Name of Project: OSEC-FMS Form No.

4
DOLE Regional Office: 12
Province: COTABATO
Municipality: MIDSAYAP
Barangay:

Name of Beneficiary Birthdate1 Address2

Type of ID Dependent6 (Name of Beneficiary of the
No. ID Number Type of Beneficiary3 Sex4 Civil Status5 Age
Extension (e.g. SSS, Voter's ID) Micro-insurance Holder)
First Name Middle Name Last Name (YYYY/M/D) BRGY. City/Municipality Province
Name

I hereby certify that the above list of beneficiaries are affected by Thypoon.

Prepared by: Certified true and correct by:

KENNETH PAUL B. PACATANG MARJORIE P. LATOJA

LEO II/FOCAL Chief LEO /NCFO Head

Notes:
*Only the gray portion of this form should be submitted to DSWD. This will be used by DSWD in name-matching to avoid duplication of beneficiaries with the other social amelioration programs.
1 – Birthdate: Year/Month/Day (YYYY/M/D)
2 – Address: (Street No, Barangay, Municipality)
3 – Type of Beneficiaries:
4 – Sex: F for female, M for Male

Example: Crop growers (please specify), Vendors (please specify), Homebased worker (please specify), Fisherfolks, Livestock/Poultry Raiser, Alternative/Small transport drivers, Laborer (please specify), Person with Disability (PWDs), Others (please specify)
5 – Civil Status: S for single, M for married
6 – Dependent – Name of the Beneficiary of micro-insurance policy holder.

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 benefits and interventions. 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.