Republic of the Philippines

Province of Iloilo
Municipality of Barotac Nuevo

CERTIFICATION

Date:

We hereby certify that , , _ years old, resident of

Name of the Authorized Representative Sex Age

is the of ,
Address Relationship Name of Beneficiary

years old, , who passed away last due to .

Age Civil Status Date of Death Cause of Death

____________________________, is eligible to claim the DOLE TUPAD Cash for Work Program salary in behalf
Name of the Authorized Representative

of the deceased .
Name of Beneficiary

Barangay Chairperson

NOTED:

MSWDO

Approved:

In-charge Personnel