57A front (New)Republic of the PhilippinesGENERAL FORM NO. 57(A)DEPARTMENT OF EDUCATION(Revised March 24, 1976)Division of Camarines SurRisk NumberREQUEST FOR BONDING AND/OR CANCELLATION OF BOND OFACCOUNTABLE OFFICIALS AND EMPLOYEES OF THEREPUBLIC OF THE PHILIPPINES1. NAME OF PERSON TO BE BONDED/WHOSE BOND IS TO BE CANCELLED2. DESIGNATION OR TITLE OF POSITIONSurnameGivenMiddle3. DATE OF INCOMING OFFICER ASSUMES ACCOUNTABILITYYearMonthDay4. STATIONMunicipalityProvince/City5. AMOUNT OF MAXIMUM ACCOUNTABILITY/CUSTODYWhen extent or character of an Officer's controlAmountover funds or property cannot be inferred from the titlea)Public Fundsor designation given, a full and complete statement of(1) As Collecting Officerduties should be given above.(2) As Disbursing Officer(Use additional sheet if necessary)b)Public Property6. SALARY ATTACHED TO THE POSITION(1) Supplies and Materials(2) Equipment(3) Others(In case of temporary appointment or designation,c)Forms and Other Valuablessalary of permanent and temporary incumbent should(1) Internal Rev. Stampsbe stated)(2) Internal Rev. Doc. Stamps7. BOND RECOMENDED(3) Customs Doc. Stamps(4) Postage and Other Stamped Stock(5) Science Stamps(6) Cash Tickets8. BOND FIXED BY LAW OR BY THE CHAIRMAN(7) OthersCOMMISSION ON AUDITTotal 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 RELIEVED11. PRESENT TITLE OR DESIGNATIONSurnameGivenMiddle12. AMOUNT OF BOND AND RISK NUMBER INFORCE13. SALARY OF PERSON TO BE RELIEVED14. DATE OF RELIEF15. CAUSE OF RELIEFYearMonthDay16. REMARKSHead of Agency or Office}City MayorEMMA I. CORNEJOProvincial TreasurerSchools Division Superintendentchanoabellano1/26/12

57A back (New)GENERAL FORM NO. 57(A)FIRST INDORSEMENT(Revised March 24, 1976),20Respectfully forwarded, through the Bureau, Provincial or City Auditor,REQUESTforBONDING AND/OR CANCELLATION OF BOND OFACCOUNTABLE OFFICIALS AND EMPLOYEES OF THETo the Treasurer of the Philippines, Manila, recommending approval of theREPUBLIC OF THE PHILIPPINESbond proposed in item 7 of the within request.Head of Agency or Office}(NAME)City MayorEMMA I. CORNEJOProvincial TreasurerSchools 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 theamount of P ______________________Cancellation of the bond of M(Brief to be filled in by the Treasurer of the Philippinesin the amount of P __________________under Risk No. ___________________is hereby noted.By Authority of theCHAIRMAN, COMMISSION ON AUDIT(Bureau, City, Provincial, Agency,chanoabellano1/26/12Corporate Auditor)

58A front (New)GENERAL FORM NO. 58 (A)(Revised March 24, 1976)REPUBLIC OF THE PHILIPPINESAPPLICATION FOR BOND OF ACCOUNTABLE OFFICIALS AND EMPLOYEES OF THEREPUBLIC OF THE PHILIPPINESI,ofhereby apply for bond as ain the service of(Bondable Position)at(Name of Office, Bureau or Government-Owned or Controlled Corporation)Province ofAPPLICANTS TO HOLD BONDABLE POSITIONS MUST ANSWER ALL QUESTIONS IN FULL(ALL REPLIES CONFIDENTIAL)1Place and date of birth2Civil status: Single, Married, or Widower/WidowHow many persons are dependent on you for support?3What salary will you receive?4Do you have any income other than your salary? If so, how much and from what source derived?5If engaged in any other business, give particulars and names of partners or associates, if any6Indicate Tax Account Number, attach latest statement of Assets andLiabilities.7Name three (3) references:8Have you ever been discharged from any position? If so, state particulars9Do you carry life insurance? If so, how much, in what company, and to whom payable?10Have you ever applied before for bond from any fidelity and guaranty company? If so, when andwhere?11Do you have any criminal or administrative records?If so, state briefly thenature thereof12Are you a member of any fraternal, social or political society?State the name andnature of each society13What 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, andin witness whereof, I affix my signature below, thisday of20IN THE PRESENCE OF:(Witness)(Signature of Applicant)SUBSCRIBE AND SWORN TO before me thisday of20The applicant presented to me his/her Residence Certificate No. A-issued atissued onDoc No.:Page No.:Book No.:MARIA JEAN R. STO. DOMINGOSeries No.:Administrative Officer Vchanoabellano1/26/12

