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CRISIS INTERVENTION SECTION

DSWD FIELD OFFICE III


DSWD-PMB-GF-013 | REV 02 | 08 JAN 2024

SAMPLE ONLY complete checkboxes that are colored red


CERTIFICATE OF ELIGIBILITY
(Outright Cash)

QN: PCN: Date:


06 28 2024
MM DD YYYY

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


This is to certify
that,
✓ ARCIE VIDAL ANGELES , Male Female 22

Kumpletong Pangalan ng kliyente (First Name Middle Name Last Name) Kasarian (Sex) Edad (Age)

CALANTIPAY, BALIWAG, BULACAN (INDICATE BARANGAY MUNICIPLITY AND PROVINCE ONLY)


and presently residing at ✓ kumpletong Tirahan (Complete Address)

has been found eligible for assistance after the assessment and validation conducted, for his/herself or in representation of his/her

SELF SELF

Relasyon ng Kinatawan sa Benepisyaryo (Relationship of the Representative to Beneficiary) Kumpletong Pangalan ng Benepisyaryo (First Name Middle Name Last Name)

Records of the case such as the following are confidentially filed at the Crisis Intervention Division (CID)

✓ General Intake Sheet Medical Certificate/Abstract Discharged Summary Death Summary


JUSTIFICATION Prescription Laboratory Request Referral Letter
✓Valid ID Presented Statement of account Treatment Promissory Note Funeral Social Case Study Report
Protocol Contract ✓
Others
Quotation/Charge slip Death Certificate BARANGAY INDIGENCY

The Client is hereby recommended to receive FOOD assistance for DAILY BASIC NEEDS

in the amount of TWO THOUSAND PESOS ONLY Php. 2,000.00 CHARGEBLE AGAINST: PSP 2024

Conforme: Prepared by: Approved by:

FRITZIE JOY E. CUNANAN


✓ LIC. NO. 0015141
ARCIE VIDAL ANGELES CIS Head/Social Welfare Officer IV

Client Social Worker Approving Authority


(Signature over Printed Name) (Signature over Printed Name) (Signature over Printed Name)

Acknowledgement Receipt

Date: 06 28 2024
MM DD YYYY

✓ Financial Assistance
TWO THOUSAND PESOS ONLY
Php
2,000.00
(Amount in words)

MEDICAL ASSISTANCE TRANSPORTATION ASSISTANCE ✓FOOD ASSISTANCE


FUNERAL ASSISTANCE EDUCATIONAL ASSISTANCE CASH RELIEF ASSISTANCE
EMERGENCY CASH TRANSFER

Tinanggap ni: Binayaran ni: Sinaksihan ni:

✓ ARCIE VIDAL ANGELES


Client RDO / SDO SWO / ADMIN
(Signature over Printed Name) (Signature over Printed Name) (Signature over Printed Name)

*E.O 163 series 2022

Page 1 of 1
DSWD Field Office III, Government Center, Brgy. Maimpis, City of San Fernando, Pampanga, Philippines 2000
Website: http://www.fo3.dswd.gov.ph Tel Nos.: (045) 961-2143

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