CHED-TDP Form

2019 version (NOT FOR SALE) ANNEX "A"

Office of the President of the Philippines
COMMISSION ON HIGHER EDUCATION
REGIONAL OFFICE

CHED TULONG DUNONG PROGRAM (CHED-TDP)

APPLICATION FORM

Instructions: Read General and Documentary Requirements. Fill in all the required information. Do not leave an item blank. If item is not applicable, indicate "N/A".

GENERAL QUALIFICATION REQUIREMENTS per Section 6 of the Joint Memorandum

Circular No.
1 Filipino citizen;
2 High school graduates; or college students with earned units in CHED-recognized programs of Private HEIs,
SUCs or LUCs with COPC with at least a passing general weighted average (GWA); or passer of
3 With combined annual gross income of parents/guardian which shall not exceed Four Hundred Thousand Pesos
(PhP400,000.00).
NOTE: Applicant shall not avail of any national government-funded assistance, except for Free Higher
DOCUMENTARY REQUIREMENTS per Section 7.2 of the Joint Memorandum
Circular No.
Academic Requirements:
a. For Incoming Freshmen students eligible for college – high school report card;
b. For Applicants with Earned Units in college in CHED-recognized programs of Private HEIs and
SUCs/LUCs with COPC – duly certified true copy of grades for the latest semester/term attended
c. For Other Applicants:
ALS - duly certified copy of ALS Accreditation and Equivalency Test Passer Certificate; and PEPT -
duly certified copy of PEPT Certificate of Advancing to the Next Level
Income Requirements - whichever is applicable :
Latest Income Tax Return and Bureau of Internal Revenue Form 2316 for fixed income earners of

Education in SUCs and LUCs under RA 10931, the “UAQTE Act of 2017.” parents/guardian, if employed; Certificate of Tax Exemption from the BIR of parents/guardian, if not employed; Certificate
of Indigence from the Barangay concerned; Certificate of Indigence/Case Study from the Department of Social Welfare and
Development; or Latest copy of contract or proof of income, for the children of Overseas Filipino Workers and seafarers.

PERSONAL INFORMATION

Manalo JEANNE SHONEI MENDOZA N/A

1. Name
(Extension
(First Name)
(Last Name) (Middle Name) Name)
2. Date of Birth (mm/dd/yy) November 05, 2001
9. Permanent Address Purok 2 Magapi, Balete, Batangas
Lipa City, Batangas
3. Place of Birth (Street/Brgy., Town/City, Province)

4. Sex Male ✓ Female 10. Zip Code 4219 11. District 3rd
✓ Single Widowed 9. Permanent Address Purok 2 Magapi, Balete, Batangas
5. Civil Status Married
(Street/Brgy., Town/City, Province)
Separate
d
Annulled 10. Zip Code 4219 11. District 3rd
6. Citizenship Others
FILIPINO 11. Name of School Last Attended Leuteboro National High School
7. Mobile Number 12. School Address
0975 830 0172 Leuteboro 2, Western Nautical Highway, Socorro Oriental Mindoro
8. E-mail Address jeanne05.manalo@gmail.com
13. School Sector: ( ✓ )Public ( )Private 14. Learner Reference Number (LRN) 110674120268
15. Highest Attained Grade (Year Level) N/A
SECOND YEAR COLLEGE 16. Type of Disability (if applicable)

17. IP affiliation (if applicable) N/A

FAMILY BACKGROUND
Father: (✓ ) Living ( ) Deceased Mother: (✓ ) Living ( ) Deceased Legal Guardian

Sonia M. Manalo Victoria M. Mendoza

18. Full Name (including middle name) Anthony M. Manalo Sitio Triangle, Matula-tula Pola,
19. Address Oriental Mindoro
Sitio Triangle, Matula-tula Pola, Oriental Mindoro
0912 276 1901 Purok 2 Magapi, Balete, Batangas
20. Contact Number 0912 276 1901
Housewife 0927 071 0650
21. Occupation Farmer
N/A
22. Name of Employer N/A N/A N/A
23. Employer Address N/A N/A
N/A
24. Total Parents Annual Gross Income ₱ 50,000 N/A
N/A
25. Number of siblings One (1)
26. School Intended to enroll or enrolled in: BATANGAS STATE UNIVERSITY - JPLPC MALVAR CAMPUS
27. School Address: MALVAR BATANGAS
28. Type of School: (✓) Public ( ) Private
29. Degree Program: BSBA MAJOR IN MARKETING MANAGEMNT

Type Grantee Institution/Agency

30. Are you enjoying other sources of educational/financial assistance? ( ) Yes or ( ) No ✓ If yes, please specify 1.
2.
I hereby certify that foregoing statements are true and correct. Any misinformation or witholding of information will automatically disqualify me from the CHED-Tulong Dunong Program. I am willing to refund the financial
benefits received if such information is discovered after acceptance of the award.
I hereby express my consent for the Commission on Higher Education to collect, record, organize, update or modify, retrieve, consult, use, consolidate, block, erase or destruct my personal data as part of my information. I
hereby affirm my right to be informed, object to processing, access and rectify, suspend or withdraw my personal data and be indemnified in case of damages pursuant to the provisions of the Republic Act No. 10173 of the
Philippines, Data Privacy Act of 2012 and its corresponding Implementing Rules and Regulations.

MANALO JEANNE SHOMEI M. MAY 25, 2021

(Signature over Printed Name of Applicant) Date Accomplished
Note: Fully accomplished form to be submitted to the CHEDRO
DO NOT FILL-OUT THIS PORTION (FOR CHED USE
ONLY)
Documents Attached:
1. Academic
Belongs to: (any of the following groups)
( ) Report Card ( ) Copy of Grades: Grade 11 or 1st semester of Grade 12
dependent of solo parent
2. Financial
senior citizens
please specify type of disability ( ) ITR ( ) Tax Exemption ( ) Certifcate of Indigency
persons with disabilities
indigenous and ethnic peoples, please specify membership
( ) Case Study DSWD ( ) OFW Contract
3. Others
( ) Solo Parent ( ) Senior Citizen ( ) IPs ( ) PWD ( ) 4Ps
Evaluated/Processed by:
CHED StuFAP Coordinator