Philippine Health Insurance Corporation

PHILHEALTH REGIONAL OFFICE X

6/F Trinidad Building, Corrales-Yacapin Sts.,
Cagayan de Oro City

CERTIFIED LIST OF ELIGIBLE NEW INDIGENT FAMILIES

Province : Misamis Oriental________

Municipality : Jasaan Misamis Oriental
Baranggay : UPPER JASAAN_____________________
Validity : _______________________ Sponsor : __________________

NAME OF HEAD OF FAMILY CIVIL REMARKS

BIRTHDAY GENDER STATU (for PhilHealth use
SURNAME FIRST NAME MIDDLE NAME
S only)

This is to certify that the above-listed names are indigent and residents of the Barangay.

Noted By: Prepared By:

_________________ EDGAR D. LUMBATAN

Barangay Chairperson Social Welfare Assisstant

DATE : ___________ DATE : ____________

BONIFACIA P. TROZO
MSWDO

DATE : ____________