OFFICE NAME

(CLUSTER NAME/ FIELD OFFICE)

DSWD-PMB-GF-011 | REV 01 / 30 SEPT 2022

GENERAL INTAKE SHEET

MAARING MAGPATULONG SUMAGOT SA DSWD PERSONNEL

QN: PCN: Time Start: Date: MM DD 2024

New Returning On-Site Walk-in Referral Off-Site

IMPORMASYON NG BENEPISYARYO (Beneficiary’s Identifying Information)

Apelyido (Last Name) Unang Pangalan (First Name) Gitnang Pangalan (Middle Name) Ext. (Sr,Jr,I,II)
BATAAN

House No./Street/Purok (Ex 123 Sun) Barangay (Ex. Batasan) City/Municipality (Ex. Quezon City) Province/District (Ex. Dist III) Region (Ex. NCR)
MM-DD-YYYY
Numero ng Telepono (Mobile No.) Kapanganakan (Birthdate) Edad (Age) Kasarian (Gender) Civil Status (Katayuang Sibil) Trabaho (Occupation) Buwanang Kita (Monthly Salary)

IMPORMASYON NG KINATAWAN (Representative’s Identifying Information)

Apelyido (Last Name) Unang Pangalan (First Name) Gitnang Pangalan (Middle Name) Ext. (Sr,Jr,I,II)

House No./Street/Purok (Ex 123 Sun) Barangay (Ex. Batasan) City/Municipality (Ex. Quezon City) Province/District (Ex. Dist III) Region (Ex. NCR)
MM-DD-YYYY
Numero ng Telepono (Mobile No.) Kapanganakan (Birthdate) Edad (Age) Kasarian (Gender) Civil Status (Katayuang Sibil) Trabaho (Occupation) Buwanang Kita (Monthly Salary)

Relasyon sa Benepisyaryo (Relationship to the Beneficiary) Time End:

Huwag susulatan ang DSWD lamang ang pwede gumamit (Do not write below this part for DSWD's use only)
Beneficiary Category Social worker's Assessment
Target Sector: Specify Sub-Category
FHONA Solo Parents
SC Indigenous People
WEDC Recovering Person who used drugs ACCORDINGLY, CLIENT INSUFFIECIENT MEANS OF INCOME AND COULD HARDLY TO
PROVIDE HIS/HER DAILY BASIC NEEDS DUE TO UNEXPECTED CIRCUMSTANCES/
YNSP 4PS DSWD Beneficiary
INADEQUATE OF FINACIAL RESOURCES. HENCE, THE CLIENT IS ELIGIBLE FOR FOOD
PWD Street Dwellers ASSISTANCE TO SUSTAIN HIS/HER DAILY FOOD NEEDS.
PLHIV Psychosocial/Mental/Learning Disability
CNSP Stateless Person/Asylum Seekers/Refugees
Others:
KOMPOSISYON NG PAMILYA (Family Composition)
Buong Pangalan Relasyon sa Benepisyaryo Edad Trabaho Buwanang kita
(Complete Name) (Relationship to the Beneficiary) (Age) (Occupation) (Monthly Salary

Material Assistance:
Financial Assistance: Psychosocial Support: Referral:
Family Food Packs
Medical Food Assistance Psychological First Aid _________
Other Food Items
Funeral Cash Assistance for Hygiene & Sleeping Kits (PFA) _________
Transportation Other Support Assistive Device & Technologies Social Work Counseling
_________
Educational Services
Provided Amount Fund Source
1 FOOD ASSISTANCE 5,000
2

"I declare under oath that I personally accomplished the GIS Form and all the
information provided herewith is TRUE, CORRECT, VALID, and COMPLETE pursuant
to existing laws, rules, and regulations of the Republic of the Philippines. I authorized
the Agency Head/Authorized Representatives to verify and validate the contents stated Interviewed by: Reviewed & Approved by:
herein. I also AGREE that any MISINTERPRETATION and information/acts to
DEFRAUD the government, including attached documents, shall cause the filing of
appropriate case/s against me."

MONETTE D. GANTANG
LIC. NO. 009105
Buong Pangalan at Pirma Social Worker Approving Authority
(Signature over Printed Name) (Signature over Printed Name) (Signature over Printed Name)

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DSWD Central/Field Office,_________ (address), Philippines (Zip Code)
Website: http://www.dswd.gov.ph Tel Nos.: ________________Telefax: _______________