Overseas Workers Welfare Administration CASH RELIEF (CARE) PROGRAM FOR THE AFFECTED OWWA MEMBERS/FAMILIES BY SUPER TYPHOON LAWIN CLAIM FORM Name of OWWA Member Tse Na [eee home aie ome) (Biff ome) Birthdate: Sex: Civil Status: Statusof Membership: [~ ]Active [ |Non-Active Name of Claimant: = — (hast Wem} (ist nome (nti toe) Relationship to the OFW: Claimant's Contact Number: Claimant's Address: Document Submitted: |] Proof of relationship to the OFW, if elaimant is not the OFW member (Pls. specify Copy of any proof of identity (Pls. Specify: ) ee “ACKNOWLEDGMENT AND DECLARATION J—)"/[hi//=il 0 Received the amount of (Php. )under Retief (CARE) Program for the affected OWWA members/families of Super Typhoon Lawin. | further declare that | belong to the family/individuals residing in calamity areas affected by Typhoon Lawin; Theres no other OFW-family member who availed of this program; and | may be liable for any false statement or representation made in this document. Signature of Ciaimant Over Printed Name Date received SRE Se PER, CERTIFICATION [EUGENES eRe ate eae Thereby certify that the information given herein are true and correct tothe best of my personal knowledge. Date of Application Signature of Cl Subse “THis PORTION is FOR OWWA USE ONLY) ete cess cl CASH RELIEF APPROVAL Php ‘Amount Granted Received by: Approved by: Processor Rogional Director