To: -------- Land Bank of the Philippines ---------------------------------------------ATAP NO. _______________
-------------ln tramuros Branch

AUTHORITY TO ACCEPT PAYMENT

FOR DEPOSIT TO SAVINGS ACCOUNT OF THE TREASURER OF THE PHILIPPINES

PAYING AGENCY	AREA CODE

PAYING AGENCY CODE	DATE PREPARED

ADDRESS	BILL NO.(YEAR-MONTH-NUMBER)

COMPUTATION OF FIDELITY BOND PREMIUM DUE

FUND CODE	TRANSACTION CODE	AMOUNT OF BOND (at 1.5% perrannum/PlSO.OO)	AMOUNT

	P

TOTAL AMOUNT PAYABLE	P

PREPARED BY: __________________________________ Signature over Printed Name and position	APPROVE BY: ____________________________________ Signature over Printed Name and position

FOR BANK'S USE ONLY DETAILS OF PAYMENT

PARTICULARS	DRAWEE BANK/NUMBER

CASH		P

CHECK

TOTAL PAYMETN RECIEVED		P

BANK MACHINE VALIDATION OF AMOUNT AND DATE