Republic of the Philippines

Department of Social Welfare and Development

Maimpis Government Center, City of San Fernando, Pampanga
Field Office III

CE RTIFICATE OF ELIGIBILITY

Client ID: 377________ _________________, 2020

This is to certify that ______________________________________________,____________________ OF BENEFICIARY MALE/FEMALE,

_________ year/s old and presently residing at BRGY. MARIA AURORA, AURORA, has been found eligible for financial
assistance for _______________________________ after a thorough assessment has been conducted.

Records of the case such as the following are confidential filed at the Crisis Intervention Unit.

GENERAL INTAKE SHEET REGISTERED DEATH CERTIFICATE

RFEFERRAL LETTER FUNERAL CONTRACT
SOCIAL CASE STUDY REPORT PERMIT TO TRANSFER
JUSTIFICATION QUARANTINE PERMIT
VALID ID PRESENTED:_____________________ PROMISSORY NOTE
BRGY. CERTIFICATE /BRGY INDIGIENCY
OTHERS:
CERTIFICATE OF ELIGIBILITY

The client hereby recommended to receive BURIAL ASSISTANCE for funeral payment in the amount of _____ FIVE THOUSAND PESOS ONLY_____
(PHP_5000.00).

Chargeable Against: CURRENT FUND

Clientele Category: ___________
Mode of Admission: REFERRAL

Prepared by:

Emie A. Dela Rosa

Lic No: 0012002
SWOII/EAICS

CONFORME: APPROVED BY:

________________________________ Corazon T. Virrey

Signature over Printed Name Lic No: 0007753
REQUESTING PARTY SWO II/PT LEADER

ACKNOWLEDGEMENT RECEIPT

PETSA: _________________, 2020

Natanggap ko ang halagang __ LIMANG LIBONG PISO (Php __5000.00) mula sa Department of Social Welfare and Development (DSWD)
para sa BURIAL ASSISTANCE for funeral payment.

TINANGGAP NI: BINAYARAN NI: SINAKSIHAN

________________________________ FLORIEZA DC. DECANO EMIE A. DELA ROSA

Pangalan at lagda Pangalan at lagda Pangalan at lagda