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Fidelity Bond Application Form BT2024

This document is an application form for a fidelity bond for Milagros Mercado, who holds the position of Barangay Treasurer of Poblacion West in Bautista, Pangasinan. The form provides her personal details, employment history, character references, and details of the position including the period of bond coverage being applied for and the total amount of accountability. It requires signatures to verify the truthfulness of the information provided and to administer the oath.

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857 views2 pages

Fidelity Bond Application Form BT2024

This document is an application form for a fidelity bond for Milagros Mercado, who holds the position of Barangay Treasurer of Poblacion West in Bautista, Pangasinan. The form provides her personal details, employment history, character references, and details of the position including the period of bond coverage being applied for and the total amount of accountability. It requires signatures to verify the truthfulness of the information provided and to administer the oath.

Uploaded by

jomar
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as XLSX, PDF, TXT or read online on Scribd
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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)

REQUEST FOR APPLICATION FOR BONDING AND/OR CANCELLATION OF


FIDELITY BOND OF ACCOUNTABLE PUBLIC OFFICER

INSTRUCTIONS:
1. ACCOMPLISH THIS FORM CORRECTLY 3.MARK APPROPRIATE BOXES WITH CHECK "ü"
2. PRINT ENTRIES LEGIBLY IN CAPITAL LETTERS

TYPE OF NEW X RENEWAL CANCELLATION, please proceed OLD RISK NUMBER:


APPLICATION:
to Item Nos. 24-32 09-221795R
1. NAME
MERCADO MILAGROS BALATICO
Surname Given Name Name Ext. (e.g., Jr.) Middle Name
2. ADDRESS
# 161 ZONE 6 POBLACION WEST BAUTISTA, PANGASINAN
2X2 ID PHOTO
3. DATE OF BIRTH (mm/dd/yyyy) 4. PLACE OF BIRTH
8/5/1980 BAUTISTA, PANGASINAN

5. SEX 7.CIVIL STATUS 8. CONTACT NUMBER

MALE X FEMALE SINGLE X WIDOWED 9678075930


6. TIN 9. EMAIL ADDRESS
724-997-254-000 X
MARRIED SEPARATED
[email protected]
10. MONTHLY INCOME (Salaries,allowances,business income and the like) 11. ESTIMATED MONTHLY EXPENSES
₱ 15,000.00 ₱ 12,000.00

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 X NO
If yes, give details:

13. a. Have you ever been found guilty of any administrative offense? b. Have you ever been found guilty of criminal case before any court?

YES X NO YES X NO
If yes, give details: If yes, give details:
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
HON. JOSEPH G. ESPINO POBLACION EAST BAUTISTA, PANG. 0915 395 4874
MR. JAYBIE Q. LAMBINO BALUYOT BAUTISTA, PANG. 0994 779 0960
ENGR. ALBINO M. MEJIA, JR. ALCALA, PANGASINAN 0917 863 4465

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.

Government Issued ID : DRIVER'S LICENSE


ID/License/Passport Number : A12-19-006609 MILAGROS B. MERCADO / 01/30/24
Date/Place of Issue : 2019 - SAN CARLOS Signature over Printed Name /Date Accomplished

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 .

Page 1 of 2
17. AMOUNT OF ACCOUNTABILITY 18. NAME OF OFFICE OR AGENCY

AMOUNT OF BRGY. GOV'T. OF POBLACION WEST


ACCOUNTABILITY

(a) Public Funds 19. ADDRESS OF OFFICE OR AGENCY

(1) As Collecting Officer P POBLACION WEST


(2) As Disbursing Officer BAUTISTA PANGASINAN
(3) As Signing Officer Municipality/City Province
(4) Investment Officer (GS Investments) 20. STATION/DIVISION (Place of assignment)

POBLACION WEST BAUTISTA, PANGASINAN

(b) Public Property 21. TITLE OF POSITION OR DESIGNATION


(1) Inventories (per GAAM) P
BARANGAY TREASURER
(2) Property, Plant & Equipment (Net Book Value)
22. DATE OF DESIGNATION OR ASSUMPTION OF
ACCOUNTABILITY

(c) Forms and other valuables 2023 NOVEMBER 24

(1) Internal Revenue Stamps P Year Month Day


(2) Postage and other Stamped Stock
(3) Official Receipt 23. BOND PERIOD COVERAGE
(4) Others Forms and valuables
One (1) year

Two (2) years


TOTAL AMOUNT P

Three (3) years


THIS BLOCK TO BE FILLED ONLY IN CASE OF BOND CANCELLATION
24. OFFICE OR AGENCY AND STATION

25. NAME OF OFFICERS TO BE RELIEVED 26. PRESENT POSITION OR DESIGNATION

Surname Given Name Middle Name


27. AMOUNT OF BOND 28. RISK NUMBER AND EFFECTIVITY DATE

29. DATE OF RELIEF 30. CAUSE OF RELIEF

Year Month Day

31. THIS IS TO CERTIFY THAT, as Head of Agency of Barangay Government of Poblacion West, 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

X Application for Bonding


New
X Renewal

Cancellation of Bond

of the above accountable public officer. ROMUALDO A. SISON / 01/30/24


Punong Barangay

Signature over Printed Name of Head of the Agency/Date


Accomplished

THIS BLOCK TO BE FILLED BY BTr ONLY


32. AMOUNT OF BOND RECOMMENDED 33. AMOUNT OF BOND PREMIUM PAYABLE

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.

Name & Signature of BTr Officer DATE

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