Republic of the Philippines

MUNICIPAL
Cordillera Administrative Region
LOGO Province of Mondragon
MUNICIPALITY OF KEKESOR

OFFICE OF THE MUNICIPAL SOCIAL WELFARE AND DEVELOPMENT

CERTIFICATE OF INDIGENCY
TO WHOM IT MAY CONCERN:

This is to certify that Mr. Jack L. Versamin, Filipino, male, 47 years old, single, is a
bona fide resident of Sitio Kinimi, Charlang, Kekesor, Mondragon, Philippines.

This further certifies that he belongs to the low-income indigent family in the
community.

This certification is issued upon the personal request of the aforementioned person
for the provision of MEDICAL ASSISTANCE.

Issued this 16th day of July, 2023 at Gandang-ganda, Kekesor, Mondragon,

Philippines.

Not Valid without Municipal Seal.

Erasures makes this document invalid.
Valid until September 16, 2023.

Prepared by:

GENE MAR B. RAGUS, RSW

SWO111 -MSWDO-OIC

Approved and Noted by:

CHINILIN O. HACIENDERA, PhD.

Municipal Mayor

Certificate No: _____________

Date Issued: _______________
OR No: ___________________
CTC No: __________________