Republic of the Philippines GENERAL FORM NO.

57(A)
(Revised March 24, 1976)
DEPARTMENT OF EDUCATION
Risk Number
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 2. DESIGNATION OR TITLE OF POSITION

Surname Given Middle

3. DATE OF INCOMING OFFICER ASSUMES ACCOUNTABILITY

Year Month Day

4. STATION

Municipality
5. AMOUNT OF MAXIMUM ACCOUNTABILITY/CUSTODY
₱
a) Public Funds
(1) As Collecting Officer
(2) As Disbursing Officer
Province/City
When extent or character of an Officer's control
Amount 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)

b) Public Property 6. SALARY ATTACHED TO THE POSITION

(1) Supplies and Materials ₱
(2) Equipment ₱ ₱
(3) Others ₱
(In case of temporary appointment or designation,
c) Forms and Other Valuables salary of permanent and temporary incumbent should
(1) Internal Rev. Stamps ₱ be stated)
(2) Internal Rev. Doc. Stamps ₱ 7. BOND RECOMENDED
(3) Customs Doc. Stamps ₱
(4) Postage and Other Stamped Stock ₱ ₱
(5) Science Stamps ₱
(6) Cash Tickets ₱ 8. BOND FIXED BY LAW OR BY THE CHAIRMAN
(7) Others ₱ COMMISSION ON AUDIT

Total Amount: ₱ ₱

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 11. PRESENT TITLE OR DESIGNATION

Surname Given 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 EMMA I. CORNEJO
Provincial Treasurer Schools Division Superintendent
chanoabellano1/26/12
GENERAL FORM NO. 57(A) FIRST INDORSEMENT
(Revised March 24, 1976) ,20

Respectfully forwarded, through the Bureau, Provincial or City Auditor,

REQUEST
for
BONDING AND/OR CANCELLATION OF BOND OF
ACCOUNTABLE OFFICIALS AND EMPLOYEES OF THE To the Treasurer of the Philippines, Manila, recommending approval of the
REPUBLIC OF THE PHILIPPINES bond proposed in item 7 of the within request.

}
Head of Agency or Office
(NAME) City Mayor EMMA I. CORNEJO
Provincial Treasurer Schools Division Superintendent

(DESIGNATION)
SECOND INDORSEMENT

(BUREAU, PROVINCE OR CITY) ,20_____

Respectfully Forwarded to the Treasurer of the Philippines, Manila

. (DATE TO BE EFFECTIVE)

Bond for the within mentioned position is approved and fixed in the
amount of P ______________________

Cancellation of the bond of M

(Brief to be filled in by the Treasurer of the Philippines in the amount of P __________________
under Risk No. ___________________is hereby noted.

By Authority of the
CHAIRMAN, COMMISSION ON AUDIT

(Bureau, City, Provincial, Agency,

chanoabellano1/26/12 Corporate Auditor)
 GENERAL FORM NO. 58 (A)
(Revised March 24, 1976)
REPUBLIC OF THE PHILIPPINES

APPLICATION FOR BOND OF ACCOUNTABLE OFFICIALS AND EMPLOYEES OF THE

REPUBLIC OF THE PHILIPPINES

I, of
hereby apply for bond as a in the service of
(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 Place and date of birth

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

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

6 Indicate Tax Account Number , attach latest statement of Assets and

Liabilities.
7 Name three (3) references:

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

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

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 the
nature thereof
12 Are you a member of any fraternal, social or political society? State the name and
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 20

IN THE PRESENCE OF:

(Witness) (Signature of Applicant)

SUBSCRIBE AND SWORN TO before me this day of 20

The applicant presented to me his/her Residence Certificate No. A- issued at
issued on

Doc No.:
Page No.:
Book No.: MARIA JEAN R. STO. DOMINGO
Series No.: Administrative Officer V

chanoabellano1/26/12
GENERAL FORM NO. 58 (A)
(Revised March 24, 1976)

CERTIFICATION OF VERIFICATION
The following description of the applicant is required to be filled and certify AND OBSERVATION
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. THIS IS TO CERTIFY that I verified the truthfulness of the answers to
the questions contained on the face of this form and found them to be
correct in so far as can be ascertained. I further certify having inquired
1 Height into the character, honesty, integrity, and efficiency of the within
2 Weight applicant and found him to be
3 Complexion PICTURE worthy of trust, confidence and reliance. Hence, the recommendation
4 Face with or without smallpox (Passport size or 2 X 2 ) of the undersigned as expressed in his 1st indorsement contained on
5 Color of eyes General Form 57-A to which this form (General Form 58-A) is attached.
6 Color of hair
7 Color of mustache
8 Color of beard
9 Birth and other marks on the:
(A) Face EMMA I. CORNEJO
(B) Body Schools Division Superintendent
(C) Hands
(D) Arms
(E) Legs and feet
Date: 20

I CERTIFY to the correctness of the foregoing description

of

ISRAEL F. PARRA, M.D.

