Republic of the Philippines

DEPARTMENT OF EDUCATION
Division of Camarines Sur

REQUEST FOR BONDING AND/OR CANCELLATION OF BOND OF

ACCOUNTABLE OFFICIALS AND EMPLOYEES OF THE
REPUBLIC OF THE PHILIPPINES
1. NAME OF PERSON TO BE BONDED/WHOSE BOND IS TO BE CANCELLED

Surname
Given
3. DATE OF INCOMING OFFICER ASSUMES ACCOUNTABILITY

Year
4. STATION

2. DESIGNATION OR TITLE OF POSI

Middle

Month

Day

Municipality
5. AMOUNT OF MAXIMUM ACCOUNTABILITY/CUSTODY

Province/City

Amount
a) Public Funds
(1) As Collecting Officer
(2) As Disbursing Officer

b) Public Property
(1) Supplies and Materials
(2) Equipment
(3) Others

c) Forms and Other Valuables

(1) Internal Rev. Stamps
(2) Internal Rev. Doc. Stamps
(3) Customs Doc. Stamps
(4) Postage and Other Stamped Stock
(5) Science Stamps
(6) Cash Tickets
(7) Others

6. SALARY ATTACHED TO THE POSI

(In case of temporary appointment or d

salary of permanent and temporary inc
be stated)

Total Amount:

When extent or character of an Officer'

over funds or property cannot be inferr
or designation given, a full and comple
duties should be given above.
(Use additional sheet if necessary)

7. BOND RECOMENDED

8. BOND FIXED BY LAW OR BY THE

COMMISSION ON AUDIT

PERSONAL RECORD OF PERSON TO BE BONDED

(Use additional or separate sheet if necessary)
9. (A) PREVIOUS EXPERIENCE

(B) CRIMINAL OR ADMINISTRATIVE RECORD

(THIS BLOCKED TO BE FILLED ONLY IN CASE OF BOND CANCELLATION)

10. NAME OF OFFICER TO BE RELIEVED

Surname

Given

11. PRESENT TITLE OR DESIGNATION

Middle

12. AMOUNT OF BOND AND RISK NUMBER INFORCE

13. SALARY OF PERSON TO BE RELIEVED

14. DATE OF RELIEF

15. CAUSE OF RELIEF

Year

Month

Day

16. REMARKS

Head of Agency or Office

City Mayor
Provincial Treasurer
chanoabellano1/26/12

EMMA

Schools Divi

GENERAL FORM NO. 57(A)

(Revised March 24, 1976)
Risk Number

G AND/OR CANCELLATION OF BOND OF

FFICIALS AND EMPLOYEES OF THE
IC OF THE PHILIPPINES
2. DESIGNATION OR TITLE OF POSITION

When extent or character of an Officer's control

over funds or property cannot be inferred from the title
or designation given, a full and complete statement of
duties should be given above.
(Use additional sheet if necessary)

6. SALARY ATTACHED TO THE POSITION

(In case of temporary appointment or designation,

salary of permanent and temporary incumbent should

8. BOND FIXED BY LAW OR BY THE CHAIRMAN

ECORD OF PERSON TO BE BONDED

onal or separate sheet if necessary)

(B) CRIMINAL OR ADMINISTRATIVE RECORD

FILLED ONLY IN CASE OF BOND CANCELLATION)

11. PRESENT TITLE OR DESIGNATION

13. SALARY OF PERSON TO BE RELIEVED

EMMA I. CORNEJO
Schools Division Superintendent

FIRST INDORSEMENT

GENERAL FORM NO. 57(A)

(Revised March 24, 1976)

,20

Respectfully forwarded, through the Bureau, Provincial or City A

REQUEST
for
BONDING AND/OR CANCELLATION OF BOND OF
ACCOUNTABLE OFFICIALS AND EMPLOYEES OF THE
REPUBLIC OF THE PHILIPPINES

To the Treasurer of the Philippines, Manila, recommending app

bond proposed in item 7 of the within request.

Head of Agency or Office

(NAME)

City Mayor
Provincial Treasurer

EMMA I. CORNEJO

Schools Division Superinte

(DESIGNATION)

SECOND INDORSEMENT
(BUREAU, PROVINCE OR CITY)

Respectfully Forwarded to the Treasurer of the Philippines, M

.

