Republic of the Philippines

Department of Education
National Capital Region
Division of City Schools
MANILA

Pupils LRN: __________________________

Barangay: _______________ Province / City: _______________

CERTIFICATE OF RESIDENCY & GUARDIANSHIP

(for Non-Manila Resident/s only)

Date Issued: _________________

To Whom it may Concern:
This is to hereby certify that the bearer, whose name appears below,

Surname Middle Name First Name

and currently residing at ____________________________________ under this Brgy.

complete home address

is the parent / legal guardian of the following learner/s under their custody and that they physically live
with them in the above-stated address:
No. Surname Middle Name First Name Grade Public School (Elem/HS)

*add row/s below this line if necessary

Issued upon request of the parent only for the purpose of claiming Learning Tablets and Sim Cards in
behalf of the learner/s living under their custody.

Prepared by: Certified Correct:

___________________________________ _________________________________
Signature over printed name Signature over printed name
OVERALL COORDINATOR / IN-CHARGE BARANGAY CHAIRMAN
(Secretary / Kagawad for Education / SK Chairman)

Not Valid
DO NOT WRITE IN THIS PORTION, without
Official FOR RECEIVING SCHOOL USE ONLY:

Control No. _________ Remarks: ___________________________

******************************** THIS FORM IS NOT FOR REPRODUCTION AND NOT FOR SALE
********************************

MANILA EDUCATION CENTER, Arroceros Forest Park

Gat Antonio J. Villegas St., Ermita, Manila, 1000
☎ 8527-2315 • 8527-5184 • 8527-5180
🌍 www.depedmanila.net
📧 sdo.manila@deped.gov.ph