; Form 3: Annex D Fidelity Bond Application Form sevuneeretimamme Genel Eredar rritte so EAVAAR A ety — ROGRNUMBER (BUREAU OF THE TREASURY) _ 4 REQUEST FOR APPLICATION FOR BONDING AND/OR CANCELLATION OF FIDELITY BOND OF ACCOUNTABLE PUBLIC OFFICER WwSTRUCTIONS. 1 ACCOMPLISH THIS FORM CORRECTLY MARK APPROPRIATE BOXES] waTHeNeC "U™ rrr oF (FH wew [_] renewar CANCELLATION, please proceed [OLD mix nuMoen| ana 10 tem Nos 24.32. For Renewal cae | RESURRECCION ROMEO mano Ne — ee AB ADDRESS | 07 TOMAS CLAUDIO ST. MAYBANCAL MORONG. RIZAL | DATE OF BIRTH even) Ye PLAGE OF TH | B31/1956 JMORONG RIZAL | | sex rev aT SONTAGT MMDER | ius (Crewe | swore Cowes fo sorssasass L — = 8. EMAIL ADDRESS 130.382.664.000 (A nansvecl] serarareo 10. MONTHLY INCOME (Ssleriesalowances,business income and the lke) | 19, ESTIMATED MONTHLY EXPENSES 3283 60,000 12. Have you ever been sepsrated from the service In any ofthe following modes: reslgnaion, retirement, dropped fom the rll, Sismistal. termination, end of term, irished contract oF phased out (abolition thepubic or priate sector? irs Ohno tyes. ove dette: [RETIRED MATERIAL CONTROL OF SUPPERVISOR CENTRAL BANK OF THE Pit Have yau ever Deen found guilty of criminal case balers ony leourt? ae Cres pAxo tyes, ve dota Case Nols. Dato Filed 1 of Casote (CHARACTER REFERENCE (injvduol mut rot bo related upto the fourth dgroo by consanguinty or aft t appcant) NAME ‘ADDRESS ‘CONTACT NUMBER "MARK PHILIP F PALPALLATOC WORONG RIZAL 9357014109 PERLITAF MARCELINO [MORONG.RIZAL 9355147562 TRECHELL JOY R. PASTORPILL [MORONG.RIZAL 9353008830 1. L se. | docare that the answor to the foregoing questions are tuo tothe best of my knowledge and botet. fully understand ‘that any msrepresentation made in this application and supporting dacuments shall cause the fing of ‘administratvelcnminal casa(s) against me Government Issued 1D {O/LicenvolPassoon Number Date/Piace of esue suescrasco aw snownnostwome nis LT DEC 2023 ana exronny rst 10 68 nested above Doe. No. be; Page No i ‘Book No, Liv; Senes of 31, 2028 TOP 1.33 252/05-30-86 IBPLIFETINE HCNELE NOLO2322/0419-0IK4 Pago tore[AMOUNT OF ACCOUNTABTUTY Ti. NAME OF OFFICE OR AGENCY amount o AccoUMTAUTY [BARANGAY MAYBANCAL (2) Pub Funds [78 ADDRESS OF OFFICE ORAGENGY | (1) As Catectng Ofc nnn MANILA EAST ROAD MAYBANCAL (2) As Disbursing Offcor i, ‘WORONG RIZAL (914sSiqnng OFfcer jari.204 Tipit Frown (6 Iovestment Offer (6S Investments) 20: STATIONIIVSION Pace of eanignment) ‘BARANGAY MAYBANCAL (0) Public Property [1 THTLE OF POSITION OR DESIGNATION (1) Invenores (per GRAM) P. (2) Property, lant & Equirent Nat Book ae) BARANGAY CAPTAIN |22, DATE OF DESIGNATION OR ASSUNPTIONOF | |ACCOUNTABILITY (6) Forms and other valuables 2023 NOVEMBER. 