(DATE TO BE EFFECTIVE)

Bond for the within mentioned position is approved and fixed i

amount of P ______________________
Cancellation of the bond of M

in the amount of P __

(Brief to be filled in by the Treasurer of the Philippines

under Risk No. ___________________is hereby noted.

By Authority of the
CHAIRMAN, COMMISSION O

(Bureau, City, Provincial, Ag

chanoabellano1/26/12

Corporate Auditor)

NT

Provincial or City Auditor,

ommending approval of the

ithin request.

MA I. CORNEJO

ivision Superintendent

ENT
,20_____

the Philippines, Manila

proved and fixed in the

he amount of P __________________

Authority of the
COMMISSION ON AUDIT

City, Provincial, Agency,

rporate Auditor)

GENERAL FO
(Revised M

REPUBLIC OF THE PHILIPPINES

APPLICATION FOR BOND OF ACCOUNTABLE OFFICIALS AND EMPLOYEES OF TH

REPUBLIC OF THE PHILIPPINES
I,

of

hereby apply for bond as a

(Bondable Position)

at

(Name of Office, Bureau or Government-Owned or Controlled Corporation)

Province of
APPLICANTS TO HOLD BONDABLE POSITIONS MUST ANSWER ALL QUESTIONS IN FULL
(ALL REPLIES CONFIDENTIAL)
1
2
3
4

Place and date of birth

Civil status: Single, Married, or Widower/Widow
How many persons are dependent on you for support?
What salary will you receive?
Do you have any income other than your salary? If so, how much and from what source derived?

If engaged in any other business, give particulars and names of partners or associates, if any

6
7

Indicate Tax Account Number

Liabilities.
Name three (3) references:

Have you ever been discharged from any position? If so, state particulars

Do you carry life insurance? If so, how much, in what company, and to whom payable?

, attach latest statement of Assets a

10 Have you ever applied before for bond from any fidelity and guaranty company? If so, when and
where?
11 Do you have any criminal or administrative records?
If so, state briefly
nature thereof
12 Are you a member of any fraternal, social or political society?
State the name a
nature of each society
13 What is the estimated total amount of monthly living expenses of yourself and family?

The answer to the foregoing questions are true to the best of my knowledge and belief, and
in witness whereof, I affix my signature below, this
day of
IN THE PRESENCE OF:

(Witness)

(Signature of Applicant)

SUBSCRIBE AND SWORN TO before me this

day of
The applicant presented to me his/her Residence Certificate No. Aissued on
Doc No.:
Page No.:
Book No.:
Series No.:
chanoabellano1/26/12

MARIA JEAN R. STO. DOM

Administrative Officer V

BLIC OF THE PHILIPPINES

GENERAL FORM NO. 58 (A)

(Revised March 24, 1976)

COUNTABLE OFFICIALS AND EMPLOYEES OF THE

IC OF THE PHILIPPINES

in the service of

POSITIONS MUST ANSWER ALL QUESTIONS IN FULL

REPLIES CONFIDENTIAL)

salary? If so, how much and from what source derived?

ticulars and names of partners or associates, if any

, attach latest statement of Assets and

m any fidelity and guaranty company? If so, when and

If so, state briefly the
State the name and

s are true to the best of my knowledge and belief, and

20

(Signature of Applicant)
20
issued at

MARIA JEAN R. STO. DOMINGO

Administrative Officer V

GENERAL FORM NO. 58 (A)

(Revised March 24, 1976)

CERTIFICATION OF VERIFICATIO
AND OBSERVATION

The following description of the applicant is required to be filled and certify

by a competent physician of the Department of health in Manila or in the
provinces. One copy of his bust picture must be pasted on the space provided
therefore hereon.

1
2
3
4
5
6
7
8
9

Height
Weight
Complexion
Face with or without smallpox
Color of eyes
Color of hair
Color of mustache
Color of beard
Birth and other marks on the:
(A)
(B)
(C)
(D)
(E)

PICTURE
(Passport size or 2 X 2 )

THIS IS TO CERTIFY that I verified the truthfulness of

the questions contained on the face of this form and foun
correct in so far as can be ascertained. I further certify h
into the character, honesty, integrity, and efficiency of th
applicant and found him to be
worthy of trust, confidence and reliance. Hence, the reco
of the undersigned as expressed in his 1st indorsement
General Form 57-A to which this form (General Form 58-A

EMMA I

Face
Body
Hands
Arms
Legs and feet

Schools Divisio

Date:
I CERTIFY to the correctness of the foregoing description
of

ISRAEL F. PARRA, M.D.

