Republic of the Philippines

DEPARTMENT OF LABOR AND EMPLOYMENT

Caraga Regional Office
Butuan City

PROJECT TITLE-
ACP/BENEFICIARY-
DOLE Integrated Livelihood Program (DILP)-Kabuhayan
DOCUMENTS REQUIRED Date Submitted Responsible Check if Remarks
attached
(FOR Direct Admin-Group)
1 Application For Fund Assistance ACP/Beneficiary
2 Application Letter by the LGU duly signed by ACP/Beneficiary
the Local Chief Executive (LCE) addressed to the
DOLE Regional Director
3 Detailed Project Proposal which is duly ACP/Beneficiary
approved/signed by LCE
• Work and Financial Plan (WFP) ACP/Beneficiary
• Detailed Estimates of Approved Project ACP/Beneficiary
Expenditures or Estimated Expenses
4 List of Beneficiaries with their addresses Beneficiary

5 Individual Beneficiary Profile (with picture) and Beneficiary

Proponent ACP Profile
6 Copy of Certificate of Registration Beneficiary

7 Copy of Constitution and By-Laws Beneficiary

8 MOA between the DOLE RO and the ACP

Association
9 Certification of Non-coverage to Pantawid MSWDO
Pamilyang Pilipino Program (4Ps) to be issued
by LSWDO
OTHER (For Provincial Offices/Regional Office)
10 Project Appraisal Report by Provincial Office DOLE PO
11 RPMT Evaluation and Recommendation Report DOLE PO

Checked by: RONABETH B. CABAÑAS

Livelihood Focal Person

Verified by: GIOVANNI S. PAREDES

Accountant III
 THIS FORM IS NOT FOR SALE
Republic of the Philippines
DEPARTMENT OF LABOR AND EMPLOYMENT
Caraga Regional Office
Butuan City

APPLICATION FOR FUND ASSISTANCE

For NGOs/POs/GOs/cooperative/union/rural worker’s associations/ Local Government Units

Project/Program: __________________________________________________________________________________________

Checklist of Requirements:

For Local Government Units (LGU) as ACP:

[ ] Application Letter by the LGU duly signed by the Local Chief Executive (LCE) addressed to the Regional Director
[ ] Detailed Project Proposal which is duly approved/signed by the LCE
[ ] Board or Sangguniang Bayan (SB) Resolution authorizing the LCE to enter into a MOA to avail of DOLE Programs
[ ] Memorandum of Agreement (MOA) between the DOLE RO and the LGU
[ ] Work and Financial Plan
[ ] Detailed Estimates of Approved Project Expenditures or Estimated Expenses
[ ] Certification of No Unliquidated Cash Advances and /or grants from DOLE

For Other Types of ACPs:

[ ] Application Letter by the ACP addressed to the DOLE Regional Director
[ ] Detailed and duly signed Project Proposal from the ACP (indicating/showing that the ACP has equity equivalent to 20% of the Total
Project Cost
[ ] Individual Beneficiary Profile (with Picture) and ACP (Proponent) Profile
[ ] Copy of ACP Certificate of Accreditation
[ ] Board Resolution authorizing a representative to enter into a MOA
[ ] Memorandum of Agreement (MOA) between the DOLE RO and the ACP
[Profile
] Audited Financial Reports (statements) for the past three
of LGU/PO/GO/Cooperative/Union/Rural (3) yearsAssociation
Workers preceding theApplicant:
date of project implementation. For applicant which
has been in operation for less than three (3) years, financial reports for the years in operation and proof of previous implementation of
similar
Name projects
of Organization: Type of Organization:
[ ] Disclosure of other related business, if any
[ ] PO [ ] Cooperative [ ] LGU
[ ] Work and Financial Plan (WFP), and sources of and details of proponent’s equity participation in the project
[ ] List and/or photographs of similar projects previously completed, if any, indicating the source of funds for implementation
Registered Addresses: [ ] PO [ ] Union [ ] others_______(pls specify)
[ ] Sworn affidavit of the secretary of the applicant organization/entity that none of its incorporators, organizers, directors or officers is an
[ ] GO [ ] Rural Workers Association
agent of or related by consanguinity or affinity up to the fourth civil degree to the official of the agency authorized to process and/or
approve proposed Memorandum of Agreement (MOA), and release funds
[Office Telephone
] Certification No:the DOLE Regional Office’s Accountant that the
from Registration No.advance
previous cash and Date with DOLE/SEC/CDA
granted has been liquidated, liquidation
documents are post-audited and properly taken up in the books.
Affiliation with other organization/s: Taxpayer Identification Number (TIN)VAT no:

