Fidelity Bond Application Form Fillable v1.0 - (1) - (1) - (1)

REPUBLIC OF THE PHILIPPINES Fidelity Bond Application Form
KAGAWARAN NG PANANALAPI (Revision No. xxx Date xxxxx)

KAWANIHAN NG INGATANG-YAMAN RISK NUMBER
(BUREAU OF THE TREASURY) (to be accomplished by BTr Officer)
REQUEST FOR APPLICATION FOR BONDING AND/OR CANCELLATION OF

FIDELITY BOND OF ACCOUNTABLE PUBLIC OFFICER
INSTRUCTIONS:
1. ACCOMPLISH THIS FORM CORRECTLY 3. MARK APPRORIATE BOXES  WITH CHECK “”
2. PRINT ENTRIES LEGIBLY IN CAPITAL LETTERS
OLD RISK NUMBER:
TYPE OF
APPLICATION: 
✔ NEW  RENEWAL  CANCELLATION, please
proceed to Item Nos. 24-32 For Renewal
1. NAME
LLAGUNO MARK ROLDAN LLAGUNO

Surname Given Name Name Ext. (e.g. Jr.) Middle Name
2. ADDRESS
Purok 2 Rizal Jovellar Albay 2X2 ID PHOTO
3. DATE OF BIRTH (mm/dd/yyyy) 4. PLACE OF BIRTH

11/15/1999 QUEZON CITY
5. SEX 7. CIVIL STATUS 8. CONTACT NUMBER
✔ MALE  FEMALE  ✔ SINGLE  WIDOWED 09489772018

6. TIN 9. EMAIL ADDRESS
 MARRIED  SEPARATED [email protected]
10. MONTHLY INCOME (Salaries, allowances, business income and the like) 11. ESTIMATED MONTHLY EXPENSES
5000 1000
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 found guilty of any administrative offense? b. Have you ever been found guilty of criminal case before any court?
 YES ✔ NO  YES 
✔ 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

LEONEL NEO STO. NINO JOVELLAR ALBAY 995433796
HERNANDO ENCISO RIZAL JOVELLAR ALBAG 9752316571
CIELO G.PUGAL RIZAL JOVELLAR ALBAY 9460094960
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 : 771015474

ID/License/Passport Number : MARK ROLDAN CASTRO LLAGUNO
Date/Place of Issue : 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. ;
Book No. ;
Series of . Signature of Officer/Person Administering Oath
Page 1 of 2
17. AMOUNT OF ACCOUNTABILITY 18. NAME OF OFFICE OR AGENCY
AMOUNT OF
ACCOUNTABILITY RIZAL, JOVELLAR, ALBAY (LGU, BRGY)
(a) Public Funds 19. ADDRESS OF OFFICE OR AGENCY

(1) As Collecting Officer P
(2) As Disbursing Officer
RIZAL
(3) As Signing Officer JOVELLAR ALBAY
(4) Investment Officer (GS Investments) Municipality/City Province
20. STATION/DIVISION (Place of assignment)
(b) Public Property

(1) Inventories (per GAAM) P 21. TITLE OF POSITION OR DESIGNATION
(2) Property, Plant & Equipment (Net Book Value)
SANGGUNIANG KABATAAN (SK) CHAIRMAN
22. DATE OF DESIGNATION OR ASSUMPTION OF
(c) Forms and Other Valuables ACCOUNTABILITY
(1) Internal Revenue Stamps P 2018 07 01

(2) Postage and Other Stamped Stocks Year Month Day
(3) Official Receipts 23. BOND PERIOD COVERAGE
(4) Other Forms and Valuables

✔ One (1) year
TOTAL AMOUNT P  Two (2) years
Compute  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 _______________ ____________________________, 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

✔ Application for Bonding

✔ New
 Renewal
 Cancellation of Bond
of the above accountable public officer. ZENAIDA L. CADAG
AGENCY ADMIN
Signature over Printed Name of Head of 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
Page 2 of 2

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REPUBLIC OF THE PHILIPPINES Fidelity Bond Application Form

KAGAWARAN NG PANANALAPI (Revision No. xxx Date xxxxx)

REQUEST FOR APPLICATION FOR BONDING AND/OR CANCELLATION OF

LLAGUNO MARK ROLDAN LLAGUNO

3. DATE OF BIRTH (mm/dd/yyyy) 4. PLACE OF BIRTH

✔ MALE  FEMALE  ✔ SINGLE  WIDOWED 09489772018

NAME ADDRESS CONTACT NUMBER

Government Issued ID : 771015474

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

(b) Public Property

(1) Internal Revenue Stamps P 2018 07 01

TOTAL AMOUNT P  Two (2) years

Compute  Three (3) years

THIS BLOCK TO BE FILLED ONLY IN CASE OF BOND CANCELLATION

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

Surname Given Name Middle Name

29. DATE OF RELIEF 30. CAUSE OF RELIEF

Year Month Day

THIS BLOCK TO BE FILLED BY BTr ONLY

Name & Signature of BTr Officer DATE

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