20
chanoabellano1/26/12

Medical Officer III

20

OF VERIFICATION
ERVATION

he truthfulness of the answers to

this form and found them to be
I further certify having inquired
nd efficiency of the within

e. Hence, the recommendation

1st indorsement contained on
General Form 58-A) is attached.

EMMA I. CORNEJO
Schools Division Superintendent

Republic of the Philippines

DEPARTMENT OF EDUCATION
Division of Camarines Sur
____________________________________
(Name of School)

____________________________________
(Address)

LIST OF ACCOUNTABLE PUBLIC OFFICER(S)

(For New Applicants)

Name of Public Officer

Prepared by:

(signature over printed name)

chanoabellano1/26/12

Designation

Amount of Accountability

Attachment B

S)
Remarks:
( WITH / WITHOUT pending case,
state nature of case, if any )

Certified and Approved by:

EMMA I. CORNEJO
Schools Division Superintendent

Republic of the Philippines

DEPARTMENT OF EDUCATION
Division of Zamboanga City
TICTAPUL NATIONAL HIGH SCHOOL
(Name of School)

Tictapul, Zamboanga City

(Address)

LIST OF BONDED PUBLIC OFFICER(S)

(For Renewal)
PREVIOUS YEARS DATA
Name of Public Officer
ROSITA M. GREGORIO

Designation
HEAD TEACHER I

Prepared by:

ROSITA M. GREGORIO
(signature over printed name)

Effective Date
From
To
02/05/2014
02/04/2015

Risk No.

public of the Philippines

RTMENT OF EDUCATION
sion of Zamboanga City

UL NATIONAL HIGH SCHOOL

(Name of School)

tapul, Zamboanga City

(Address)

Attachment B

ONDED PUBLIC OFFICER(S)

(For Renewal)
PREVIOUS YEARS DATA
Amount
Bond
100,000.00

Premium
1,500.00

Remarks:
( WITH / WITHOUT pending case,
state nature of case, if any )

Certified and Approved by:

0
Administrative Officer V

Republic of the Philippines

DEPARTMENT OF EDUCATION

GENERAL FORM NO. 57(

(Revised March 24, 197
Risk Number

Division of Zamboanga City

REQUEST FOR BONDING AND/OR CANCELLATION OF BOND OF

ACCOUNTABLE OFFICIALS AND EMPLOYEES OF THE
REPUBLIC OF THE PHILIPPINES
1. NAME OF PERSON TO BE BONDED/WHOSE BOND IS TO BE CANCELLED

Surname
Given
3. DATE OF INCOMING OFFICER ASSUMES ACCOUNTABILITY

Year
4. STATION

2. DESIGNATION OR TITLE OF POSITION

Middle

Month

Day

Municipality
5. AMOUNT OF MAXIMUM ACCOUNTABILITY/CUSTODY

Province/City

When extent or character of an Officer's control

Amount
a) Public Funds
(1) As Collecting Officer
(2) As Disbursing Officer

b) Public Property
(1) Supplies and Materials
(2) Equipment
(3) Others

c) Forms and Other Valuables

(1) Internal Rev. Stamps
(2) Internal Rev. Doc. Stamps
(3) Customs Doc. Stamps
(4) Postage and Other Stamped Stock
(5) Science Stamps
(6) Cash Tickets
(7) Others

or designation given, a full and complete statement of

duties should be given above.
(Use additional sheet if necessary)

6. SALARY ATTACHED TO THE POSITION

(In case of temporary appointment or designation,

salary of permanent and temporary incumbent should

Total Amount:

over funds or property cannot be inferred from the title

be stated)

7. BOND RECOMMENDED

8. BOND FIXED BY LAW OR BY THE CHAIRMAN

COMMISSION ON AUDIT

PERSONAL RECORD OF PERSON TO BE BONDED

(Use additional or separate sheet if necessary)
9. (A) PREVIOUS EXPERIENCE

(B) CRIMINAL OR ADMINISTRATIVE RECORD

(THIS BLOCKED TO BE FILLED ONLY IN CASE OF BOND CANCELLATION)