No. of Employees:
PREVIOUS GRANT/ASSISTANCE RECEIVED FROM DOLE
Date Title Amount Duration Status

Other related information/request/intervention/s from DOLE:

Attached are the documents/requirements which I/we attest to their veracity. Any false statement would cause the automatic cancellation of the
services/contract/grant and applicant shall refund amount received and /or pay damages to DOLE or other sanctions in accordance with law.
I/We declare that the answers given above are true and correct.
______________________________________
Signature of Representative of Organization*
*Must have Board Resolution/Partnership/Cooperative Board authorization.

For SPES (this serves as Contract of Service between DOLE and Employer):

I, ________________________________ (employer’s name) of ________________________________________

(Establishment) do hereby commit to employ applicant (attached application form/s as endorse by DOLE)

From ____________________________to __________________________and undertake to pay P_____________ Equivalent

to 60% of the wage of P ______________

Concurred by: Committed by:

________________________________________ _________________________________________________
DOLE (Name and Signature) Employer/Authorized Representative (Name and Signature)
Date: ____________________ Date: ___________________________

Brief Remarks: Certified Funds Available: [ ] 40 % DOLE Counterpart

____________________________
Chief Accountant
Date Accomplished ___________________
Date: ________________

Address: Nimfa Tiu Bldg. III, JP Rosales Ave., Butuan City OP-13-001
Revision No.: 02
Email : dolecaraga13@gmail.com Date Issued: 10/7/2019
Tel. No : (085) 225-3229/ 817-2358
 For DOLE Only
Evaluated by: Verified and Recommended by: Recommending Approval by: Approved by:

______________________ _____________________ _____________________ ________________________

Name, Position & signature Name, position & signature Name, Position & signature Name, position & signature

Date: _______________ Date: ___________________ Date: ___________________ Date: __________________

Voucher No.: ____________________________ Check No.: ___________________________________

Amount: _______________________________ Amount: ___________________________________

Date: _________________________________ Date: ____________________________________

Address: Nimfa Tiu Bldg. III, JP Rosales Ave., Butuan City OP-13-001
Revision No.: 02
Email : dolecaraga13@gmail.com Date Issued: 10/7/2019
Tel. No : (085) 225-3229/ 817-2358
 THIS FORM IS NOT FOR SALE
Republic of the Philippines
DEPARTMENT OF LABOR AND EMPLOYMENT
CARAGA Regional Office

ANNEX Z

DOLE KABUHAYAN PROGRAM

GROUP BUSINESS PLAN

PROJECT BRIEF
Proponent ACP/Proponent Beneficiary :
Proposed Business/Project :
No. of Beneficiaries :
Total Project Cost :
• DOLE Support :
• Proponent ACP/Proponent :
Beneficiary
• Others :
Total :
Contact Person :
Contact Number :

II. EXECUTIVE SUMMARY

• Marketing Aspect
• Production Aspect
• Management Aspect
• Financial Aspect
• Collaboration of Stakeholders’ Commitments (Organization/ACP, beneficiaries, etc.)

III. ORGANIZATION/ACP/PROPONENT OVERVIEW

• History, structure and organization

• Strategic direction
• People and relevant skills and expertise
• Address/location

IV. INTRODUCTION

A. Background Information
B. Purpose and objectives of the proposed business/project
C. Direct and indirect beneficiaries
D. Brief description of the proposed business

OM-13-005
Address: Nimfa Tiu Bldg. III, JP Rosales Ave., Butuan City Revision No: 02
Email : dolecaraga13@gmail.com Date Issued:
Tel. No : (085) 225-3229/ 817-2358 10/7/2019
 THIS FORM IS NOT FOR SALE
Republic of the Philippines
DEPARTMENT OF LABOR AND EMPLOYMENT
CARAGA Regional Office

V. THE PROPOSED BUSINESS/PROJECT

A. Marketing Plan
Describe/specify the following:
• Analysis of the market
✓ How the business would fit in?
✓ Who are the competitors
✓ What are the opportunities/threats?

