PROTECTIVE SERVICES DIVISION

(SWAD OFFICE-MALAYBALAY CITY)

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

GENERAL INTAKE SHEET

MAARING MAGPATULONG SUMAGOT SA DSWD PERSONNEL

QN: 7 PCN: Time Start: Date:

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)

House No./Street/Purok (Ex 123 Sun) Barangay (Ex. Batasan) City/Municipality (Ex. Quezon City) Province/District (Ex. Dist III) Region (Ex. NCR)

Numero ng Telepono (Mobile No.) Kapanganakan (Birthdate) Edad (Age) Kasarian (Gender) Civil Status (Katayuang Sibil) Trabaho (Occupation) Buwanang Kita (Monthly Salary)

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)

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
Target Sector: Specify Sub-Category
FHONA Solo Parents
THE CLIENT IS A ___________________ COLLEGE STUDENT. THE
SC Indigenous People CLIENT'S FAMILY HAS A LIMITED SOURCE OF INCOME
WEDC Recovering Person who used drugs THROUGH _______________________. FAMILY'S EARNING
YNSP 4PS DSWD Beneficiary COULD NOT FULLY SUSTAIN THE EDUCATIONAL NEEDS OF THE
PWD Street Dwellers CLIENT. CLIENT IS FOUND IN NEED AND ELIGIBLE FOR THE
PLHIV Psychosocial/Mental/Learning Disability ASSISTANCE. HENCE, THIS REQUEST
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 Other Food Items Psychological First Aid _________
Funeral Cash Assistance for Hygiene & Sleeping Kits (PFA) _________
Transportation Other Support Assistive Device & Technologies _________
Social Work Counseling
Educational Services
Provided Amount Fund Source
1 SCHOOL NEEDS P3,500.00 2023
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 Interviewed by: Reviewed & Approved by:
contents stated 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."

RAMIEL A. GUINANDAM
Social Worker Approving Authority
(Signature over Printed Name) (Signature over Printed Name) (Signature over Printed Name)

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DSWD Field Office X, Masterson Avenue, Upper Carmen, Cagayan de Oro City, Philippines 9000
Website: http://www.fo10.dswd.gov.ph Tel Nos.: (088)565-5795 Email: [email protected]