KUNG ANG STUDENT MAGKI-CLAIM

ILAGAY ANG YEAR O GRADE LEVEL DITO

CRISIS INTERVENTION SECTION
FIELD OFFICE V
DSWD-PMB-GF-011 | REV 02 | 08 JAN 2024

GENERAL INTAKE SHEET

MAARING MAGPATULONG SUMAGOT SA DSWD PERSONNEL

QN: PCN: Date:

MM DD YYYY
New Returning On-site Walk-in Referral Off-site
Part I: To be filled out by Client
IMPORMASYON NG KINATAWAN (Client’s Identifying Information)
DE LA CRUZ JUAN FLORES
Apelyido (Last Name) Unang Pangalan (First Name) Gitnang Pangalan (Middle Name) Ext. (Sr,Jr,I,II)

PUROK 3 SAN ROQUE DARAGA ALBAY BICOL

House No./Street/Purok (Ex 123 Sun) Barangay (Ex. Batasan) City/Municipality (Ex. Quezon City) Province/District (Ex. Dist III) Region (Ex. NCR)
0966-000-000 JANUARY 01 2000 24 MALE SINGLE N/A N/A
Numero ng Telepono (Mobile No.) Kapanganakan (Birthdate) Edad (Age) Kasarian (Sex) Civil Status (Katayuang Sibil) Trabaho (Occupation) Buwanang Kita (Monthly Salary)
MM-DD-YYYY

SELF
Relasyon sa Benepisyaryo (Relationship to the Beneficiary)

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 (Sex) Civil Status (Katayuang Sibil) Trabaho (Occupation) Buwanang Kita (Monthly Salary)
MM-DD-YYYY
KOMPOSISYON NG PAMILYA (Family Composition) Note: Gamitin ang Likurang bahagi ng papel kung kinakailangan
Buong Pangalan Relasyon sa Benepisyaryo Edad Trabaho Buwanang kita
(Complete Name) (Relationship to the Beneficiary) (Age) (Occupation) (Monthly Salary

MARIA DE LA CRUZ KAPATID 30 FOOD VENDOR 10,000.00

(SA LIKOD NA LANG ANG IBA)
Part II: To be Filled out by DSWD Personnel
Client Category Social worker's Assessment
Target Sector: Specify Sub-Category The client is being recommended for educational assistance as augmentation support
for his/her school needs. Client belongs to an indigent family with income just enough
FHONA Solo Parents KIA/WIA
to support their daily family expenses. Moreover, both internal and external resources
SC Indigenous People of the family were already exhausted, and could not oblige other family members to
WEDC Recovering Person who used drugs extend financial help due to the same economic situation. Relative to the resumption
YNSP 4PS DSWD Beneficiary of classes, emerging expenses such as school projects, curriculum requirements,
PWD Street Dwellers fare expenses and prepaid load for internet are just a few of the innumerable
PLHIV Psychosocial/Mental/Learning Disability concerns of the client. In order to defray the costly education and help maintain and
CNSP Stateless Person/Asylum Seekers/Refugees restore the client’s social functioning, the undersigned recommends for the provision
Others: of educational assistance as augmentation support for school fees and other related
expenses.
Financial Assistance: Material Assistance: Psychosocial Support: Referral:

Medical Food Assistance Family Food Packs Psychosocial First Aid ___AKB__
Funeral Cash Relief Other Food Items (PFA) _________
Transportation Assistance Hygiene/Sleeping Kits
Emergency Cash Social Work Counseling _________
Educational Assistive Device & Technologies
Transfer-AICS

Provided Amount Fund Source

1 Educational Assistance 5,000.00 PSP FUND 2024
2

We are committed to protect and respect the privacy of our

clients and beneficiaries and we will only collect, record, store,
process and use personal information in accordance with
Interviewed by: Reviewed & Approved by:
Republic Act No. 10173 or the Data Privacy Act of 2012. By
signing this form you are giving your consent to the DSWD and
hereby agree to the terms and conditions set herein and with the
applicable Data Privacy Policy of the Department.

