Department of the Interior and Local Government

CY 2022 Seal of Good Local Governance

(For National Orientation Purposes Only)

Form CM 4.1 Change Request

City/Municipality of : Income Class :

Province : Region :

INSTRUCTIONS: PLEASE READ BEFORE PROCEEDING TO THE ITEMS.

For the RAT Members: (1) Fill-out this Form in case of a necessary change in partner agency-sourced data as validated at the local
level. (2) Request must be accompanied by supporting documents (e.g. certifications, photos). THERE SHOULD BE A SEPARATE
CHANGE REQUEST FORM FOR EVERY AGENCY. (3) Write name and affix signature. (4) Request must be concurred by the Regional
Director. (5) Send to BLGS-LGPMD thru the LGPMS-RFP along with the other accomplished Forms.

This is to certify that there is a discrepancy observed in the LGU data on (please indicate indicator)
______________________________________ as collected, reviewed and validated compared to the data
provided by (please indicate name of agency) __________________________________.

Relative herein, may we request this data to be changed subject to the review of the concerned agency
partner, details as follows:

Original NGA Data Changes Justification

Accomplished by: Concurred by:

______________________________________ ______________________________________
Signature over Printed Name Signature over Printed Name
RAT Leader DILG Regional Director

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