20 (1) rtemat Revenve Stamas e voor Ment ey (2) Postage and otter Stamped Stock (@) Oficial Recoint (4) mers Fos and valuables ras, BOND PERIOD COVERAGE JZ] One (1) year TOTAL AMOUNT Laas (2) woeyears Thee 2) youre THIS BLOCK TO BE FILLED ONLY IN CASE OF BOND CANCELLATION S59) 24. OFFICE OR AGENCY AND STATION 25, NAME OF OFFICERS TO BE RELIEVED 2. PRESENT POSITION OR DESIGNATION Sarena Given ame uae Hane [27 AMOUNT OF BOND 26, RISK NUMBER AND EFFEGTIITY DATE 2s, DATE OF RELIEF 30. CAUSE OF RELIEF Yes Te ey Fu ISIS TOCEN HET Innis rewa oF Ae OF Teoma ue truthiuiness of te answers tothe questions contained on the Tave of his Torn and found tiem correct insofar as can be ascertained and t 12 safe and conservative risk. Hence, the undersigned is recommending approval and -Appicatiom fe Bonding Ci new Ey Renew J cancataion of ond ofthe stove accountable pubic coe. Signglre over Prints Nome of Waa of tn ‘Roencyate Accomplished THIS BLOCK TO BE FLLED BY BT OMY '32, AMOUNT OF BOND RECOMMENDED [53, AMOUNT OF BOND PREMIUM PAYABLE “This sto certly that Ihave carefully evaluated the request for appucarion [_] renewat. [_] CANCELLATION ‘of Fidolty Bond of the above-mentioned accountable public ofceF Tae Spare BT Oar aForm 4: Annex € | nae oF pusuc orncen TYPE OF Accounramusry ROMEGH RESURRECOON abe Contedand Arpoved by: eee aria & Deagialon of Ravarass OaAnnex € REVISED SCHEDULE OF PREMIUM RATES 1 CASH ACCOUNTABILITY THINTAUM CASH MAXIMUM CASH accountasiTy | accountaaity | AMOUNTOF BOND | BOND il Zof their Tolal Gash | Bond Premium a 5,001.00 8,000.00 |" xseounabity | nore lose than PYG 3,007.00 42,000.00 9,000.00, 150.00 42,001.00 715,000.00 71,250.00 168.75 75,001.00 "18,000.00 13,500.00 202.50 18,001.00 21,000.00 16.750.00 251.25 21,001.00. 25,000.00 78,900.00 283.50 25,001.00. ‘30,000.00 22,500.00 337.60 '30,001.00. ‘35,000.00 26,250.00 393.75 35,001.00 40,000.00 30,000.00 450.00 40,001.00. 50,000.00) 37,500.00 562.50 50,001.00 (60,000.00 ‘45,000.00. 675.00 60,001.00 ‘80,000.00 {60,000.00 900.00 80,001.00 100,000.00 "75,000.00 7,125.00, 100,001.00 250,000.00 700,000.00 41,500.00 250,001.00 ‘500,000.00 225,000.00 3,375.00 '500,001.00 "750,000.00 360,250.00 5,253.75 750,001.00 77,000,000.00) ‘500,000.00 7,500.00 7,000,001.00 2,500,000.00 "750,000.00 71,250.00 2,500,001.00 5,000,000.00. 7,500,000.00 22,500.00 '5,000,001.00 25,000,000.00 3,500,000.00 500.00 25,000,001.00 "75,000,000.00 4,000,000.00 {60,000.00 75,000,001.00 100,000,000.00 ,000,000.00 "75,000.00 7100,000,001.00 '500,000,000.00 '8,000,000.00 120,000.00 '500,000,00.00 | 7,000,000,000.00 77,000,000.00 I! PROPERTY ACCOUNTABILITY 1. Property, Plant & Equipment (Net Book Value) 20% of ter Total Vlue | “age x 1.5% = Premium 2 iments ier GAS) otrarteavnee | 22 noi = Promum Il FOR ACCOUNTABLE FORMS a) Internal Revenue Stamp 'b) Postage and other Standard Stamped Stock | 10% of their Total Value ) Official Receipt Value Rounded Of =x 1.5% = Premium 4) Other Accountable Forms and Valuables to the nearest hundred