Bond Application For Individual

BOND APPLICATION
(For Individual/Single Proprietorship)
The undersigned hereby applies for a Surety bond in the amount of PESOS: Seven Hundred Thousand (Php 700,000.00) in favor
of the PHILIPPINE CHARITY SWEEPSTAKES OFFICE (PCSO) to fully and faithfully guarantee the remittance of the previous day's
Net Cash Balance for his/her/its lotto outlet/s within the prescribed period in accordance with the Agency Agreement
executed.
For your consideration, I am giving hereunder the following information:
Note: Do not leave any question unanswered, if not applicable, please write "N/A"
1. Name Civil Status Age

(Surname ) (Given Name ) (Middle Name )
2. Residential Address Zip Code
3. Telephone No. Cellphone No/s. Email
4. Spouse's Name Occupation
5. Business/Employment Address, if any
Telephone No. Cellphone No/s. Email
6. EMPLOYMENT/BUSINESS BACKGROUND:
6.a. Lotto Outlet Address
Date of First Operation
Number of lotto outlets being operated
Locations of other lotto outlet/s
Average Monthly Income from Lotto Operations
6.b. If engaged in other business, its nature:
Total Gross Annual Income from other business:
6.c. If employed, what is your occupation?
Name of Employer :
Office Address
Telephone No. Cellphone No/s. Email
Total Gross Annual Income from employment:
7. REAL/PERSONAL PROPERTIES
7.a. TCT/CCT No. LOCATION FAIR MARKET VALUE WITH ENCUMBRANCE

(Land and Improvement) (Yes/No)
P
P
P
7.b. PERSONAL PROPS DATE ACQUIRED FAIR MARKET VALUE WITH ENCUMBRANCE
(Yes/No)
P
P
P
8. Do you have any savings or checking account? If so, in what bank and what is the present balance? _______________________________
_________________________________________________________________________________________________________________
9. If any of the above mentioned properties is/are presently mortgaged, please state name of mortgage, amount of original loan, present
balance and when due: _____________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
10. Do you carry fire insurance on any of those properties? If so, with what company and for what amount? ___________________________
_________________________________________________________________________________________________________________
11. Do you own stocks of companies listed in the Philippine Stock Exchange? If so, state name of issuing company, kind and number of shares
owned and current value thereof. _____________________________________________________________________________________
_________________________________________________________________________________________________________________
Bond Application (page 2)
12. If you carry life insurance, state how much, in what company, the beneficiary, how long has the policy been in force and approximate value
thereof: _____________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
13. Are you indebted, besides mortgage, to anyone for sums of money? If so, state name of creditor, how much on what account and when
due: ____________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
14. State whether you are co-maker in a loan, indemnitor in a bond undertaking, or guarantor for anyone and to what extent? ____________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
15. Have you ever had a bond cancelled, or an application declined by any surety company? When and why? __________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
16. If you have been issued bond/s before, state particulars below:
Name of Surety Type of Bond Amount Name of Obligee Date Terminated
17. Give below names, occupations, and address of responsible persons for reference in no case naming relatives:
Name Occupation Address
The above and foregoing statements and infomation are true and correct to the best of my knowledge and belief,
knowing that on the basis of which the GSIS shall be guided in considering this bond application.
Dated at ______________________________________________ this _________________ day of _________________________ 20_____
CONSENT DECLARATION STATEMENT

I hereby confirm that I have read and understand fully the GSIS Privacy Statement (https://www.gsis.gov.ph/gsis-privacy-statement ) pursuant to
the requirements of Republic Act No. 10173, otherwise known as the Data Privacy Act, and thereby give my consent to the manner of collection,
use access, disclosure and processing of my sensitive personal information by the GSIS.
Signature
REPUBLIC OF THE PHILIPPINES)
) S.S.
_________________________)
SUBSCRIBED AND SWORN to before me this ___________________ day of ________________________________, 20 ________

in ____________________________________________, affiant exhibited to me his/her Government Issued ID (GSIS, SSS, UMID, PAG-IBIG,
Philhealth, TIN, OSCA, Passport, Driver's License, etc.) with the following particulars:
ID NO. ISSUED ON ISSUED AT
Doc. No. ; NOTARY PUBLIC

Page No. ;
Book No. ;
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Bond Application For Individual

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BOND APPLICATION

(For Individual/Single Proprietorship)

1. Name Civil Status Age

7.a. TCT/CCT No. LOCATION FAIR MARKET VALUE WITH ENCUMBRANCE

Name of Surety Type of Bond Amount Name of Obligee Date Terminated

Name Occupation Address

Dated at ______________________________________ this _ day of _____________ 20_

CONSENT DECLARATION STATEMENT

SUBSCRIBED AND SWORN to before me this _ day of ______, 20

ID NO. ISSUED ON ISSUED AT

Doc. No. ; NOTARY PUBLIC

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