20 Medical Officer III

chanoabellano1/26/12
 Republic of the Philippines
DEPARTMENT OF EDUCATION
Division of Camarines Sur
____________________________________
(Name of School)
____________________________________
(Address) Attachment B

LIST OF ACCOUNTABLE PUBLIC OFFICER(S)

(For New Applicants)

Remarks:
Name of Public Officer Designation Amount of Accountability ( WITH / WITHOUT pending case,
state nature of case, if any )

Prepared by: Certified and Approved by:

EMMA I. CORNEJO
(signature over printed name) Schools Division Superintendent

chanoabellano1/26/12
 Republic of the Philippines
DEPARTMENT OF EDUCATION
Division of Camarines Sur
___________________________________
(Name of School)
___________________________________
(Address)
Attachment B
LIST OF BONDED PUBLIC OFFICER(S)
(For Renewal)

PREVIOUS YEARS DATA Remarks:

Name of Public Officer Designation Effective Date Amount ( WITH / WITHOUT pending case,
Risk No.
From To Bond Premium state nature of case, if any )

Prepared by: Certified and Approved by:

MARIA JEAN R. STO. DOMINGO

(signature over printed name) Administrative Officer V

chanoabellano1/26/12
 Republic of the Philippines GENERAL FORM NO. 57(A)
(Revised March 24, 1976)
DEPARTMENT OF EDUCATION
Risk Number
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 2. DESIGNATION OR TITLE OF POSITION

Surname Given Middle

3. DATE OF INCOMING OFFICER ASSUMES ACCOUNTABILITY

Year Month Day

4. STATION

Municipality
5. AMOUNT OF MAXIMUM ACCOUNTABILITY/CUSTODY
₱
a) Public Funds
(1) As Collecting Officer
(2) As Disbursing Officer
Province/City
When extent or character of an Officer's control
Amount 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)

b) Public Property 6. SALARY ATTACHED TO THE POSITION

(1) Supplies and Materials ₱
(2) Equipment ₱ ₱
(3) Others ₱
(In case of temporary appointment or designation,
c) Forms and Other Valuables salary of permanent and temporary incumbent should
(1) Internal Rev. Stamps ₱ be stated)
(2) Internal Rev. Doc. Stamps ₱ 7. BOND RECOMENDED
(3) Customs Doc. Stamps ₱
(4) Postage and Other Stamped Stock ₱ ₱
(5) Science Stamps ₱
(6) Cash Tickets ₱ 8. BOND FIXED BY LAW OR BY THE CHAIRMAN
(7) Others ₱ COMMISSION ON AUDIT

Total Amount: ₱ ₱

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 11. PRESENT TITLE OR DESIGNATION

Surname Given 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 MARIA JEAN R. STO. DOMINGO
Provincial Treasurer Administrative Officer V
chanoabellano1/26/12
GENERAL FORM NO. 57(A) FIRST INDORSEMENT
(Revised March 24, 1976) ,20

Respectfully forwarded, through the Bureau, Provincial or City Auditor,

REQUEST
for
BONDING AND/OR CANCELLATION OF BOND OF
ACCOUNTABLE OFFICIALS AND EMPLOYEES OF THE To the Treasurer of the Philippines, Manila, recommending approval of the
REPUBLIC OF THE PHILIPPINES bond proposed in item 7 of the within request.

}
Head of Agency or Office
(NAME) City Mayor MARIA JEAN R. STO. DOMINGO
Provincial Treasurer Administrative Officer V

(DESIGNATION)
SECOND INDORSEMENT

(BUREAU, PROVINCE OR CITY) ,20_____

Respectfully Forwarded to the Treasurer of the Philippines, Manila

(DATE TO BE EFFECTIVE)

Bond for the within mentioned position is approved and fixed in the
amount of P ______________________

Cancellation of the bond of M

(Brief to be filled in by the Treasurer of the Philippines in the amount of P __________________
under Risk No. ___________________is hereby noted.

