of my knowledge and babe. | uly underetand that any misrepresent made in ths apptcaton and supporing documents shal cause te fing of asminstratvelenminalc2so(¢) Goverment issues 10 —iN___ JP GrcenePassot Number suey aiaEL e.g 606 BatePuace of soe Ty .cavee Sale for es Nase Bs or 18, SUBSCRIBED AND SWORN to betreme ie. Q JUN 2009 tigen pers HHG aN EVIE oe NOTARY PUBLIC UNTIL 30\UNE 2022 @yviraeot sar wast Ho 3795 12/1020) FereecusotrcSuroese ov ino! Prove ate Doce. _29S ie Sa[AMOUNT OF RECOUNT [FENANE OF OFFICE OR ROENGT amuittne SHLCUNANE eapataa hd ACCOUNTABILITY a. CMTE (2) Pune Fund ———_ Jivronessor orner on naener 1 A8Cotecting Oficer 3) Sng Otee 4) ovement Offer ( vestments) EN. ACUINALYL ay Po StaroWDinsiON (Pace tamara) GEN. & AGUINALDD, caniTE (0) Pubic Property (2)Prepery, Plat 8 Equent et oo au fr. ILE OF POSITION OR DESIGNATION Sk hee (6) Forms and ater valuties ur ‘ al (ileal Revene Somes veer i or (2)Peatage and ter Samped Sick (G)OMoat Recast (8) Oma Fer an akties [Z ominyear ToTAL AMOUNT a CO eines tree @ years See [ps NAME OF OFFICERS TOBE RELIEVED fs presen posmmon on DESIGNATION fz Anounr oF BOND fn WSK NONGER ANG EPPETWATYOATE fs onre oF REL fo cause or REL 31, THIS IS TO CERTIFY THAT, as Head of Agoney ot _CEN-€. AUT NAW Oi (ANTE 1 vented te maniuness cof the anewor othe quoetions contained on the fae hs fom and ound them covet insofar as canbe asceranad end te! he Sppleantis a sate and conservative isk Hen, te un [irae nrg [YR [eames ot ond A Bla le NEU A BY ANCELES ote above accountable pe foe, Pane Meo ‘Signature ve Pinte Name of Head of he AgensyOae egnod i recommending approval and authrsng te request for fz, AMOUNT OF BOND RECOMMENDED ss. AMOUNT OF BOND PREMIUM PAYABLE ‘This iso certty that have carefully evaluated he request for JaPeuicaTion [__] Renewa [—]canceuarion ‘of Fdeiy Bond of he above-mentoned accountable pubic ofcer, PITTAGENCY cone: casos, BUREAU OF THE TREASURY Region V-4A ‘CONFIRMATION LETTER HON. NELIA BENCITO ANGELES (NPT (MUNICIPAL MAYOR: ‘MUNICIPAL GOVERNIZENT OF OF GENE, AGUINALDO ‘SEN. E AGUINALDO, CAVITE si ‘Tranemital No, andes of your oc esc as een roid and ly ered the egy Bonded Pube 21.08.19-0639, 3/24 720. 4 Eli SRE] cer mantel oy conte tobe Name aa Potion of Bonde Pub =e Tne, [ocala |_—_ een oe cia Sao” | aentee [nen TORNAENTABAHUS Teqnancay rootacion | s2i-2ii025/&| 1690000 |3y2/anzy| 3/4/2022 CWYNETH MARI P.MENDOZA | canancayeoaLAcion | 21211006 A) #1890000 | 1/0/1500] 072022 Sa eae BARANGAY POBLACION Iv | 421-211027 R| 18,900.00 |3/24/2021) 3/24/2022 ee BARANGAY POBLACION Iv | 421-211028 | 18,900.00 |3/24/2021] 3/24/2022 oe BARANGAY POBLACION Il | 421-211029 R| 22,500.00 |3/24/2021| 3/28/2022 oe ee BARANGAY POBLACION Il | 421-211030 R] 22,500.00 | 3/24/2021] 3/24/2022 ey BARANGAY BATAS DAO | 421-211031 R} 16,750.00 | 3/24/2021] 1/0/1900 aston aicostxe | srsyucayearasono |ear21e2 | 91675000 |s/asara| s/2sz022 ae: BARANGAY TABORA | 421-211033 | 22,500.00 | 3/24/2022| 3/24/2022 amannacavsvt | ayraycarrasora |anratans n| 92.5000 fareuaon} sue senac P. ear BARANGAY A DALUSAG | 421-211035 R} 18,900.00 |3/24/2021) 3/10/2022 seroaenero | satncnreasTaOs Jars assy a} 92625000 | yoszai| sasrne LENNY ANGANIBAN BARANGAY CASTANOS | 42, >1:038 126,250.00 |3/24/2021) 3/24/2022 min cena Jen CAE oa BARANGAY KAYMISAS | 421-211039 R| 18,900.00 | 3/24/2021) 3/24/2022