PHIUPPINE OVERSEAS LA BOR OFFICE - BERLIN

Overseas Workers Welfare Administration

WELFARE ASSISTANCE PROGRAM (WAP)
AFTER-CARE NEEDS ASSISTANCE FOR COVID-19

CLAIM FORM

MEMBER'S DATA

Name: DV~ Ge;ieAJZO ~ -.{l/(570.f

(Middlc Name)
(LastN-) (FintN-,c) (Suffix)

Age: 6~ Date ofBirth: .4~ •/.A 't) · .fjf'/ Sex: M ·:,ie.

CoontactNmnber : .+4-ö. 1f1~ (2.3 f~3ß"C1 StatusofMembership: Active: _ _ _ Inactive: X
Occupation: !J vr.f l City, State: µ 11.,,;th. {zffe'll,-,~ Type of illnes: L,d)yl/. J ,/Cf
Employer/Principal: /c-li"n~f.-y,., e:g!r+, c1,,;_.. :r( ?c T~JnrLJhlkrU//tvtA-Jih.·1- /4u··7clze..,
Address: -:r~,,,,,,,.,.. ;✓ ~ S"-ir . 2-2-, r {1~ z~ Ml#l1~

Philippine Agency Agency:

Foreign Placement -=-- -
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CLAIMANrs DATA

Name: 1)VQ-uC G6runz„9 fPe7'ofZ-

(LastNmnc) CFintNamc> (Middlc Name) (Suffix)

Age: 3 .f Date ofBirth: ,{j. M::J, ~1fl/ Civil Status /1/t -;,,,,-ri e d

Coontact Number : -+4Lf A1e fv 3 g-~ 3 ffOi Status of Membership: Active: _ _ _ Inactive: )<:

Documents Submited (check box)

l . Passport 12)
2. Medical Certificate or Laboratory Test, with
Covid-19(+)result D
3. Bank Accot.mt :
Accot.mt Name:
IBAN Nmnber:
NameofBank

APPROVED FOR PAYMENT: