Name of Project: OSEC-FMS Form No.

4
DOLE Regional Office:
Province:
Municipality:

Barangay:

LIST OF BENEFICIARIES

Name of Beneficiary Address2 Interested for If Yes,

Birthdate1 E-payment/Bank Account No. Dependent7 (Name of
Type of ID Type of Skills Training Indicate
No. ID Number Contact No. (indicate the type of account Occupation4 Sex5 Civil Status6 Age Beneficiary of the Micro-
Extension (e.g. SSS, Voter's ID) Beneficiary3 (Y - Yes skills training
First Name Middle Name Last Name (YYYY/MM/DD) Barangay City/Municipality Province District and no. as applicable) insurance Holder)
Name N - No) needed9

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I hereby certify that the above list of beneficiaries are displaced workers, underemployed or self-employed workers that have lost their livelihood or whose earnings were affected by the COVID-19 pandemic.

Further, I certify that they or any member of their families were verified are not Government Employees (i.e. Local Government Units and Job Orders, are not Beneficiaries of (A) Department of Finance's (DOF) Small Business Wage Subsidy (SBWS) program, (B) Social Security System (SSS) Unemployment Benefit and are not Barangay Health Workers and Barangay Tanod

Prepared and Certified true and Correct by:

 CESAR N. NACORDA
LGU Authorized representative
Signature over Printed Name

Notes:
*Only the gray portion of this form should be submitted to concerned agencies, i.e DSWD for data matching/validation.
1 – Birthdate: Year/Month/Day (YYYY/MM/DD)
2 – Address: (Street No, Barangay, City/Municipality, Province, District)

3 –Type of Beneficiaries:
• Underemployed/Self-employed
• Minimum wage/below minimum wage earners that were displaced due to:
a. temporary suspension of business operations
b. calamity/crisis situation (please specify): COVID 19 pandemic, Earthquake, Typhoon (please specify), Volcanic eruption (please specify), Global/National financial
crisis, others
c. closure of company, retrenchment
• PWDs, Senior citizens, Former rebels, Former Violent Extremist Groups, Indigenous People

4 - Occupation - Transport workers, Vendors, Crop growers (please specify, i.e tobacco farmer), Homebased worker (please specify, i.e sewer), Fisherfolks, Livestock/Poultry Raiser, Small transport drivers, Laborer (please specify), Barangay Tanod, Barangay Health Workers
• Others (please specify)
5 – Sex: F for female, M for Male
6 – Civil Status: S for single, M for married
7 – Dependent: Name of the Beneficiary of micro-insurance policy holder.
8 - Trainings: Agriculture crops production, Aquaculture, Automotive, Construction, Welding, Information and Communication Technology,Electrical and electronics, Furniture making, Garments and textiles, Food Processing, Cooking, Housekeeping, Tourism, Customer Services, Others (please specify)

Note: Statement of Informed Consent

I understand the purpose of this profiling activity. I voluntarily and willfully give my consent to be part of this undertaking. I certify that the information that I will give are true and correct and that any misrepresentation and falsification of information may void their application to TUPAD. I authorize the use, processing and sharing of my personal data for the purpose that is intended for without prejudice to my rights
stated in the Data Privacy Act of 2012.