Name of Project: TUPAD

DOLE Regional Office 5

Province: ALBAY
Municipality: CAMALIG
Barangay: COTMON

LIST OF BENEFICIARIES
E-payment/
Name of Beneficiary Birthdate1 Address2 Bank Account
Type of ID No. (indicate
Type of Civil
No. (e.g. SSS, ID Number Contact No. the type of Occupation4 Sex5
Extension (YYYY/MM/DD City/ Beneficiary3 Status6
First Name Middle Name Last Name Barangay Province District Voter's ID) account and
Name ) Municipality no. as
applicable)
1

10

11

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I hereby certify that the above list of beneficiaries are displaced workers, underemployed or self-employed workers in the INFORMAL SECTOR that have lost their livelihood or whose earnings were affected by the COVID-19 pandemic; and NONE are living in the same house

Further, I certify that they, or any member of their families , were verified to have NOT received cash assistance from Department of Finance (DOF)'s Small Business Wage Subsidy Program and Social Security System (SSS) Unemployment Benefit.
Furthermore, NONE among the above list of beneficiaries are government employees (i.e. Local Government Units and Job Order Personnel), elected barangay officials and its appointed Barangay Health Workers and Barangay Tanod.

Prepared and Certified true and Correct by:

DENNISE L. MISOLANIA
LGU Authorized Representative or DOLE Officer (if direct admin)
Signature over Printed Name

Notes:
*Only the gray portion of this form should be submitted to concerned agencies, i.e DSWD for data matching/validation.
1 – Birthdate: Year/Month/Day (YYYY/MM/DD)
2 – Address: (Street No, Barangay, City/Municipality, Province, District)
3 –Type of Beneficiaries:
• Underemployed/Self-employed
• Minimum wage/below minimum wage earners that were displaced due to:
a. temporary suspension of business operations
b. calamity/crisis situation (please specify): COVID 19 pandemic, Earthquake, Typhoon (please specify), Volcanic eruption (please specify), Global/National financial
crisis, others
• PWDs, Senior citizens, Former rebels, Former Violent Extremist Groups, Indigenous People

4 - Occupation - Transport workers, Vendors, Crop growers (please specify, i.e tobacco farmer), Homebased worker (please specify, i.e sewer), Fisherfolks, Livestock/Poultry Raiser, Small transport drivers, Laborer (i.e. construction laborer, farm laborer; please
specify ).
• Others (please specify)
5 – Sex: F for female, M for Male
6 – Civil Status: S for single, M for married
7 – Dependent: Name of the Beneficiary of micro-insurance policy holder.
8 - Trainings: Agriculture crops production, Aquaculture, Automotive, Construction, Welding, Information and Communication Technology,Electrical and electronics, Furniture making, Garments and textiles, Food Processing, Cooking, Housekeeping, Tourism, Customer Services, Others (please specify)

Note: Statement of Informed Consent

I understand the purpose of this profiling activity. I voluntarily and willfully give my consent to be part of this undertaking. I certify that the information that I will give are true and correct and that any misrepresentation and falsification of information may void their application to TUPAD. I authorize the use, processing and sharing of my personal d
purpose that is intended for without prejudice to my rights stated in the Data Privacy Act of 2012.
 OSEC-FMS Form No. 4
Version 3

Interested
Dependent7 (Name of for Skills
If Yes, Indicate skills
Age Beneficiary of the Micro- Training
training needed8
insurance Holder) (Y - Yes
N - No)
9 pandemic; and NONE are living in the same household.

SS) Unemployment Benefit.

nod.

urism, Customer Services, Others (please specify)

D. I authorize the use, processing and sharing of my personal data for the