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Attachment 2
Form 4: Annex E
Barangay 1 Gen Mariano Alvarez,City of Cavite
Date:12/05/2023
Form 3: Annex D
Fidelity Bond Application Form
REPUBLIC OF THE PHILIPPINES (Revision No. xxx Date xxxxx)
KAGAWARAN NG PANANALAPI
KAWANIHAN NG INGATANG-YAMAN RISK NUMBER
(to be accomplished by BTr Officer)
(BUREAU OF THE TREASURY)
INSTRUCTIONS:
1. ACCOMPLISH THIS FORM CORRECTLY 3.MARK APPROPRIATE BOXES WITH CHECK "ü"
2. PRINT ENTRIES LEGIBLY IN CAPITAL LETTERS
5,700.00 5,000.00
12. Have you ever been separated from the service in any of the following modes: resignation, retirement, dropped from the rolls, dismissal,
termination, end of term, finished contract or phased out (abolition) in the public or private sector?
YES √ NO
If yes, give details:
13. a. Have you ever been charge of any administrative and/or criminal b. Have you ever been found guilty of any administrative and/or
offense? criminal case before anyadministrative body, tribunal or court?
YES √ NO YES √ NO
If yes, give details: N/A If yes, give details: N/A
Case No/s.
Date Filed:
Status of Case/s:
14. CHARACTER REFERENCE (Individual must not be related up to the fourth degree by consanguinity or affinity to applicant)
NAME ADDRESS CONTACT NUMBER
JOSEPHINE F. FAME 866 ARNALDO 11 ST DALAHICAN CAVITE CITY 9278056111
JANETH F. FABILA 957 Don Pedro Bsautista St Dalahican Cavite City 9553336098
ROGELIO C. FAMY JR 866 Arnaldo Arnaldo II St Dalahican Cavite City 0915-7420589
15. I declare that the answer to the foregoing questions are true to the best of my knowledge and belief. I fully understand that any
misrepresentation made in this application and supporting documents shall cause the filing of administrative/criminal case(s)
against me.
16. SUBSCRIBED AND SWORN to before me this_________________________, affiant exhibiting his/her validly issued Government
ID as indicated above.
Doc. No. ;
Page No. ; Signature of Officer/Person Administering
Book No. ; Oath
Series of .
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17. AMOUNT OF ACCOUNTABILITY 18. NAME OF OFFICE OR AGENCY
AMOUNT OF
Barangay 1 Gen.Mariano Alvarez
ACCOUNTABILITY
2023 12 5
(c) Forms and other valuables
31. THIS IS TO CERTIFY THAT, as Head of Agency of _____________ ______________________________, I verified the truthfulness
of the answers to the questions contained on the face of this form and found them correct insofar as can be ascertained and that the
applicant is a safe and conservative risk. Hence, the undersigned is recommending approval and authorizing the request for
Cancellation of Bond
16,750.00 251.25
This is to certify that I have carefully evaluated the request for APPLICATION RENEWAL CANCELLATION
of Fidelity Bond of the above-mentioned accountable public officer.
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