• Products or services to be offered

✓ Quality
✓ Affordability

• Brand strategy
✓ What makes the product/service unique
✓ Advantage against competitors

• Distribution strategy
✓ How big is your volume requirement?
✓ What is your delivery schedule?
✓ What is your mode of selling (cash or credit or both)?

• Product strategy
✓ How you will sustain the delivery of product/service

• Pricing strategy
✓ What is your buying price?
✓ What is your selling price (mark-up)?

• Promotion strategy
✓ How you will promote your product/service

• Prospective Buyers
✓ Who are your buyers
✓ Where are they
✓ How big is your market share?
B. Production Plan
Describe/specify the following:
• Production Cycle (step by step procedures in producing the product/service)
• Plant/Workplace (building, size, lay-out, location)
• Raw Materials (how many, availability from supplier, cost)
• Facilities required and their production capacity (equipment, tools and materials)
OM-13-005
Address: Nimfa Tiu Bldg. III, JP Rosales Ave., Butuan City Revision No: 02
Email : dolecaraga13@gmail.com Date Issued:
Tel. No : (085) 225-3229/ 817-2358 10/7/2019
 THIS FORM IS NOT FOR SALE
Republic of the Philippines
DEPARTMENT OF LABOR AND EMPLOYMENT
CARAGA Regional Office

• Personnel (how many directly involved, production capacity, skills/training needed,

support services, remuneration)
• Safety and Health (safety measures, protective gears)
• Productivity (production capacity of personnel/equipment)
• Space (total area for production, stockroom for raw materials, office/transaction space)

C. Management Plan
Describe/specify the following:
• Composition of Project Management Team
• Specific Duties and Responsibilities
• Organizational Structure
• Tasks Assigned to Production Workers
• Specific training needs
• Commitment of Stakeholders
• Profit sharing scheme

D. Financial Plan
• Monthly Working Capital Requirement
a. Cost of Direct Raw Materials

Materials Unit Cost Quantity Total Cost

Total

b. Cost of Direct Labor

Labor Rate Quantity Total Cost OM-13-006

Revision No: 01
Date Issued:
12/01/2017
Total

c. Overhead Cost

1. PMT Supervision/Administrative Cost

Position Rate Quantity Total Cost

Total

2.* Marketing Cost: ______________________

3.* Utilities : ______________________

OM-13-005
Address: Nimfa Tiu Bldg. III, JP Rosales Ave., Butuan City Revision No: 02
Email : dolecaraga13@gmail.com Date Issued:
Tel. No : (085) 225-3229/ 817-2358 10/7/2019
 THIS FORM IS NOT FOR SALE
Republic of the Philippines
DEPARTMENT OF LABOR AND EMPLOYMENT
CARAGA Regional Office

4.* Transportation : ______________________

5.* Rent : ______________________

6.* Others : ______________________

(Note *: Show breakdown of computation)

d. Capital Outlay (Equipment/Tools)

Item Unit Cost Quantity Total Cost

Total

e. Pre-Operating Costs
i. Cost of Trainings (Show computation per training)
ii. Licenses/permits
iii. Other attendant costs

2. Total Project Cost

FUNDING SOURCE
TOTAL
ITEM Proponent/
COST DOLE Beneficiaries Others
Org
1. Land
2. Building
3. Working Capital
• Raw Materials
• Labor
• Equipment
• Overhead/
Administrative Cost
• Rent
• Marketing
• Utilities
• Transportation
4. Pre-Operating Expenses
• Training
• Licenses/Permits
• Others

