Republic of the Philippines

REGIONAL FIELD OFFICE- CORDILLERA ADMINISTRATIVE REGION

BPI compound, Guisad, Baguio City
Telefax No. (074) 445-4973

DECLARATION OF SINGLE CLAIM

I hereby declare that I, ________________________with Registry System for Basic Sectors in

(Name of the Farmer)
Agriculture (RSBSA) number of ____________________________ was only able to claim once
(System Generated RSBSA Number)
of the cash assistance under the Rice Competitiveness Enhancement Fund - Rice Farmers
Financial Assistance (RCEF-RFFA) Program withdrawn on ___________________________ at
(Date of Withdrawal)
____________________________________.
(USSC branch or Caravan Distribution Site)

In this regard, I attest that I did not claim the cash assistance twice as opposed to the reported
_____________________________at____________________________________________.
(Date of reported 2nd Withdrawal) (USSC branch or Caravan Distribution Site of the reported
2nd Withdrawal)
Thus, I am not guilty of the allegation of double claim under the Program.

Attached is a copy of my personal identification card for your reference.

Sworn by:
_______________________________________
SIGNATURE OVER PRINTED NAME OF FARMER
RSBSA System-Generated No._______________________

Testified by:

_________________
LGU Representative

_______________________
DA-RFO CAR Representative
 Republic of the Philippines
REGIONAL FIELD OFFICE- CORDILLERA ADMINISTRATIVE REGION
BPI compound, Guisad, Baguio City
Telefax No. (074) 445-4973

DECLARATION OF DOUBLE CLAIM AND RETURN OF CASH

I hereby declare that I, ________________________with Registry System for Basic Sectors in

(Name of the Farmer)
Agriculture (RSBSA) number of ______________________________ was able to claim twice
(System Generated RSBSA Number)
of the cash assistance under the Rice Competitiveness Enhancement Fund - Rice Farmers
Financial Assistance (RCEF-RFFA) Program and issued twice of the DA - Interventions
Monitoring Card (IMC) on _____________________and ____________________________ at
(Date of 1st Withdrawal) (Date of 2nd Withdrawal)
___________ _____________________and _______________________________________
(USSC branch or Caravan Distribution Site) (USSC branch or Caravan Distribution Site)
respectively.
The double claiming of the cash assistance was due to
___________________________________________________________________________
______________________________. With this, I am willingly returning the Five Thousand
Pesos (P5,000.00) cash assistance and turning over the DA - IMC issued the second time.
Attached is a copy of my personal identification card for your reference.

Sworn by:
____________________________________
SIGNATURE OVER PRINTED NAME OF FARMER
RSBSA System-Generated No._________________

Testified by:

_________________
LGU Representative

_______________________
DA-RFO CAR Representative