ANNEX B (052824)

Republic of the Philippines

Local Social Welfare and Development Office
City/Municipality, Region
APPLICATION FORM FOR SOLO PARENT
Case Number:
(10 digit PSGC-YYMM-sequential 5 digits)
I. IDENTIFYING INFORMATION
Full Name: Last Name, First Name, Middle Name, Extension Philsys Card Number:
Date of Birth: MM/DD/YYYY Age: Place of Birth: Sex:
Address: No. Street, Barangay, City/Municipal, Province
Educational Attainment: Civil Status:
Occupation: Religion:
Company/Agency: Monthly Income:
Employment Status: ___Employed ___Self-employed ___ Not employed
Contact number/s: Email Address:
Pantawid Beneficiary? ____Y ____N Indigenous Person? ____Y ____N LGBTQ+? ____Y ____N
If Yes, Household ID #: If Yes, Name of Affliation: PWD? ____Y ____N
II(Last, Name
. HOUSEHOLD COMPOSITION
First, Middle, Birthdate Educational Monthly
Ext) Sex Relationship Age (mm/dd/yy) Civil Status Attainment Occupation Income

NOTE: Include family member and other members of the household especially minor children. Use back side for additional members.
III. Classification/Circumstances of being a solo parent (Dahilan bakit naging solo parent)?

IV. Needs/Problems of being a solo parent (Kinakailangan/Problema ng isang solo parent)?

V. IN CASE OF EMERGENCY
Name: Relationship:
Address: Contact number/s:
I hereby certify that the information given above are true and correct. I further understand that any misinterpretation that may have made will
subject me to criminal and civil liabilities provided for by existing laws. In addition, I hereby give my consent to share the information above to
the member agencies of the Inter-Agency Coordinating and Monitoring Committee on solo parents.

Signature/Thumbmark over Printed Name Date

FOR SPD/SPO USE ONLY

STATUS New Terminated
Renewal Disapproved
Solo Parent Identification Card Number: ________________________ Date Issuance: ________________________
Solo parent category: ____________________________________ Beneficiary Code: ______________________
 SOLO PARENT CATEGORY AND REQUIREMENTS b1 Spouse of OFW 1. Birth certificate/s of dependents.
2. Marriage certificate, if the applicant is the spouse of the OFW, or birth
certificate or the other competent proof of the relationship between the applicant
and the OFW, if the applicant is a family member of the OFW.
Code Description Requirements 3. Philippine Overseas Employment Administration Standard Employment
Contract (POEA-SEC) or its equivalent document.
a1 Birth of a child as 1. Birth certificate/s of the child or children
2. Complaint affidavit 4. Photocopy of the OFW's passport with stamps showing continuous twelve (12)
a consequence of 3. Medical record on the incident of rape months of overseas work, or a certification from the Bureau of Immigration.
rape 4. Sworn affidavit declaring that the solo parent has the sole parental care and 5. Proof of income of the OFW's spouse or family member.
support of the child or children at the time of the execution of affidavit: Provided, 6. Sworn affidavit declaring that the solo parent is not cohabiting with a partner or
co-parent and has sole parental care and support of the child or children:
that for purposes of issuance of subsequent SPIC and booklet, only the sworn b2 Relative of OFW: Provided, That for purposes of issuance of subsequent SPIC and booklet,
affidavit shall be submitted every year
5. Affidavit of a barangay official attesting that the solo parent is a resident of the requirement numbers (3), (4), (5), and (6) under this paragraph shall be
barangay and the child or children is/are under the parental care and support of submitted every year; and
the solo parent 7. Affidavit of a barangay official attesting that the solo parent is a resident of the
6. Solo Parents Orientation Seminar Certificate of Attendance barangay and that the child or children is/are under the parental care and support
of the solo parent.
8. Solo Parents Orientation Seminar Certificate of Attendance

a2 Widow/widower 1. Birth certificate/s of the child or children;

2. Marriage certificate;
3. Death certificate of the spouse;
4. Sworn affidavit declaring that the solo parent is not cohabiting with a partner or
co-parent, and has the sole parental care and support of the child or children:
Provided, that for purposes of issuance of subsequent SPIC and booklet, only the
sworn affidavit shall be submitted every year
c Unmarried 1. Birth certificate/s of the child or children.
2. Certificate of No Marriage (CENOMAR).
5. Affidavit of a barangay official attesting that the solo parent is a resident of the
person: 3. Sworn affidavit declaring that the solo parent is not cohabiting with a partner or
barangay and that the child or children is/are under the parental care and support co-parent and has sole parental care and support of the child or children:
of the solo parent. Provided, That for the purposes of issuance of subsequent SPIC and booklet,
6. Solo Parents Orientation Seminar Certificate of Attendance requirement numbers (2), (3) and (4) under this paragraph shall be submitted
every year; and
4. Affidavit of a barangay official attesting that the solo parent is a resident of the
barangay and that the child or children is/are under the parental care and support
of the solo parent.
5. Solo Parents Orientation Seminar Certificate of Attendance

a3 Spouse of person 1. Birth certificate/s of the child or children;

