Professional Documents
Culture Documents
Apelyido (Last Name) Unang Pangalan (First Name) Gitnang Pangalan (Middle Name) Ext. (Sr,Jr,I,II)
Numero ng Telepono (Mobile No.) Kapanganakan (Birthdate) Edad (Age) Kasarian (Gender) Trabaho (Occupation) Buwanang Kita (Monthly Salary)
Apelyido (Last Name) Unang Pangalan (First Name) Gitnang Pangalan (Middle Name) Ext. (Sr,Jr,I,II)
Numero ng Telepono (Mobile No.) Kapanganakan (Birthdate) Edad (Age) Kasarian (Gender) Trabaho (Occupation) Buwanang Kita (Monthly Salary)
Huwag susulatan ang DSWD lamang ang pwede gumamit (Do not write below this part for DSWD's use only)
3
"I declare under oath that I personally accomplished the GIS Form and all the
information provided herewith are TRUE, CORRECT, VALID & COMPLETE pursuant
to exisiting laws, rules and regulations of the Republic of the Philippines. I authorized
Interviewed by: Reviewed & Approved by:
the Agency Head/validate the contents stated herein. I also AGREE that any
attached documents shall cause the filling of appropriate case/s against me"
_______________________________________________________________________________________________
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DSWD Central Office, IBP Road, Batasan Pambansa Complex, Constitution Hills, Quezon City, Philippines 112
Website: http://www.dswd.gov.ph Email: ciu.co@dswd.gov.ph Tel Nos.: 8962-2813 or 8931-8100 local 509,510 Telefax: (632) 931-8191
PROTECTIVE SERVICES DIVISION
CRISIS INTERVENTION SECTION
FIELD OFFICE MIMAROPA
DSWD-PMB-GF-000 | REV 00 / xx xxx xxxx
CERTIFICATE OF ELIGIBILITY
(Financial Assistance)
Mal Fem
This is to certify that, , e ale
Kumpletong Pangalan (First name, Middle name, Last name) Kasarian (Sex) Edad (Age)
has been found eligible for assistance after assessment and validation conducted, for his/herself or through the representation of his/her
Relasyon ng Kinatawan sa Benepisyaryo (Relationship of the Representative to Beneficiary) Buong Pangalan ng Benepisyaryo (Name of Beneficiary)
Records of the case such as the following are confidentially filed at the Crisis Intervention Division (CID)
The Client is hereby recommended to receive EDUCATIONAL assistance for SCHOOL NEEDS
in the amount of THOUSAND PESOS ONLY Php. ,000 CHARGEBLE AGAINST: PSP 2022
(Year)
Acknowledgement Receipt
Date: 12 29 2022