Republic of the Philippines

Office of the President of the Philippines

NATIONAL COMMISSION OF SENIOR CITIZENS
SENIOR CITIZEN DATA FORM
Reference Code: -
REGION IV-A PROVINCE Batangas
CITY/MUNICIPALITY Tanauan City BARANGAY Banjo Laurel
I. IDENTIFYING INFORMATION
1. Name of Senior Futalan Maria Cora Apostol
Citizen Last Name First Name Middle Name Extension (Jr,Sr)
2. Address IV-A Batangas Tanauan City Banjo Laurel
Region Province City/Municipality Barangay
238
House No./Zone/Purok/Sitio Street
3. Date of Birth 0 1 0 8 6 3 4. Place of Birth 6. Marital Status
Dumaguete City Single
m m d d y y
7. Contact Number 0920-2367105 8. Email Address 9. Messenger
vital.purifiedwater@gmail.com
10. Religion 11. Ethnic Origin 12. Language Spoken /
Roman Catholic Written
13. OSCA ID 14. GSIS/SSS 15. TIN
Number

16. Philhealth 17. SC Association / Org ID No. 18. Other Gov't. ID

19. Capability to 20. Service/ Business/ 21. Current Pension

1 Yes 2 No
Travel Employment (specify) (specify)

II. FAMILY COMPOSITION

22. Name of Spouse

Last Name First Name Middle Name Extension (Jr,Sr)
23. Father's Name Futalan Gregorio
Last Name First Name Middle Name Extension (Jr,Sr)
24. Mother's Maiden Apostol Precilla
Name Last Name First Name Middle Name
25. Child(ren) Full name Working/not
Occupation Income Age
working
Romie F. Sayaman - Labayen Entrepreneur 33 yrs. Old Working
R. Policarpio F. Sayaman Businessman 31 yrs old Working

25.A Other Dependents

III. DEPENDENCY PROFILE

26. Living/Residing with (check all applicable) 27. Housing
1 Alone 2 Grand Child(ren) 3 Common Law Spouse 1 No privacy 2 Overcrowded in home
4 Spouse 5 In-law(s) 6 Care Institution 3 Informal Settler 4 No permanent house
7 Child(ren) 8 Relative(s) 9 Friend(s) 5 High cost of rent 6 Longing for independent living quiet atmosphere
10 Others, pls specify 7 Others, specify

IV. EDUCATION / HR PROFILE

28. Educational Attainment 29. Areas of Specialization / Technical Skills (Check all applicable)
1 Elementary Level 2 Elementary Graduate 3 High School Level 1 Medical 2 Teaching 3 Legal Services
4 High School Graduate 5 College Level 6 College Graduate 4 Dental 5 Counseling 6 Farming
7 Post Graduate 8 Vocational 9 Not Attended School 7 Fishing 8 Cooking 9 Arts
30. Share Skill (Community Service) 10 Engineering 11 Carpenter 12 Plumber
1 13 Barber 14 Mason 15 Sapatero
2 16 Evangelization 17 Tailor 18 Chef/Cook
3 19 Millwright 20 Others, specify
Reference code Prefix : A=Region I (Ilocos); B=Region II (Cagayan Valley); C=Region III (Central Luzon); D=Region IVA (CALABARZON); E=Region IVB (MIMAROPA);F=Region V (Bicol);
G=Region IV (Western Visayas); H=Region VII (Central Visayas); I=Region VIII (Eastern Visayas); J=Region IX (Zamboanga Peninsula);
K=Region X (Northern Mindanao); L=Region XI (Davao); M=Region XII (SOCCSKSARGEN); N=Region XIII (CARAGA); O=NCR; P=CAR; Q=BARMM
NCSC-SCDF v. 4.0b THIS FORM IS NOT FOR SALE
Page 1 of 2
31. Involvement in Community Activities (Check all applicable)
1 Medical 2 Resource Volunteer 3 Community Beautification
4 Community / Organization Leader 5 Dental 6 Friendly Visits
7 Neighborhood Support Services 8 Legal Services 9 Religious
10 Counseling / Referral 11 Sponsorship 12 Others, specify

V. ECONOMIC PROFILE
32. Source of Income and Assistance (Check all applicable)
1 Own earnings, salary / wages 2 Own Pension 3 Stocks / Dividends
4 Dependent on children / relatives 5 Spouse's salary 6 Insurance
7 Spouse's Pension 8 Rentals / sharecrops 9 Savings
10 Livestock / orchard / farm 11 Fishing 12 Other, specify
33.A Assets: Real and Immovable Properties (Check all applicable) 33.B Assets: Personal and Movable Properties
1 House 2 Lot / Farmland 3 House & Lot Automobile Personal Computer Boats
4 Commercial Building 5 Fishpond / resort Heavy Equipment Laptops Drones
6 Others, specify Motorcycle Mobile Phones Specify
34. Monthly Income (in Philippine Peso) 35.A Problems / Needs Commonly Encountered (Check all applicable)
60,000 and above 50,000 to 60,000 40,000 to 50,000 35.A Economic
30,000 to 40,000 20,000 to 30,000 10,000 to 20,000 1 Lack of income / resources
5,000 to 10,000 1,000 to 5,000 Below 1,000 2 Loss of income / resources
3 Skills / capability training (specify)
4 Livelihood opportunities (specify)
5 Others, specify
V. HEALTH PROFILE
36.A Medical Concern 36.D Aural
Blood Type: O A B Aural impairment
Physical Disability (specify): History of Mild Stroke Others
Health problems / ailments 36.E Social / Emotional
Hypertension Arthritis / Gout Coronary Heart Disease Feeling neglect / rejection
Diabetes Chronic Kidney Disease Feeling neglect / rejection
Alzheimer's / Dementia Feeling helplessness / worthlessness
Chronic Obstructive Pulmonary Disease Feeling loneliness / isolate
Others, pls specify Lack leisure / recreational activities
36.B Dental Concern Lack SC friendly environment
Needs Dental Care Others, specify
Others 36.F Area / Difficulty
36.C Optical High Cost of medicines
Eye impairment Lack of medicines
Needs eye care Lack of medical attention
Others Others
37. List of Medicines for Maintenance
Febuxostat (Atenurix)
Atorvastatin (Adivast)
Cilostazol (Pletaal)
Telmisartan Micardis)(

38. Do you have a scheduled medical/physical check-up? Yes No

38.A If Yes, when is it done? Yearly Every 6 months Others

This certifies that I have willingly given my personal consent and willfully participated in the provision of data and relevant information
regarding my person, being part of the establishment of database of Senior Citizens.

Maria Cora Futalan

_______________________________
Name and Signature of Senior Citizen
Right Thumb Print of Senior Citizen

Romie F. Sayaman - Labayen

__________________________________ Daughter
________________________
Name and Signature of Assisting Person 1 Relationship to Senior Citizen

__________________________________ ________________________
Name and Signature of Assisting Person 2 Relationship to Senior Citizen

_________________________________ ________________________
Name of Signature of Interviewer/Verifier Organization/Office

Date of Interview: __________________________________

Place of Interview: __________________________________

THIS FORM IS NOT FOR SALE Page 2 of 2