58A back (New)GENERAL FORM NO. 58 (A)(Revised March 24, 1976)CERTIFICATION OF VERIFICATIONThe following description of the applicant is required to be filled and certifyAND OBSERVATIONby a competent physician of the Department of health in Manila or in theprovinces. One copy of his bust picture must be pasted on the space providedtherefore hereon.THIS IS TO CERTIFY that I verified the truthfulness of the answers tothe questions contained on the face of this form and found them to becorrect in so far as can be ascertained. I further certify having inquired1Heightinto the character, honesty, integrity, and efficiency of the within2Weightapplicant and found him to be3ComplexionPICTUREworthy of trust, confidence and reliance. Hence, the recommendation4Face with or without smallpox(Passport size or 2 X 2 )of the undersigned as expressed in his 1st indorsement contained on5Color of eyesGeneral Form 57-A to which this form (General Form 58-A) is attached.6Color of hair7Color of mustache8Color of beard9Birth and other marks on the:(A)FaceEMMA I. CORNEJO(B)BodySchools Division Superintendent(C)Hands(D)Arms(E)Legs and feetDate:20I CERTIFY to the correctness of the foregoing descriptionofISRAEL F. PARRA, M.D.20Medical Officer IIIchanoabellano1/26/12

Attach B (New)Republic of the PhilippinesDEPARTMENT OF EDUCATIONDivision of Camarines Sur____________________________________(Name of School)____________________________________(Address)Attachment BLIST OF ACCOUNTABLE PUBLIC OFFICER(S)(For New Applicants)Name of Public OfficerDesignationAmount of AccountabilityRemarks:( 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 Superintendentchanoabellano1/26/12

Attach B (Renewal)Republic of the PhilippinesDEPARTMENT OF EDUCATIONDivision of Zamboanga CityTICTAPUL NATIONAL HIGH SCHOOL(Name of School)Tictapul, Zamboanga City(Address)Attachment BLIST OF BONDED PUBLIC OFFICER(S)(For Renewal)Name of Public OfficerDesignationPREVIOUS YEARS DATARemarks:Effective DateRisk No.Amount( WITH / WITHOUT pending case,FromToBondPremiumstate nature of case, if any )ROSITA M. GREGORIOHEAD TEACHER I02/05/201402/04/2015100,000.001,500.00Prepared by:Certified and Approved by:ROSITA M. GREGORIO0(signature over printed name)Administrative Officer V

57A front (Renewal)Republic of the PhilippinesGENERAL FORM NO. 57(A)DEPARTMENT OF EDUCATION(Revised March 24, 1976)Division of Zamboanga CityRisk NumberREQUEST FOR BONDING AND/OR CANCELLATION OF BOND OFACCOUNTABLE OFFICIALS AND EMPLOYEES OF THEREPUBLIC OF THE PHILIPPINES1. NAME OF PERSON TO BE BONDED/WHOSE BOND IS TO BE CANCELLED2. DESIGNATION OR TITLE OF POSITIONSurnameGivenMiddle3. DATE OF INCOMING OFFICER ASSUMES ACCOUNTABILITYYearMonthDay4. STATIONMunicipalityProvince/City5. AMOUNT OF MAXIMUM ACCOUNTABILITY/CUSTODYWhen extent or character of an Officer's controlAmountover funds or property cannot be inferred from the titlea)Public Fundsor designation given, a full and complete statement of(1) As Collecting Officerduties should be given above.(2) As Disbursing Officer(Use additional sheet if necessary)b)Public Property6. SALARY ATTACHED TO THE POSITION(1) Supplies and Materials(2) Equipment(3) Others(In case of temporary appointment or designation,c)Forms and Other Valuablessalary of permanent and temporary incumbent should(1) Internal Rev. Stampsbe stated)(2) Internal Rev. Doc. Stamps7. BOND RECOMMENDED(3) Customs Doc. Stamps(4) Postage and Other Stamped Stock(5) Science Stamps(6) Cash Tickets8. BOND FIXED BY LAW OR BY THE CHAIRMAN(7) OthersCOMMISSION ON AUDITTotal 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 RELIEVED11. PRESENT TITLE OR DESIGNATIONSurnameGivenMiddle12. AMOUNT OF BOND AND RISK NUMBER INFORCE13. SALARY OF PERSON TO BE RELIEVED14. DATE OF RELIEF15. CAUSE OF RELIEFYearMonthDay16. REMARKSHead of Agency or Office}City MayorProvincial TreasurerAdministrative Officer V

57A back (Renew)GENERAL FORM NO. 57(A)FIRST INDORSEMENT(Revised March 24, 1976),20Respectfully forwarded, through the Bureau, Provincial or City Auditor,REQUESTforBONDING AND/OR CANCELLATION OF BOND OFACCOUNTABLE OFFICIALS AND EMPLOYEES OF THETo the Treasurer of the Philippines, Manila, recommending approval of theREPUBLIC OF THE PHILIPPINESbond proposed in item 7 of the within request.Head of Agency or Office}(NAME)City Mayor0Provincial TreasurerAdministrative 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 theamount of P ______________________Cancellation of the bond of M(Brief to be filled in by the Treasurer of the Philippinesin the amount of P __________________under Risk No. ___________________is hereby noted.By Authority of theCHAIRMAN, COMMISSION ON AUDIT(Bureau, City, Provincial, Agency,Corporate Auditor)

