Republic of the Philippines Department of Social Welfare and Development Crisis Intervention Unit Field Office I -San Fernando City, La Union CERTIFICATE OF ELIGIBILITY Date This is to certify that ™ ©) ‘Name of Client ‘Years old and presently residing at ‘Age ‘Adaress has been found eligible for Kind of Assistance After thorough assessment has been conducted. Records of case ( )GLS. ( )C.E. ( ) Medical Records ( ) others are in confidential file of the Crisis Intervention Unit. Client is hereby recommended for (__) Medical/ (_) Burial/ (_) FA for basic /essential () Transportation Assistance (_) Educational Assistance Needs assistance in the amount of. pesos only. Php Chargeable Against (_)CIU (_)EAICS Assessed by: ‘Social Welfare Officer IT PRC Liease No, Conforme: Signature over Printed Name /Thumb mark of the client Approved: LOUIE A. ACOSTA ‘SWO IIL, CIS Head PRC Ligense No, OO13117