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Attachment B List of Bonded Public Officers - Renewal

Bureau of the Treasury form for the list of bonded public officers for renewal

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AGENCY LETTERHEAD

LIST OF BONDED PUBLIC OFFICERS
(FOR RENEWAL)
PREVIOUS YEAR'S DATA
NAME OF PUBLIC OFFICER DESIGNATION

EFFECTIVE DATE

AMOUNT
RISK NO.

From

To

BOND

PREMIUM

REMARKS
(WITH/WITHOUT
PENDING CASE,
STATE NATURE OF CASE,
if any)

Prepared by:

Certified and Approved by:

Signature over printed name

Name & Designation of Authorized Officical
 
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