Document No.

WVSU-OSA-SOI-01-F03
FORM
Revision No. 0
Date of Effectivity: July 10, 2015
WEST VISAYAS STATE
Issued by: OSA
UNIVERSITY
Page No. Page 1 of 2

GOVERNMENT BARANGAY SCHOLARSHIP FORM

_____ Semester, SY _____________

Date: _____________

THE PRESIDENT
This University

Sir/Madam:

May I apply for the start/continuance of my _________________________

Scholarship for the SY, ___________, ________ Semester, I have complied with all
the requirements for the said scholarship. Thank you.

Very truly yours,

_________________________
Signature over Printed Name of Scholar
_________________________
Course/Year & Section
Recommending Approval:

_________________________________
College Dean

Action Taken: ( ) Approved ( ) Disapproved

NANCY S. SURMIEDA, Ph. D.

Dean, OSA

A. PERSONAL DATA

Name of Student: ___________________________ Course/Year & Section: _____

STFAP Bracket: ______Age: ____ Birth Date: _______________ Gender: _______
Name of Parents: ________________Complete Home Address: ________________
Contact Number: ________ Scholarship enjoyed the previous term:_____________
Adviser: _______________________________
 Document No. WVSU-OSA-SOI-01-F03
FORM
Revision No. 0
Date of Effectivity: July 10, 2015
WEST VISAYAS STATE
Issued by: OSA
UNIVERSITY
Page No. Page 2 of 2

B. CERTIFICATION:

To whom it may concern:

This is to certify that __________________________ is a legitimate

son/daughter of Brgy. Captain/Council Person/Sanguniang Kabataan Official
(Chairperson/Councilor) of Brgy. _____________________ Municipality / City of
_________________ province of _______________, is duly enrolled at WVSU
College of _______________________,Course, Year & Section ____________ is
hereby granted exemption from tuition and matriculation fees this _____ semester,
SY ________. Pursuant to Section 393/Section 434 of Republic Act 7180 (Local
Government Code).

____________________
Registrar

C. ATTACH THE FOLLOWING DOCUMENTS SPECIFIED FOR

SCHOLARSHIP/GRANT
1. Barangay Scholars – (a) ITR of Parents (must not exceed Php 120,000
annually) or BIR Exemption, (b) Certification from the DILG that he/she
is an incumbent Barangay Official, (c) Birth Certificate (NSO), (d)
Parent’s Marriage Contract, (e) Copy of grades (no grade lower than
2.5 in all subjects)
2. SK Scholars – (a) Certification from DILG as to the status of being an
SK Official, (b) ITR of Parents (must not exceed Php 120,000 annually)
or BIR Exemption, (c) Copy of grades (no grade lower than 2.5 in all
subjects)

Note: Age limit - until 21 years old only. Duration of Scholarship – 4 years
only. Only 2 dependents of each Brgy. Officials are allowed to avail of this
scholarship at the same time. Must present updated original certifications
every semester. Dependents and SK officials from other provinces are NOT
qualified recipients of this scholarship. Those from Iloilo Province can attend
WVSU if the course they will enroll in is not offered in the nearest SUC to their
residence. They must present a certificate from their Registrar to this effect. If
they insist to study at WVSU, they must be ready to pay for their tuition and
other fees.