10. NAME OF OFFICER TO BE RELIEVED

Surname

Given

11. PRESENT TITLE OR DESIGNATION

Middle

12. AMOUNT OF BOND AND RISK NUMBER INFORCE

13. SALARY OF PERSON TO BE RELIEVED

14. DATE OF RELIEF

15. CAUSE OF RELIEF

Year
16. REMARKS

Month

Day

Head of Agency or Office

City Mayor
Provincial Treasurer

Administrative Officer V

GENERAL FORM NO. 57(A)

(Revised March 24, 1976)
Risk Number

D/OR CANCELLATION OF BOND OF

ALS AND EMPLOYEES OF THE
F THE PHILIPPINES

D OF PERSON TO BE BONDED
separate sheet if necessary)

ONLY IN CASE OF BOND CANCELLATION)

Administrative Officer V

FIRST INDORSEMENT

GENERAL FORM NO. 57(A)

(Revised March 24, 1976)

,20

Respectfully forwarded, through the Bureau, Provincial or City Au

REQUEST
for
BONDING AND/OR CANCELLATION OF BOND OF
ACCOUNTABLE OFFICIALS AND EMPLOYEES OF THE
REPUBLIC OF THE PHILIPPINES

To the Treasurer of the Philippines, Manila, recommending approva

bond proposed in item 7 of the within request.

Head of Agency or Office

(NAME)

City Mayor
Provincial Treasurer

0
Administrative Officer

(DESIGNATION)

SECOND INDORSEMENT
(BUREAU, PROVINCE OR CITY)

Respectfully Forwarded to the Treasurer of the Philippines, Ma

(DATE TO BE EFFECTIVE)

Bond for the within mentioned position is approved and fixed in

amount of P ______________________
Cancellation of the bond of M

in the amount of P ___

(Brief to be filled in by the Treasurer of the Philippines

under Risk No. ___________________is hereby noted.

By Authority of the
CHAIRMAN, COMMISSION ON

(Bureau, City, Provincial, Ag

Corporate Auditor)

NT

Provincial or City Auditor,

mmending approval of the

ithin request.

0
nistrative Officer V

ENT
,20_____

the Philippines, Manila

proved and fixed in the

the amount of P __________________

y Authority of the
, COMMISSION ON AUDIT

City, Provincial, Agency,

orporate Auditor)

SWORN STATEMENT OF ASSETS, LIABILITIES AND NET WORTH

DISCLOSURE OF BUSINESS INTERESTS AND FINANCIAL CONNECTIONS
AND IDENTIFICATION OF RELATIVES IN THE GOVERNMENT SERVICE
As of December 31, 20
(Required by Republic Act No. 6713)
Name:
Surname

First Name

M.I.

Address:
Spouse Name:
Surname

First Name

M.I.

Position/Income:
Office:
Office Address:
Position/Income:
Office:

Unmarried children below 18 years of age:

Name

Date

1.
2.
3.
4.
5.
A. ASSETS, LIABILITIES AND NET WORTH
1. ASSETS
a. Real Properties

Kind

Location

Year

Mode of

Assessed

Acquired

Acquisition

Value

A
Land
Bldg. e

Fair Market
Value
(Current)

Total:

b. Personal and Other Properties

Kind

Year Acquired

Ac

Total:

2. LIABILITIES ( Loans, mortgages, etc. )

Nature

Amou

Total:
NET WORTH [ Total Assets (1a + 1b) less Total Liabilities (2) ]

chanoabellano1/26/12

SETS, LIABILITIES AND NET WORTH

ERESTS AND FINANCIAL CONNECTIONS
ATIVES IN THE GOVERNMENT SERVICE

Republic Act No. 6713)

Date of Birth

ILITIES AND NET WORTH

Acquisition Cost
Land,
ImproveBldg. etc.
ment

Acquisition Cost

Amount

B. BUSINESS INTERESTS AND FINANCIAL CONNECTIONS

Do you have any business interests and other financial connections including thos
of your spouse and unmarried children below 18 years of age living with you in you
household? [
] Yes
[
] No. If yes, give particulars:
Name of Firm/
Name

Company

Nature of business
interests and/or
financial connections

Address

C. IDENTIFICATION OF RELATIVES IN THE GOVERNMENT SERVICE

To the best of your knowledge, are you related within the fourth degree of
consanguinity or affinity to anyone working in the government?
[
] Yes
[
] No. If yes, give particulars:
Name

Position

Relationship

Name/Ad

I hereby certify to the best of my knowledge and information, that these are true stateme
of my assets, liabilities, net worth, business interests and financial connections, including those of
spouse and unmarried children below 18 years of age and names of my relatives in the governmen
as of December 31 ,
20
, as required by law and in accordance with Republic Act 6713.