JUAN F. DE LA CRUZ
Buong Pangalan at Pirma Social Worker Approving Authority
(Signature over Printed Name) (Signature over Printed Name) (Signature over Printed Name)

Page 1 of 1
DSWD Field Office V, Magnolia St. PBN-Buraguis,Legazpi City,Philippines,4500
Website:fo5.dswd.gov.ph Email:[email protected] Facebook:DSWD Region V
Youtube Twitter Instagram : @dswdfo5
 KUNG REPRESENTATIVE ANG MAGKI-CLAIM
ILAGAY ANG YEAR O GRADE LEVEL DITO
CRISIS INTERVENTION SECTION
FIELD OFFICE V
DSWD-PMB-GF-011 | REV 02 | 08 JAN 2024

GENERAL INTAKE SHEET

MAARING MAGPATULONG SUMAGOT SA DSWD PERSONNEL

QN: PCN: Date:

MM DD YYYY
New Returning On-site Walk-in Referral Off-site
Part I: To be filled out by Client
IMPORMASYON NG KINATAWAN (Client’s Identifying Information)
DE LA CRUZ MARITES FLORES
Apelyido (Last Name) Unang Pangalan (First Name) Gitnang Pangalan (Middle Name) Ext. (Sr,Jr,I,II)

PUROK 3 SAN ROQUE DARAGA ALBAY BICOL

House No./Street/Purok (Ex 123 Sun) Barangay (Ex. Batasan) City/Municipality (Ex. Quezon City) Province/District (Ex. Dist III) Region (Ex. NCR)
0966-000-000 DECEMBER 01 1964 59 MALE SINGLE N/A N/A
Numero ng Telepono (Mobile No.) Kapanganakan (Birthdate) Edad (Age) Kasarian (Sex) Civil Status (Katayuang Sibil) Trabaho (Occupation) Buwanang Kita (Monthly Salary)
MM-DD-YYYY

MOTHER
Relasyon sa Benepisyaryo (Relationship to the Beneficiary)

IMPORMASYON NG BENEPISYARYO (Beneficiary’s Identifying Information)

DE LA CRUZ JUAN FLORES

Apelyido (Last Name) Unang Pangalan (First Name) Gitnang Pangalan (Middle Name) Ext. (Sr,Jr,I,II)
PUROK 3 SAN ROQUE DARAGA ALBAY BICOL
House No./Street/Purok (Ex 123 Sun) Barangay (Ex. Batasan) City/Municipality (Ex. Quezon City) Province/District (Ex. Dist III) Region (Ex. NCR)
0966-000-000 JANUARY 01 2000 24 MALE SINGLE N/A N/A
Numero ng Telepono (Mobile No.) Kapanganakan (Birthdate) Edad (Age) Kasarian (Sex) Civil Status (Katayuang Sibil) Trabaho (Occupation) Buwanang Kita (Monthly Salary)
MM-DD-YYYY
KOMPOSISYON NG PAMILYA (Family Composition) Note: Gamitin ang Likurang bahagi ng papel kung kinakailangan
Buong Pangalan Relasyon sa Benepisyaryo Edad Trabaho Buwanang kita
(Complete Name) (Relationship to the Beneficiary) (Age) (Occupation) (Monthly Salary

MARIA DE LA CRUZ KAPATID 30 FOOD VENDOR 10,000.00

(SA LIKOD NA LANG ANG IBA)
Part II: To be Filled out by DSWD Personnel
Client Category Social worker's Assessment
Target Sector: Specify Sub-Category The client is being recommended for educational assistance as augmentation support
for his/her school needs. Client belongs to an indigent family with income just enough
FHONA Solo Parents KIA/WIA
to support their daily family expenses. Moreover, both internal and external resources
SC Indigenous People of the family were already exhausted, and could not oblige other family members to
WEDC Recovering Person who used drugs extend financial help due to the same economic situation. Relative to the resumption
YNSP 4PS DSWD Beneficiary of classes, emerging expenses such as school projects, curriculum requirements,
PWD Street Dwellers fare expenses and prepaid load for internet are just a few of the innumerable
PLHIV Psychosocial/Mental/Learning Disability concerns of the client. In order to defray the costly education and help maintain and
CNSP Stateless Person/Asylum Seekers/Refugees restore the client’s social functioning, the undersigned recommends for the provision
Others: of educational assistance as augmentation support for school fees and other related
expenses.
Financial Assistance: Material Assistance: Psychosocial Support: Referral:

Medical Food Assistance Family Food Packs Psychosocial First Aid ___AKB__
Funeral Cash Relief Other Food Items (PFA) _________
Transportation Assistance Hygiene/Sleeping Kits
Social Work Counseling _________
Educational Emergency Cash Assistive Device & Technologies
Transfer-AICS

Provided Amount Fund Source

1 Educational Assistance 5,000.00 PSP FUND 2024
2

We are committed to protect and respect the privacy of our

clients and beneficiaries and we will only collect, record, store,
process and use personal information in accordance with
Interviewed by: Reviewed & Approved by:
Republic Act No. 10173 or the Data Privacy Act of 2012. By
signing this form you are giving your consent to the DSWD and
hereby agree to the terms and conditions set herein and with the
applicable Data Privacy Policy of the Department.