OM-13-005
Address: Nimfa Tiu Bldg. III, JP Rosales Ave., Butuan City Revision No: 02
Email : dolecaraga13@gmail.com Date Issued:
Tel. No : (085) 225-3229/ 817-2358 10/7/2019
 THIS FORM IS NOT FOR SALE
Republic of the Philippines
DEPARTMENT OF LABOR AND EMPLOYMENT
CARAGA Regional Office

a. Financial Statements (three (3) year period)

• Income Statement (Profit-and-Loss Statement)

✓ How much does the business earn over a given period of time

b. Cash Flow Statement

✓ How much cash is needed to meet monthly obligations, when will it be
needed and where it is coming from

• Balance Sheet Statement

✓ Summary of all financial data at a given point in time showing the business’
growth in terms of net worth

E. Stakeholders’ Commitments

OM-13-005
Address: Nimfa Tiu Bldg. III, JP Rosales Ave., Butuan City Revision No: 02
Email : dolecaraga13@gmail.com Date Issued:
Tel. No : (085) 225-3229/ 817-2358 10/7/2019
FORMAT

(NAME OF ASSOCIATION)
(Association’s Address)

NAME OF BENEFICIARY ADDRESS

1.

2.

3.

4.

5.

7.

8.

9.

10.

11.

12.

13

14.

15.
 THIS FORM IS NOT FOR SALE

KABUHAYAN PROGRAM BENEFICIARY PROFILE FORM1

Project ID Number2:

PROJECT LOCATION3
________
Region: __ Province: Municipality/City: District: __ Barangay: _________ No. & Street Name:
_
PROJECT DETAILS
☐ Group ☐ Formation ☐ Restoration ☐ ACP
Type of Project4: Program Component5: Name/Title of Project6: Mode of Implementation7:
☐ Individual ☐ Enhancement ☐ Direct Admin
PERSONAL INFORMATION
Last First Middle ☐ Male mm/dd/yyyy If yes, specify:
Name: _________ ________ ______ Sex: Birthdate: ___________ Civil Status: __ Have disability? __
☐ Female
No. & Street Name Barangay District Municipality/City Province
Home Address: _________ _________ __ Contact No.: _________ Type of Beneficiary: _________________
SOCIAL SECURITY
GSIS No.: _________ Pag-IBIG No.: _________ PhilHealth No.: _________ SSS No.: _________ Others, specify: _________

I certify that the information provided in this form are true and correct. If registrant cannot sign, affix fingerprints in the presence of DOLE personnel.
Registrant is required to affix fingerprints
________ LEFT THUMB RIGHT THUMB

Signature
___________
Date Signed

OM-13-016
Revision No: 00
Date Issued:
10/23/2019

INSTRUCTIONS
1
All beneficiaries or members who will be involved in the project are required to fill-up this form.
2 Project ID Number – To be determined once the project is approved.
3 Project Location – refers to the place where the project, whether group or individual type of project, is located or found. Under this, indicate the specific region, province, municipality/city, district, barangay, and no./Street Name.

PROJECT DETAILS:
4
Type of Project – choose only one (1) Type of Project by ticking the box.
5
Program Component – choose only one (1) Program Component by ticking the box.
6 Name/Title of Project - Indicate the Name/Title that best describe the livelihood project. Example: Meat Processing, Rice Retailing, Ginger Tea Production, Starter Kit, etc.
7 Mode of Implementation - choose only one (1) Mode of Implementation by ticking the box.
SAMPLE ONLY
 Annex “B”

[ Insert Logo and Letterhead of Certifying Office ]

CERTIFICATION OF NON-COVERAGE TO
PANTAWID PAMILYANG PILIPINO PROGRAM (4Ps)

This is to certify that Mr./Ms._____________________, of legal age, residing at

(Name)

____________________________, is not a beneficiary of the Pantawid Pamilyang

(Address)

Pilipino Program (4Ps) of the Department of Social Welfare and Development (DSWD).

This certification is issued for whatever purpose or purposes it may serve

him/her.

Issued this ______ day of _____________ in ____________________________.

(Date) (Month and Year) (Place of issuance)

_______________________________
(Name and Signature of the Authorized Official)
_______________________________
(Position)
_______________________________
(Name of Agency/Institution with affixed dry seal)