I hereby authorize the Ombudsman or his duly authorized representative to obtain and se
from all appropriate government agencies including the Bureau of Internal Revenue, such documen
that may show my assets, liabilities, net worth, business interests and financial connections, to incl
those of my spouse and unmarried children below 18 years of age living with me in my household
covering previous years to include the year first assumed office in the government.

Date:

, 20

Signat
Community Certificate No.:
Issued at:
Date Issued:
SUBSCRIBED AND SWORN TO before me this
affiant exhibiting his Community Tax Certificate as indicated above.

TIN:
B:

day of

MARIA JEAN R. S

Administrativ

chanoabellano1/26/12

STS AND FINANCIAL CONNECTIONS

s and other financial connections including those

dren below 18 years of age living with you in your
s
[
] No. If yes, give particulars:
Nature of business
interests and/or
financial connections

Date of
Acquisition or
Connection

LATIVES IN THE GOVERNMENT SERVICE

, are you related within the fourth degree of

to anyone working in the government?
] No. If yes, give particulars:
Name/Address of Office

ge and information, that these are true statements

ts and financial connections, including those of my
ge and names of my relatives in the government
aw and in accordance with Republic Act 6713.

duly authorized representative to obtain and secure

g the Bureau of Internal Revenue, such documents
siness interests and financial connections, to include
18 years of age living with me in my household

Signature

, 20

MARIA JEAN R. STO. DOMINGO

Administrative Officer V

REVISED SCHEDULE OF PREMIUM RATES

I. CASH ACCOUNTABILITY
MINIMUM CASH
ACCOUNTABILITY

MAXIMUM CASH
ACCOUNTABILITY

5,001.00
9,001.00
12,001.00
15,001.00
18,001.00
21,001.00
25,001.00
30,001.00
35,001.00
40,001.00
50,001.00
60,001.00
80,001.00
100,001.00
250,001.00
500,001.00
750,001.00
1,000,001.00
2,500,001.00
5,000,001.00
25,000,001.00
75,000,001.00

9,000.00
12,000.00
15,000.00
18,000.00
21,000.00
25,000.00
30,000.00
35,000.00
40,000.00
50,000.00
60,000.00
80,000.00
100,000.00
250,000.00
500,000.00
750,000.00
1,000,000.00
2,500,000.00
5,000,000.00
25,000,000.00
75,000,000.00
100,000,000.00

AMOUNT OF BOND
75% of their Total Cash
Accountability

9,000.00
11,250.00
13,500.00
16,750.00
18,900.00
22,500.00
26,250.00
30,000.00
37,500.00
45,000.00
60,000.00
75,000.00
100,000.00
225,000.00
350,250.00
500,000.00
750,000.00
1,500,000.00
3,500,000.00
4,000,000.00
5,000,000.00

II. PROPERTY ACCOUNTABILITY

1. Government Securities
2. Equipment
3. Supplies and Materials

30% of their Total Value

30% of their Total Value
30% of their Total Value

III. FOR ACCOUNTABLE FORMS

a)
b)
c)
d)
e)
f)
g)
h)
i)
j)

Internal Revenue Stamp

Documentary Stamp
Customs Documentary Stamp
Cash Tickets
Postage and Other Stamp Stocks
Cattle Registration Certificates
Marriage Certificates
Auto Driver Certificates
Motor Vehicle License
Other Accountable Forms
having Face Value

10 % of their Total Value

rounded off to the
nearest hundred

Attachment A

UM RATES

BOND PREMIUM
Bond Premium shall not be
less than 150.00

150.00
168.75
202.50
251.25
283.50
337.50
393.75
450.00
562.50
675.00
900.00
1,125.00
1,500.00
3,375.00
5,253.75
7,500.00
11,250.00
22,500.00
52,500.00
60,000.00
75,000.00

10 % of their Total Value

rounded off to the
nearest hundred

X 1.5% = PREMIUM

chanoabellano1/26/12