By Authority of the
CHAIRMAN, COMMISSION ON AUDIT

(Bureau, City, Provincial, Agency,

chanoabellano1/26/12 Corporate 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: Position/Income:
Surname First Name M.I. Office:
Address: Office Address:

Spouse Name: Position/Income:

Surname First Name M.I. Office:

Unmarried children below 18 years of age:

Name Date of Birth

1.
2.
3.
4.
5.

A. ASSETS, LIABILITIES AND NET WORTH

1. ASSETS
a. Real Properties

Year Mode of Assessed Fair Market Acquisition Cost

Kind Location Value Land, Improve-
Acquired Acquisition Value
(Current) Bldg. etc. ment

Total: ₱
b. Personal and Other Properties

Kind Year Acquired Acquisition Cost

Total: ₱
2. LIABILITIES ( Loans, mortgages, etc. )

Nature Amount

Total: ₱

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

chanoabellano1/26/12
 B. BUSINESS INTERESTS AND FINANCIAL CONNECTIONS
Do you have any business interests and other financial connections including those
of your spouse and unmarried children below 18 years of age living with you in your
household? [ ] Yes [ ] No. If yes, give particulars:
Name of Firm/ Nature of business Date of
Name Address interests and/or Acquisition or
Company
financial connections Connection

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/Address of Office

I hereby certify to the best of my knowledge and information, that these are true statements
of my assets, liabilities, net worth, business interests and financial connections, including those of my
spouse and unmarried children below 18 years of age and names of my relatives in the government
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 secure
from all appropriate government agencies including the Bureau of Internal Revenue, such documents
that may show my assets, liabilities, net worth, business interests and financial connections, to include
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
Signature
Community Certificate No.: TIN:
Issued at: B:
Date Issued:

SUBSCRIBED AND SWORN TO before me this day of , 20 ,

affiant exhibiting his Community Tax Certificate as indicated above.

MARIA JEAN R. STO. DOMINGO

Administrative Officer V

chanoabellano1/26/12
 Attachment A

REVISED SCHEDULE OF PREMIUM RATES

I. CASH ACCOUNTABILITY

MINIMUM CASH MAXIMUM CASH

AMOUNT OF BOND BOND PREMIUM
ACCOUNTABILITY ACCOUNTABILITY
75% of their Total Cash Bond Premium shall not be
₱ 5,001.00 ₱ 9,000.00
Accountability less than ₱ 150.00
9,001.00 12,000.00 ₱ 9,000.00 ₱ 150.00
12,001.00 15,000.00 11,250.00 168.75
15,001.00 18,000.00 13,500.00 202.50
18,001.00 21,000.00 16,750.00 251.25
21,001.00 25,000.00 18,900.00 283.50
25,001.00 30,000.00 22,500.00 337.50
30,001.00 35,000.00 26,250.00 393.75
35,001.00 40,000.00 30,000.00 450.00
40,001.00 50,000.00 37,500.00 562.50
50,001.00 60,000.00 45,000.00 675.00
60,001.00 80,000.00 60,000.00 900.00
80,001.00 100,000.00 75,000.00 1,125.00
100,001.00 250,000.00 100,000.00 1,500.00
250,001.00 500,000.00 225,000.00 3,375.00
500,001.00 750,000.00 350,250.00 5,253.75
750,001.00 1,000,000.00 500,000.00 7,500.00
1,000,001.00 2,500,000.00 750,000.00 11,250.00
2,500,001.00 5,000,000.00 1,500,000.00 22,500.00
5,000,001.00 25,000,000.00 3,500,000.00 52,500.00
25,000,001.00 75,000,000.00 4,000,000.00 60,000.00
75,000,001.00 100,000,000.00 5,000,000.00 75,000.00

II. PROPERTY ACCOUNTABILITY

1. Government Securities 30% of their Total Value 10 % of their Total Value

2. Equipment 30% of their Total Value rounded off to the
3. Supplies and Materials 30% of their Total Value nearest hundred

III. FOR ACCOUNTABLE FORMS

a) Internal Revenue Stamp

b) Documentary Stamp
c) Customs Documentary Stamp
d) Cash Tickets
e) Postage and Other Stamp Stocks 10 % of their Total Value X 1.5% = PREMIUM
f) Cattle Registration Certificates rounded off to the
g) Marriage Certificates nearest hundred
h) Auto Driver Certificates
i) Motor Vehicle License
j) Other Accountable Forms
having Face Value

chanoabellano1/26/12