MARITES F. DE LA CRUZ
Buong Pangalan at Pirma Social Worker Approving Authority
(Signature over Printed Name) (Signature over Printed Name) (Signature over Printed Name)

Page 1 of 1
 KUNG ANG STUDENT MAGKI-CLAIM
CRISIS INTERVENTION SECTION
FIELD OFFICE V
DSWD-PMB-GF-013 | REV 02 | 08 JAN 2024

CERTIFICATE OF ELIGIBILITY
(Outright Cash)

QN: PCN: Date:

MM DD YYYY
New Returning On-site Walk-in Referral Off-site

Male Female
This is to certify that, JUAN FLORES DE LA CRUZ (kompletong middle name po) , 21
Kumpletong Pangalan ng kliyente (First Name Middle Name Last Name) Kasarian (Sex) Edad (Age)

and presently residing at PUROK 1 POBLACION, RAPU-RAPU, ALBAY

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 N/A
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 Discharge Summary Death Summary

Justification Prescriptions Laboratory Request Referral Letter
Valid I.D. Presented Statement of Account Promissory Note Social Case Study Report
Treatment Protocol Funeral Contract Others
Quotation/Chargeslip Death Certificate COR/COE

The Client is hereby recommended to receive EDUCATIONAL assistance for Payment for miscellaneous fees, education needs, and other related expenses

in the amount of FIVE THOUSAND PESOS ONLY Php. 5000 CHARGEBLE AGAINST: PSP 2024

Conforme: Prepared by: Approved by:

JUAN F. DE LA CRUZ
Client Social Worker Approving Authority
(Signature over Printed Name) (Signature over Printed Name) (Signature over Printed Name)

Acknowledgement Receipt

MM DD YYYY
Date:

Financial Assistance FIVE THOUSAND PESOS ONLY Php 5000

(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:

JUAN F. DE LA CRUZ
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 V, Magnolia St. PBN-Buraguis,Legazpi City,Philippines,4500
Website:fo5.dswd.gov.ph Email:[email protected] Facebook:DSWD Region V
Youtube Twitter Instagram : @dswdfo5
 KUNG REPRESENTATIVE ANG MAGKI-CLAIM
CRISIS INTERVENTION SECTION
FIELD OFFICE V
DSWD-PMB-GF-013 | REV 02 | 08 JAN 2024

CERTIFICATE OF ELIGIBILITY
(Outright Cash)

QN: PCN: Date:

MM DD YYYY
New Returning On-site Walk-in Referral Off-site

Male Female
This is to certify that, MARITES FLORES DE LA CRUZ (kompletong middle name po) , 43
Kumpletong Pangalan ng kliyente (First Name Middle Name Last Name) Kasarian (Sex) Edad (Age)

and presently residing at PUROK 1 POBLACION, RAPU-RAPU, ALBAY

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

MOTHER JUAN FLORES DE LA CRUZ - CHILD (kompletong middle name po)

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 Discharge Summary Death Summary

Justification Prescriptions Laboratory Request Referral Letter
Valid I.D. Presented Statement of Account Promissory Note Social Case Study Report
Treatment Protocol Funeral Contract Others
Quotation/Chargeslip Death Certificate COR/COE

The Client is hereby recommended to receive EDUCATIONAL assistance for Payment for miscellaneous fees, education needs, and other related expenses

in the amount of FIVE THOUSAND PESOS ONLY Php. 5000 CHARGEBLE AGAINST: PSP 2024

Conforme: Prepared by: Approved by:

MARITES F. DE LA CRUZ
Client Social Worker Approving Authority
(Signature over Printed Name) (Signature over Printed Name) (Signature over Printed Name)

Acknowledgement Receipt

MM DD YYYY
Date:

Financial Assistance FIVE THOUSAND PESOS ONLY Php 5000

(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:

MARITES F. DE LA CRUZ
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 V, Magnolia St. PBN-Buraguis,Legazpi City,Philippines,4500
Website:fo5.dswd.gov.ph Email:[email protected] Facebook:DSWD Region V
Youtube Twitter Instagram : @dswdfo5