CHED-Scholarship Application Form: 2639 ANNEX "A"

2019 version (NOT FOR SALE)

Office of the President of the Philippines

COMMISSION ON HIGHER EDUCATION
REGIONAL OFFICE 1

CHED STUDENT FINANCIAL ASSISTANCE PROGRAMS (StuFAPs)

APPLICATION FORM
Instructions: Read General and Documentary Requirements. Fill in all the required information. Do not leave an item blank. If item is not applicable, indicate "N/A".
Application period: Until August 15 of the current academic year
PERSONAL INFORMATION
TORREVILLAS, RIZALYN MINDORO
(Last Name) Maiden Name
1. Name (First Name) (Middle Name)
put extension, if any: i.e. Jr., III (for Married Women)
2. Date of Birth (mm/dd/yy) 12/14/2004
9. Present Address NEW CORTEZ, New Corella, Davao del Norte
3. Place of Birth MATIN AO NEW CORELLA
4. Sex ☐ Male
Female
☑ 10. Zip Code 8104

☑ Single ☐Widowed 9. Permanent Address NEW CORTEZ, NEW CORELLA, DAVAO DEL NORTE, Sarrat, ILOCOS NORTE
5. Civil Status ☐ Married ☐Separated
☐ Annulled ☐Others 10. Zip Code 2914
6. Citizenship FILIPINO 11. Name of School Last Attended NEW CORELLA NATIONAL HIGH SCHOOL
7. Mobile Number 639510224567
12. School Address POBLACION, NEW CORELLA
8. E-mail Address [email protected]
13. School Sector: ( / ) Public ( ) Private 15. Type of Disability (if applicable) N/A
14. Highest Attained Grade/Year Level Incoming 2nd Year 16. IP affiliation (if applicable) N/A
FAMILY BACKGROUND
Father: ( / ) Living ( ) Deceased Mother: ( / ) Living ( ) Deceased Legal Guardian
17. Name REY BENDIJO TORREVILLAS MARILYN MINDORO TORREVILLAS
18. Address N/A MATIN-AO, NEW CORTEZ, NEW CORELLA

19. Contact Number N/A 09638665589

20. Occupation N/A CLEANER
21. Name of Employer N/A N/A
22. Employer Address N/A N/A
23. Highest Educational Attainment N/A ELEMENTARY GRADUATE
24. No. of Siblings in the family 18 years old and
24. Total Parents Taxable Income 50000.00 below 2

25. Is your family a beneficiary of the DSWD’s pantawid Pamilyang Pilipino Program (4Ps)? ( ) Yes ( / ) No

26. School Intended to enroll or enrolled in: University of Mindanao

27. School Address: TAGUM CITY
28. Type of School: ( ) Public ( / ) Private
29. Degree Program: BACHELOR OF SCIENCE IN ACCOUNTANCY

Type Grantee Institution/Agency

30. Are you enjoying other sources of educational/financial assistance? ( ) Yes or ( / ) No If yes, please specify 1. _______ _________________
2. _______ _________________
I hereby certify that foregoing statements are true and correct. Any misinformation or witholding of information will automatically disqualify me from the CHED Scholarship Program. I am willing to refund the financial benefits received if such information is
discovered after acceptance of the award.
I hereby express my consent for the Commission on Higher Education to collect, record, organize, update or modify, retrieve, consult, use, consolidate, block, erase or destruct my personal data as part of my information. I hereby affirm my right to be
informed, object to processing, access and rectify, suspend or withdraw my personal data and be indemnified in case of damages pursuant to the provisions of the Republic Act No. 10173 of the Philippines, Data Privacy Act of 2012 and its corresponding
Implementing Rules and Regulations.

Jun 18, 2024

RIZALYN MINDORO TORREVILLAS
(Signature over Printed Name of Applicant) Date Accomplished
Note: Fully accomplished form to be submitted to the CHEDRO
DO NOT FILL-OUT THIS PORTION (FOR CHED USE ONLY)
Belongs to: (any of the following groups) Documents Attached:
☐ dependent of solo parent 1. Academic
☐ senior citizens ( ) Report Card ( ) Copy of Grades: Grade 11 and 1st semester of Grade 12
☐ persons with disabilities please specify type of disability 2. Financial
☐ indigenous and ethnic peoples please specify membership
( ) ITR ( ) Tax Exemption ( ) Certifcate of Indigency
( ) Case Study DSWD ( ) OFW Contract
3. Others
( ) Solo Parent ( ) Senior Citizen ( ) IPs ( ) PWD
School intended to enrol in University of Mindanao
School address TAGUM CITY
Type of School ( ) Public ( / ) Private
Course BACHELOR OF SCIENCE IN ACCOUNTANCY ( ) Priority ( ) Non-Priority
Evaluated/Processed by:

CHED StuFAP Coordinator Date

CRITERIA OF ELIGIBILITY per CMO 8, s. 2019
1. Filipino citizen; DOCUMENTARY REQUIREMENTS per CMO 8, s. 2019
2. Graduating high school students/High school graduate Academic Requirements - any one of the following:
3. General Weighted Average (GWA) of at least 90% or above. ( ) 1. High school report card
4. Combined annual gross income of parents/guardian not to exceed Four Hundred ( ) 2. Duly certified true copy of grades for Grade 11 and 1st semester of Grade 12 for
Thousand Pesos (PhP400,000.00) or solo parent/guardian whose annual gross income graduating high school students
does not exceed the said amount; In highly exceptional cases where income exceeds Income Requirements - any one of the following:
Php400,000.00, the CHEDRO StuFAPs Committee shall determine the merits of the ( ) 1. Latest ITR of parents or guardian if employed
application ( ) 2. Certificate of Tax Exemption from the BIR
5. Avail of only one government funded financial assistance program. ( ) 3. Certificate of Indigency from their Barangay
NOTE: ( ) 4. Certificate/Case Study from DSWD
Beneficiaries of free higher education under RA 10931 can only receive ( ) 5. Latest copy of contract or proof of income for children of Overseas Filipino
stipend under this program Workers (OFW) and seafarers.