Form 4: Annex E

(AGENCY LETTERHEAD)

LIST OF BONDED ACCOUNTABLE PUBLIC OFFICER/S

TYPE OF APPLICATION
PREVIOUS YEAR'S DATA
AMOUNT PREFERRED
(Check "ü" the DESIGNATION EFFECTIVITY DATE BOND
NAME OF PUBLIC OFFICER appropriate column) (e.g. Disbursing/ RISK NO. REMARKS (WITH/WITHOUT PENDING
COVERAGE
Collecting/Signing From To ADMINISTRATIVE AND CRIMINAL CASE)
Officer) (1, 2, or 3
ACCOUNTABILITY BOND PREMIUM YEARS)
NEW RENEWAL ( For Renewal)

WITHOUT PENDING ADMINISTRATIVE

Kristine Mae B. Soriano ✓ SK Chairperson
AND CRIMINAL CASE

WITHOUT PENDING ADMINISTRATIVE

Gerardo V. Camacho Jr. ✓ SK Treasurer AND CRIMINAL CASE

Prepared by: Certified and Approved by:

KRISTINE MAE B. SORIANO GERARDO V. CAMACHO JR. ALEJANDRO A. BARROZO

Signature over printed name Signature over printed name Punong Barangay