Republic of the Philippines

Ormoc City
OFFICE FOR SENIOR CITIZENS AFFAIRS

SOCIAL PENSION INTAKE FORM

PART I – PERSONAL INFORMATION

1. NAME OF SC _______________________________________NHTS – PR HH No. __________________

Pangan (Surname / First Name / Middle Name) (To be filled up by the RSPO)

2. SEX ________ Male _________ Female _________ 3. AGE _________

Lalaki Babaye Edad

4. CIVIL STATUS _____ Single ______ Married _______ Widowed ________ Separated _________
5. DATE OF BIRTH _____________________ 6. PLACE OF BIRTH _______________________
Kanus-a gipanganak (Month / Day/Year) Asa gipanganak

7. ADDRESS ___________________________________________________________________________
Puy-anan (House No. / Street / Sitio / Barangay)

8. CONTACT DETAILES: Landline _________________ E-Mail _________________Mobile No._________

9. AFFILIATION (Pls. check) _______ FSCAP ______ COSE __________ OTHERS (Specify)______________
10. LIVING ARRANGEMENT (Pls. check) Living alone _______ Living with relatives __________
Owned house _____ Rented _________ No. of Years_________
11. PENSIONER _______ NON PENSIONER ________
12. IF PENSIONER (Pls. check) GSIS _______ SSS ______ Private _________ How much?__________ _____
13. IF NON PENSIONER, ARE YOU RECEIVING SUPPORT FROM FAMILY MEMBERS / RELATIVES / FRIENDS? ________
14. HOW MANY MEALS DO YOU HAVE IN ONE DAY? ______ Three (3) ______ Two (2) ______ One (1)
15. DO YOU HAVE DISABILITY? _____ Yes _____ No. If YES, what type (i.e. blind, deaf) ________________________
16. ARE YOU IMMOBILE? _________ BEDRIDDEN? __________ DEPENDENT ON ASSISTIVE DEVICE? ____________
17. DO YOU HAVE PRE-EXISTING ILLNESSES? (i.e. hypertension, diabetes, arthritis) __________________________
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PART II – CHAPTER VALIDATION

BARANGAY: _______________________ VALIDATED BY: __________________________

Barangay Senior President CSWD Implementor/District President

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PART III – INTERVIEW and APPROVAL

DATE ACCOMPLISHED: _____________

APPROVED BY: CORAZON O. AGRAVIADOR

OSCA HEAD

NOTED BY: ALEXANDRA KRIS T. VALENCIANO

SWO II-DISTRICT INCHARGE