BARANGAY CERTIFICATION

(First Time Jobseekers Assistance Act - RA 11261)

This is to certify that Mr./Ms. , a resident of

Bgy. Zone for years/months, is a qualified availee of
RA 11261 or the First 7'ime Jobseekers Act of 2019.

I further certify that the holder/bearer was informed of his/her rights, including the
duties and responsibilities accorded by RA 11261 through the Oath of Undertaking
he/she has signed and executed in the presence of our Barangay Official.

Signed this day of ,20

in the City/Municipality of

This certification is valid only (one (1) year from the issuance).

Punong Barangay

Date

Witnessed by:

Barangay Official/Designation/Position

Date

//26/ form /
 OATH OF UNDERTAKING

I, , years of age,
resident of Bgy Zone , for (years/months), availing the
benefits of Republic Act 11261, otherwise known as the First Time Jobseekers Act
of 2019, do hereby declare, agree and undertake to abide and be bound by the
following:
1. That this is the first time that I will actively look for a job, and therefore requesting
that a Barangay Certification be issued in my favor to a'vail the benefits of the
law;

2. That I am aware that the benefit and privilege/s under the said law shall be valid
only for one (1) year from the date that the Barangay Certification is issued;

3. That I can avail the benefits of the law only once;

4. That I understand that my personal information shall be included in the

Roster/List of First Time Jobseekers and will not be used for any unlawful
purpose;

5. That I will inform and/or report to the Barangay personally, through text or other
means, or through my family/relatives once I get employed; and

6. That I am not a beneficiary of the JobStart Program under R.A. No. 10869 and
other laws that give similar exemptions for the documents or transactions
exempted under
R.A No. 11261

7. That if issued the requested Certification, I will not use the same in any fraud,
neither falsify nor help and/or assist in the fabrication of the said certification.

8. That this undertaking is made solely for the purpose of obtaining a Barangay
Certification consistent with the objective of R.A. No. 11261 and not for any other
purpose.

9. That I consent to the use of my personal information pursuant to the Data Privacy
Act and other applicable laws, rules, and regulations.

Signed this day of , 20 in the

City/Municipality of

First Time Jobseeker

Witnessed by:

Barangay Official/Designation/Position

Date
RA 11261 Form
 ROSTER OF BENEFICIARIES/AVAILEES
(RA 11261 - FIRST TIME JOBSEEKERS
ACT) BGY. 121 ZONE 9
City of MANILA

SEX/
NAME OF DATE OF BIRTH EDUCATIONAL LEVEL
AGE GENDER
BENEFICIARY/AVAILEE
Last flame First Name Elementary/
Middle Name Month Date Year M College Course OSY
Hi h School
DELA GRUZ JUAN SANTIAGO / Political Science
F 19 5 15
2000 X

Note: This form shall be accomplished by the barangay or concerned agency to be submitted to DILG through City/Municipality or DICT)

Prepared by:

Name, Designation & Name, Designation & Signature

Signature

Date
Date
Conducted Road Clearing Location of Road Clearing Date of Action Remarks
Operations Operations operation taken
(Check appropriate e (Street name/Address)
column)

Yes No

MONTHLY COMMULATIVE MONITORING REPORT

ON ROAD CLEARING OPERATIONS
REGION__________
PROVINCE________
MUNICIPALITY/CITY__________
BARANGAY__________
 *If ✔, enc VAC Form 1

BARANGAY DATA CAPTURE FORM

MONITORING OF INCIDENCE ON VIOLENCE AGAINST CHILDREN (VAC)
For the period:
Region:___________________
Province:______________________________________
City/Municipality:_______________________________
BARANGAY:_________________

VAW GENDER(2) AGE( TYPES OF VIOLENCE PEPRATORS(5)

VICTI MAL FEMAL 3) (4)
MS E E
(1) (2A) (2B) Physical Sexual Psychological/ Neglect(4
Abuse(4 emotional abuse(4c) d)
Abuse(4 b) Immediat Other
a) e family Close
@1 @1
member(5 Relative(5
@1 @1 @1 @1 a) b)

