Bond Application

Bond Information

Name*

First Last

Office: (Give full title of position of which bond is required)*

Appointment Date*

Years Beginning:*

Years Ending*

Terms of this office is:*

Bond in Favor of: (Name and Address - "Obligee")*

Amount of Bond:*

Effective Date:*

Application - Personal Information

Residence Address:*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Value of Real Estate Owned (if any):

Amount Encumbered:*

Value of Personal Property Owned:*

Particulars and amount of your debts:

Income from this Office:

State Total Income (include Income from this Office):*

Have you ever applied to any other source for a bond?*

Yes
No

If Yes: State when, to whom and whether it was successful:

Have you previously occupied this position?*

Yes
No

If Yes: Please provide dates:

Name of Surety:*

Occupation prior to assuming present position:*

Does the Applicant occupy more than one Bonded position?*

Yes
No

Internal Control Information

Is there an anuual audit by a CPA independent of your organization?*

Yes
No

Date of completion of last audit (a copy of the audit report is required if bond exceeds $750,000):

Name and address of CPA performing the audit:

Approximate amount of money handled during the year:*

Largest amount at one time under your control:*

During what months of the year are your receipts the largest?*

In what bank(s) are the receipts of this office now deposited?*

Under what authority have these depositories been designated?*

Are the fund withdrawn from this bank by the check of the applicant?*

Yes
No

If yes, is a countersignature required?

Yes
No

If yes, who provides the countersignature?

Does someone not authorized to make deposits or withdrawals reconcile the bank accounts?*

Yes
No

If no, please explain what alternate safeguard is in place:

If tax collector, name and address of entity to whom the bond will be issued:

If property tax collector is in Pennsylvania, current tax duplicate applicant is responsible for and breakdown of entities where taxes will be admitted.

County:

Township:

School District:

Other:

Applicant Full Name (This acts as your signature):*

Applicant's Phone:*

Applicant's Email:*

Today's Date:*

School Pool for Excess Liability Limits

Joint Insurance Fund

Bond Information

Application - Personal Information

Internal Control Information

If property tax collector is in Pennsylvania, current tax duplicate applicant is responsible for and breakdown of entities where taxes will be admitted.

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