DECLARATION OF RECIPIENT

I, ANTONETTE B. DUMALE, Filipino citizen, of legal age, and a resident of PRK. 1, BRGY. TUBI-ALA,
SURALLAH, SOUTH COTABATO, duly states that I am a first time recipient of cash assistance from the
National Government through the Assistance Program of the NCCA and has not been a beneficiary of
any of the following government agencies and any assistance program under the Joint Memorandum
Circular No. 1, s. 2020:

1. TUPAD of the Department of Labor (DOLE);

2. SAP of the Department of Social Welfare and Development (DSWD);
3. First Batch of the NCCA Assistance Program;
4. Assistance Program of the Artists’ Welfare of the Philippines, Inc. supported by NCCA;
5. DEAR of the Film Development Council of the Philippines;
6. Assistance Program of the Film Academy of the Philippines supported by the NCCA;
7. Other programs and assistance spearheaded by the National Government.

I hereby authorize the NCCA or their duly authorized representative/s to obtain and secure from all
appropriate government agencies, including but not limited to: Department of Interior and Local
Government, Department of Social Welfare and Development, and the Department of Labor and
Employment, such documents that may show receipt or availment of other forms of assistance provided
during this time of Public Health Emergency due to Covid-19. Otherwise, if found and proven to be a
recipient of other assistance program, I shall return the amount received from the NCCA under this
Program.

By submitting this Form, I am authorizing the NCCA to collect the above information to be used solely for
the evaluation and processing of my application. I hereby certify that all information given are true and
correct and that any misrepresentation and/or manifestation of fraud in this application shall be a
ground for disapproval of my application and/or the filing of the administrative and/or criminal charges
against me.

This declaration is being issued as part of the supporting documents for the request of cash assistance
from the National Commission for Culture and the Arts (NCCA) and for whatever legal or administrative
purpose it may serve.

ANTONETTE B. DUMALE

Signature over Printed Name