Philippine Consulate General – Dubai

OFFICE OF THE SOCIAL WELFARE ATTACHÉ FORM NO. - 20001

GENERAL INTAKE SHEET

Instruction: Write legibly and don’t leave anything blank. Incomplete information will
disqualify you for the assistance. DO NOT PHOTOCOPY THE FORM.

April 22, 2020

Date: ______________________ Immigration Classification: Intake Type:
Case No.: ____________________ (__) Documented (__) Walk-In X
(__)
Rescued
Case Category: ________________ X Undocumented
(__) (__) Referred X
(__)
Reach-out

I. BASIC INFORMATION:
Asis Jenneth Zafra
Name: _____________________________________ 47
Age ____ Female Civil Status:
Sex: _____
Married
_____________
Surname First Name Middle Name
Caloocan CIty
Date of Birth: ___________________________ Place of Birth: _________
December 13
____________________________ 1972
Month Date Year Municipality Province/City
Country
Catholic
Religion: ____________________________ Educational Attainment:
Highschool Graduate
________________________________
Complete Address in the Philippines:
0920 San Vicente St, Bilibiran Binangonan Rizal
__________________________________________________________
Complete Address Abroad:
49 D Street Villa 95 D Mirdif, Dubai
___________________________________________________________________
0528193292
Contact Number in UAE: ________________________ Date of Arrival in UAE:
June 22, 2007 None
_______________ _______
Name of Employer:
None
_________________________________________________________________________
Domestic Helper/ NannyActual Salary received:
Actual Work/Job Abroad: ________________________
None
________________________
Jessa Asis
Name of the next of kin (NOK) in the Philippines: _________________________ Relationship:
Daughter
___________
09126161151
Contact # of NOK: ____________________Address of the NOK:
0920 San Vicente St, Bilibiran Binangonan Rizal
___________________________________

II. FAMILY COMPOSITION:

Civil Educational Monthly
Name Birthday Age Sex Relationship Occupation Remarks
Status Attainment Income
Jessa Asis 13
Mar. 28, 2007 F Daughter Single K-12 None None
Joan Asis Jan.4, 200218 F Daughter Single K-12 None None
Jane Asis Jan.4, 200218 F Daughter Single K-12 None None
Raffy Asis 19
Sept.10, 2000 M Son Single K-12 None None
21
Ma. Elena AsisSept.19, 1998 F Daughter Single Undergrad. None None
22
Jennyrose Asis Nov.16, 1997 F Daughter Single Undergrad. None None
Ronald Asis 23
Nov.15, 1996 M Son MarriedUndergrad. None None

III. PROBLEM PRESENTED AND ASSISTANCE NEEDED /ASSESSMENT:

I I am currently unemployed and staying out and having a difficulty paying for a rent and providing food for m
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last January 22 and finished my grace period last February and unfortunately I wasnt able to find a new em
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of COVID. Im also not exempted just like with those residence who got a visa amnesty that is extended till
__________________
financial help that will sustain my basic needs to survive my stays at home during this quarantine period. I w
________________________________________________________________________________
_________
 I actually have 11 children. Six boys and five girls which are all staying in the Philippines. And I am the one
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But due to the pandemic, i am not able to give anything to my family members. I hope you understand my
________________________________________________________________________________
__________________
________________________________________________________________________________
_________
________________________________________________________________________________
_________
________________________________________________________________________________
_________
(You may continue at the back page)

V. RECOMMENDATIONS (TO BE FILLED OUT BY DSWD):

________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
___________________________

Jenneth Zafra Asis

Signature over printed name of OF Signature over Printed
name SW Attaché