LIBERTY INSURANCE CORPORATION

2/F JCS Building, 119 dela Rosa cor., C. Palanca Streets

Legaspi Village, Makati City
Telephone nos. 810-1347/819-1961 Fax no. 818-8639

BOND APPLICATION FORM

(Individual/Single Proprietorship)

HEIR'S
The undersigned hereby applies for an_______________________ Bond in the amount of
542,715.44 BDO SM HYPERMARKET DAET BRANCH
P________________ in favor of ____________________________________________ to fully and
the savings deposit left by my late mother EDNA PADA PARDO
faithfully guarantee ________________________________________________________________

(Indicate details of undertaking or attach copy of contract or corresponding document or documents

for which bond is required)

For your consideration, I/We am/ are giving hereunder the following information:

1. ERIKA MAE PADA PARDO

Name ________________________________ FILIPINO Status ______
Nationality ________ SINGLE
2. PUROK 4, BARANGAY GABON, TALISAY, CAMARINES NORTE
Residential Address ___________________________________________________
3. N/A
Office Address _______________________________________________________
4. N/A
What is your occupation? _______________________________________________
5. N/A
How long have you been engaged as such? _________________________________
6. N/A
What is your monthly salary?____________________________________________
7. If you are engaged in business, please describe its nature and state the monthly or annual
income you derive from this source. ________________________________
8. Do you have any savings or checking account? If so, with what bank and what is the
BDO SM HYPERMARKET DAET BRANCH
present balance? ______________________________________________________
9. If you own real estate properties, please give the following particulars (If land, state if
titled or unregistered, whether residential, commercial or agricultural and also area
thereof. If store, bodega, etc.) and type of construction (concrete, timber, light material,
etc.)

Description Location Area Assessed Value Market Value

N/A
A. __________ ________ ____ _____________ _________________
B. __________ ________ ____ _____________ _________________
C. ___________ ________ ____ _____________ _________________

10. If any of the above-mentioned property/ies is/are presently mortgaged, please state the
following:

Description of Name of Amount of Present

Property _ Mortgagee Original Loan Balance Due Date

N/A
A. _____________ __________ ______________ _________ ____________
B. _____________ __________ ______________ _________ ____________
C. _____________ __________ ______________ _________ ____________

11. Do you carry fire insurance or any of these properties? If so, please state the following:

Description of Name of Amount of

Property _ Insurance Co. Insurance _ Expiry Date

N/A
A. ___________________ ______________ _________ ____________
B. ___________________ ______________ _________ ____________
C. ___________________ ______________ _________ ____________

12. Do you own stocks of companies listed in the Philippines Stocks Exchange?
YES __________ ✓
NO _________

Issuing Company Kind No. of Shares Current Value

A. __________________ _________ _________ ____________

B. __________________ _________ _________ ____________
C. __________________ _________ _________ ____________
 13. Do your carry Life Insurance? YES _________ ✓
NO _________

Name of Insurance Co. Face Value Beneficiary Date Issued

A. ___________________ _________ ___________________ ____________

B. ___________________ _________ ___________________ ____________
C. ___________________ _________ ___________________ ____________

14. Are you indebted to anyone for sums of money? YES _______ ✓
NO________

Name of Creditor Amount of Loan Date Due Security

A. _____________________ _______________ _________ ____________

B. _____________________ _______________ _________ ____________
C. _____________________ _______________ _________ ____________

15. Have you ever been issued a bond? YES _______ ✓

NO________

Surety Company Type of Bond Amount Obligee Security

A. _________________ ______________ _________ _________ _______

B. _________________ ______________ _________ _________ _______
C. _________________ ______________ _________ _________ _______

16. Are you an endorser or surety for anyone? YES _______ ✓

NO________

17 For proper evaluation of your subject application for Bond, please submit the following
documents:

a. Copy of contract, agreement, instrument, purchase order, etc., subject of the bond
b. Latest Audited Financial Statement/Income Tax Return
c. Copy of Approved Registration of Business Name
d. List of completed projects/works (Indicate owner, description, amount and year of
completion) and
e. List of on-going projects/works and indicate percentage of completion
f. Copy of OCT/CT covering real properties owned.
g. Co-signer’s statement – if applicable
h. Cash collateral equal to the amount of the bond – if applicable

THE ABOVE AND FOREGOING STATEMENT AND REPRESENTATION ARE TRUE AND
CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF AND ARE MADE FOR THE
PURPOSE OF INDUCING LIBERTY INSURANCE CORPORATION.

Dated at _________________________this ______ day of ___________________ 200___

Signature over printed name

SSS ___________________________
Passport No. __________________________

Submitting agent: _________________

Code No. ________________________