BTR-Form 57A

Agency or Office (Opisina)*

NAME OF PERSON TO BE BONDED/WHOSE BOND IS TO CANCELLED

Surname (Apelyido) *

Given (Pangaran) *

Middle Name

Designation or Title of Position (Posisyon)

Salary (Sweldo/Honorarium).

DATE INCOMING OFFICER ASSUMES ACCOUNTABILITY

Year (Tuig san Pagka Appoint) *

Month (Bulan) *

Day (Adlaw) *

STATION

Municipality (Munisipyo) *

Province/City (Probinsya or Ciudad) *

AMOUNTS OF MAXIMUM ACCOUNTABILITY/CUSTODY (PHP)

Public Funds

As Collecting Officer

As Disbursing Officer

Public Property

Supplies & Materials

Equipment

Others

Forms and Other Valuables

Internal Rev. Stamps

Internal Rev. Doc. Stamps

Customs Doc. Stamps

Postage & other Stamped Stock

Science Stamps

Cash Tickets

Total Cash

Bond - Cash

Bond Equipment & Other Properties

Bond - Supplies

Total Bond Premium

11. PRESENT TITLE OR DESIGNATION (Posisyon san babalyuhan na opisyal)

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

(Paga suratan lang kun may babalyuhan na opisyal)

10. NAME OF OFFICER TO BE RELIEVED (Pangaran san babalyuhan na opisyal)

Surname

Given

12.a AMOUNT OF BOND (Kantidad san dati na bond)

12.b RISK NUMBER IN FORCE (Dati na Risk Number)

13. SALARY OF PERSON TO BE RELIEVED (Sweldo san babalyuhan na opisyal)

15. CAUSE OF RELIEF (Dahilan san pagbalyo)

Year (Tuig san pagbalyo)

Month (Bulan)

Day (Adlaw)

Head of Agency (for LGUs - Mayor/Vice Mayor/Liga President/DILG Officer) *

Position/Designation*

Name of Agency*

BONDING AND/OR CANCELLATION OF BOND OF ACCOUNTABLE OFFICIALS AND EMPLOYEE OF THE REPUBLIC OF THE PHILIPPINES

Name (Pangaran san Aplikante) *

Designation (Posisyon) *

(OFFICE/AGENCY)

Head of Agency (Mayor/Vice Mayor/Liga President/DILG Officer) *

Designation/Name of Agency*

APPROVAL

ENDORSEMENT