ANNEX G

Overseas Workers Welfare Administration

WELFARE ASSISTANCE PROGRAM (WAP)
FOR OFW-MEMBERS WHO ARE DISPLACED OR LAID-OFF
DUE TO ECONOMIC AND POLITICAL SITUATIONS, PANDEMIC, ETC.

CLAIM FORM
Displaced Laid-Off
Trafficked Others
COVID19

Name of OWWA Member:

(Last Name) (First Name) (Middle Name) (Suffix Name)

Birthdate: Sex: Civil Status: Status of Membership: Active Inactive

Contact No.: Occupation: Jobsite:

Latest Date of Arrival in Taiwan: Address:

IF CLAIMANT IS NOT THE MEMBER

Name of Claimant:
(Last Name) (First Name) (Middle Name) (Suffix Name)

Relationship to the OFW: Claimant's Contact Number: e-Mail Address:

Claimant's Address:

DOCUMENTS SUBMITTED
Photocopy of passport (bearing page with personal data, latest stamps of departure and arrival) & ARC (Alien Resident Card)
Picture of Bank Account Number of applicant including the name of the bank, account number and bank code.
Certification from MOH or Quarantine facility as proof of positive covid19 diagnosis; Result of RT-PCR Test

ACKNOWLEDGMENT AND DECLARATION

Received the amount of 200 US Dollar equivalent to NTD _____ ) under the
Welfare Assistance Program (WAP) for the affected OFW-members/families of COVID19 pandemic. I further declare that:
I am a member-OFW identifed as Covid19 Positive
I, on behalf of my family, personally claim the assistance amounting to
There is no other OFW-family member who availed of this program, and;
I am liable for any false statement or misrepresentation made in this document.

Signature of Claimant Over Printed Name Date Received

CERTIFICATION
I hereby certify that the information given herein are true and correct to the best of my personal knowledge.

Date Received Signature of Claimant Over Printed Name

THIS PORTION IS FOR OWWA USE ONLY

WAP APPROVAL NTD

Received by: Approved by:

RUTH ROSELYNN C. VIBAR

Welfare Officer