OSCA FORM NO. 3 CMO.OSCA.F.003 REV.

003 16 MAY 2022

Series of 2022

REPUBLIC OF THE PHILIPPINES

CITY MAYOR’S OFFICE
OFFICE FOR SENIOR CITIZENS AFFAIRS Requirements:
MAIN OFFICE 1. OSCA ID or Government Issued ID
Agton Street, Toril, Davao City, Davao Del Sur With Birthdate / Mailing Address
(OSCA bldg.) Tel. No.: 272 4029 2. Verified Complaint Letter
(CSWDO bldg.) Tel. No.: 241-1000 Loc. 394-395 3. Official Receipt / Invoice
CITY OF DAVAO

COMPLAINT FORM ON VIOLATION OF R.A. 9994

Fill in all the required information. Do not leave an item blank. If item is not applicable, indicate "N/A".
Name of Complainant

Age Sex OSCA ID No. Place Issued

Complete Address:

Name of Respondent: (Sales Girl/Waiter/etc)

Name of Establishment / Operator

Address / Location
Date of Incidence Time of Incidence
For Transportation Indicate Plate No.
Other Information

Nature of Violations : Please check appropriate box and underline specific concern:

Not granted 20%discount in hotels and similar lodging establishments

Not granted 20% discount in restaurants
Not granted 20% discount in recreation centers
Not granted 20% discount in admission fees charged by theaters, concert halls, cinema houses, circuses,
carnivals and other similar places of culture/leisure
Not granted 20% discount in private hospitals and medical facilities on
Medical Service Dental Services

Diagnostic / Laboratory fees Professional Fees

Not Granted 20% Discount in fare for

Domestic Air Sea Travel Land Travel
Not granted exemption from training fees for socio economic programs
Not granted 5% discount on prime and basic necessities (DTI)
Not granted 5% discount on prime and basic necessities (DA)
Not granted 20% discount in funeral and burial services
Name of Deceased relative: Age:

Not given priority attention or absence of express lane for OP

Others. Please Specify:

__________________________________
Name and Signature of Complainant
Contact No.____________________
Date_________________________
Received by: ARIEL A. AXALAN
OSCA Staff In-Charge
Date:_____________________