@1 @1

CHILD
1
CHILD
2
CHILD
3
CHILD
PREPATORS(5)
4 Actions taken by the barangay

ACQ Stran Local Law OTHE REFF REFF REF REF REFF OTHE
UAN gers Office Enforc RS ERED ERED FER FER ERED RS(PL
TAN (5d) r(5e) er (EX: TO TO ED ED FOR EASE
CE(5 (5f) guardi (BSO) (PNP) TO( TO(M (LEGA SPECI
c) an) (6a) (6b) NBI) EDIC L FY)
(5g) (6c) AL ASSIS (6f)
TRE TANC
ATM E)
ENT)
(6e)
(6d)

*IF@, ENCODE “1" on the applicable fields

*IF “OTHERS’, please specify
SUMBITTED BY: (PUNONG BARANGAY_____________ WITH SIGNATURE)
 *If ✔, enc VAW Form 1

BARANGAY DATA CAPTURE FORM

MONITORING OF INCIDENCE ON VIOLENCE AGAINST WOMEN (VAW)
VA TYPES OF ACTIONS TAKEN BY BARANGAY(3)
W VIOLENCE(2a) *IF@,
VIC P Sexu Psyc Eco ISSU REF REF REFF Referre Referr Others:
TIM hy al holo no ED FER FER ERED d for ed for (ex:
(1) si abus gical mic TO ED ED TO medical legal NGO’S/
ca e(2b / al BSO( TO TO NBI(3e treatme assist FBO’S)
l ) Emo abu 3a) DS PNP ) nt(3f) ance (3h)
a tiona se WD( (3d) (3g)
b l 3b)
us Abus (2d)
e( e(2c)
2
a)

ENCODE “1" on the applicable fields

*IF “OTHERS’, please specify

SUMBITTED BY: (PUNONG BARANGAY_____________ WITH SIGNATURE)

 Republic of the Philippines

DEPARTMENT OF THE INTERIOR AND LOCAL GOVERNMENT

www.dilg.gov.ph
BARANGAY DRUG-CLEARING PROGRAM
REGION _ _
Province/City/Municipal: _ _
Month / Year: _ _

NO NAME PWUDS INTERVENTION

PROGRAMS

USER PUSHER USER PUSHER

Prepared By: Certified By:

ADAC FOCAL PERSON

Signature Local Chief Executive
Date
A. APPLICATION FOR DECLARATION OF DRUG-CLEARED STATUS
B. Drug-Free Barangay

Folder shall contain the following:

Tab Documentary Attachments

Application Letter from BADAC addressed to RD, PDEA/ ROCBDC,
A
Chairman
BADAC Reactivation and Revitalization
1. BADAC Reactivation Resolution,
2. BADAC Revitalization Resolution;
3. Monitoring Mechanism;
4. BADAC Resolution on Existence of Drug Awareness,
B Preventive Education and Information and Other Related
Programs;
5. BADAC Resolution on Barangay Rehabilitation Referral
Desk (with pictures); and
6. Annual Investment Plan highlighting the budget for Anti-Drug
Initiatives

Certification for Absence of Drug Personalities, Illegal Drug

Activities and Illegal Drug Facilities from RIO, PDEA
Validation Report from Intelligence Officer, PNP and attested
by COP, PNP
3. Validation Report from Provincial Intelligence Officer,
PDEA and attested by PO/DO, PDEA

Note: All validation report shall attest the following:

a) Absence of any PWUDs, pushers, drug den maintainers,

coddlers, protectors, financiers, cultivators,
manufacturers and others,
b) Absence of any illegal drug activities; and
c) Absence of any illegal drug facilities (drug den, marijuana
cultivation site, clandestine laboratory and chemical
warehouses).

Implementation of Demand Reduction Programs/Activities

After Activity Reports with pictures and captions of the
implementation of various anti-illegal drug advocacy
D campaign activities conducted for the Barangay.
RETENTION OF DRUG-CLEARED STATUS