SALN frontSWORN STATEMENT OF ASSETS, LIABILITIES AND NET WORTHDISCLOSURE OF BUSINESS INTERESTS AND FINANCIAL CONNECTIONSAND IDENTIFICATION OF RELATIVES IN THE GOVERNMENT SERVICEAs of December 31,20(Required by Republic Act No. 6713)Name:Position/Income:SurnameFirst NameM.I.Office:Address:Office Address:Spouse Name:Position/Income:SurnameFirst NameM.I.Office:Unmarried children below 18 years of age:NameDate of Birth1.2.3.4.5.A. ASSETS, LIABILITIES AND NET WORTH1. ASSETSa. Real PropertiesKindLocationYearMode ofAssessedFair MarketAcquisition CostAcquiredAcquisitionValueValueLand,Improve-(Current)Bldg. etc.mentTotal: b. Personal and Other PropertiesKindYear AcquiredAcquisition CostTotal: 2. LIABILITIES ( Loans, mortgages, etc. )NatureAmountTotal: NET WORTH [ Total Assets (1a + 1b) less Total Liabilities (2) ]chanoabellano1/26/12

SALN backB. BUSINESS INTERESTS AND FINANCIAL CONNECTIONSDo you have any business interests and other financial connections including thoseof your spouse and unmarried children below 18 years of age living with you in yourhousehold? [ ] Yes [ ] No. If yes, give particulars:NameName of Firm/AddressNature of businessDate ofCompanyinterests and/orAcquisition orfinancial connectionsConnectionC. IDENTIFICATION OF RELATIVES IN THE GOVERNMENT SERVICETo the best of your knowledge, are you related within the fourth degree ofconsanguinity or affinity to anyone working in the government?[ ] Yes [ ] No. If yes, give particulars:NamePositionRelationshipName/Address of OfficeI hereby certify to the best of my knowledge and information, that these are true statementsof my assets, liabilities, net worth, business interests and financial connections, including those of myspouse and unmarried children below 18 years of age and names of my relatives in the governmentas 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 securefrom all appropriate government agencies including the Bureau of Internal Revenue, such documentsthat may show my assets, liabilities, net worth, business interests and financial connections, to includethose of my spouse and unmarried children below 18 years of age living with me in my householdcovering previous years to include the year first assumed office in the government.Date:, 20SignatureCommunity Certificate No.:TIN:Issued at:B:Date Issued:SUBSCRIBED AND SWORN TO before me thisday of, 20,affiant exhibiting his Community Tax Certificate as indicated above.MARIA JEAN R. STO. DOMINGOAdministrative Officer Vchanoabellano1/26/12

Attachment A (Premium rates)Attachment AREVISED SCHEDULE OF PREMIUM RATESI. CASH ACCOUNTABILITYMINIMUM CASHMAXIMUM CASHAMOUNT OF BONDBOND PREMIUMACCOUNTABILITYACCOUNTABILITY 5,001.00 9,000.0075% of their Total CashBond Premium shall not beAccountabilityless than 150.009,001.0012,000.00 9,000.00 150.0012,001.0015,000.0011,250.00168.7515,001.0018,000.0013,500.00202.5018,001.0021,000.0016,750.00251.2521,001.0025,000.0018,900.00283.5025,001.0030,000.0022,500.00337.5030,001.0035,000.0026,250.00393.7535,001.0040,000.0030,000.00450.0040,001.0050,000.0037,500.00562.5050,001.0060,000.0045,000.00675.0060,001.0080,000.0060,000.00900.0080,001.00100,000.0075,000.001,125.00100,001.00250,000.00100,000.001,500.00250,001.00500,000.00225,000.003,375.00500,001.00750,000.00350,250.005,253.75750,001.001,000,000.00500,000.007,500.001,000,001.002,500,000.00750,000.0011,250.002,500,001.005,000,000.001,500,000.0022,500.005,000,001.0025,000,000.003,500,000.0052,500.0025,000,001.0075,000,000.004,000,000.0060,000.0075,000,001.00100,000,000.005,000,000.0075,000.00II. PROPERTY ACCOUNTABILITY1. Government Securities30% of their Total Value10 % of their Total Value2. Equipment30% of their Total Valuerounded off to the3. Supplies and Materials30% of their Total Valuenearest hundredIII. FOR ACCOUNTABLE FORMSa)Internal Revenue Stampb)Documentary Stampc)Customs Documentary Stampd)Cash Ticketse)Postage and Other Stamp Stocks10 % of their Total ValueX 1.5% = PREMIUMf)Cattle Registration Certificatesrounded off to theg)Marriage Certificatesnearest hundredh)Auto Driver Certificatesi)Motor Vehicle Licensej)Other Accountable Formshaving Face Valuechanoabellano1/26/12