2. Marriage certificate
deprived of 3. Certificate of detention or a certification that the spouse is serving sentence for
liberty: at least three (3) months issued by the law-enforcement agency having actual
custody of the detained spouse or commitment order by the court pursuant to a d Legal guardian / 1. Birth certificate/s of the child or children.
2. Proof of guardianship, such as the decision granting legal guardianship issued
conviction of the spouse; Adoptive parent / by a court; proof of adoption, such as the decree of adoption issued by a court, or
4. Sworn affidavit declaring that the solo parent is not cohabiting with a partner or
co-parent, and has the sole parental care and support of the child or children: Foster parent: order of Adoption issued by the DSWD or the National Authority on Child Care
Provided, That for purposes of issuance of subsequent SPIC and booklet, (NACC); proof of foster care such as the Foster Parent License issued by the
requirement numbers (3) and (4) under this paragraph shall be submitted every DSWD or the NACC.
year; and 3. Sworn affidavit declaring that the solo parent is not cohabiting with a partner or
5. Affidavit of a barangay official attesting that the solo parent is a resident of the co-parent and has sole parental care and support of the child or children:
barangay and that the child or children is/are under the parental care and support Provided, That for purposes of issuance of subsequent SPIC and booklet,
of the solo parent. requirement number (3) and (4) under this paragraph shall be submitted every
6. Solo Parents Orientation Seminar Certificate of Attendance year; and
4. Affidavit of a barangay official attesting that the solo parent is a resident of the
barangay and that the child or children is/are under the parental care and support
of the solo parent.
5. Solo Parents Orientation Seminar Certificate of Attendance

a4 Spouse of person 1. Birth certificate/s of the child or children;

2. Marriage certificate or affidavit of cohabitation;
with physical or 3. Medical records, medical abstract, or a certificate of confinement in the
mental National Center for Mental Health or any medical hospital or facility as a result of
the spouse's physical or mental incapacity, which record, medical abstract or
incapacity: certificate of confinement of the incapacitated spouse should have been issued
not more than three (3) months before the submission, or a valid Person With e Relative within 1. Birth certificate/s of the child or children.
2. Death certificate, certificate of incapacity, or judicial declaration of absence or
Disability ID issued pursuant to Republic Act No. 10754 and Republic Act No. the fourth (4th) presumptive death of the parents or legal guardian; police or barangay records
7277, or the Magna Carta for Disabled Persons; civil degree of evidencing the fact of disappearance or absence of the parent or legal guardian
4. Sworn affidavit that the solo parent is not cohabiting with a partner or co-parent for at least six (6) months.
and has sole parental care and support of the child or children: Provided, That for consanguinity or 3. Proof of relationship of the relative to the parent or legal guardian, such as birth
purposes of issuance of subsequent SPIC and booklet, requirement numbers (3) affinity: certificate, marriage certificate, family records, or other similar or analogous proof
and (4) under this paragraph shall be submitted every year; and of relationship.
5. Affidavit of a barangay official attesting that the solo parent is a resident of the 4. Sworn affidavit declaring that the solo parent has sole parental care and
barangay and that the child or children is/are under the parental care and support support of the child or children: Provided, That for purposes of issuance of
of the solo parent. subsequent SPIC and booklet, requirement numbers (3) and (4) under this
6. Solo Parents Orientation Seminar Certificate of Attendance paragraph shall be submitted every year; and
5. Affidavit of a barangay official attesting that the solo parent is a resident of the
barangay and that the child or children is/are under the parental care and support
of the solo parent; and
6. Solo Parents Orientation Seminar Certificate of Attendance

a5 Due to legal 1. Birth certificate/s of the child or children.

2. Marriage certificate.
separation or de 3. Judicial decree of legal separation of the spouses or, in the case of de facto f Pregnant 1. Medical record of her pregnancy.
2. Affidavit of a barangay official attesting that the solo parent is a resident of the
facto separation: separation, an affidavit of two (2) disinterested persons attesting to the fact of woman: barangay; and
separation of the spouses; and
4. Sworn affidavit declaring that the solo parent is not cohabiting with a partner or 3. Sworn affidavit declaring that the solo parent is not cohabiting with a partner or
co-parent, and has sole parental care and support of the child or children: co-parent who is providing support to the pregnant woman.
Provided, That for purposes of issuance of subsequent SPIC and booklet, 4. Solo Parents Orientation Seminar Certificate of Attendance
requirement numbers (3) and (4) under this paragraph shall be submitted every
year; and
5. Affidavit of a barangay official attesting that the solo parent is a resident of the
barangay and that the child or children is/are under the parental care and support
of the solo parent.
6. Solo Parents Orientation Seminar Certificate of Attendance FOR SOLO PARENT AVAILING OF ADDITIONAL BENEFITS
1. Affidavit of no employment; or.
Income Tax Return (ITR) or similar tax returns; or
Any verifiable proof of income
2. Social case study issued by the C/MSWDO; or
a6 Due to nullity or 1. Birth certificate/s of the child or children.
2. Marriage certificate, annotated with the fact of declaration of nullity of marriage Barangay Certificate of Indigency.
annulment of or annulment of marriage.
marriage 3. Judicial decree of nullity or annulment of marriage or judicial recognition of
foreign divorce.
4. Sworn affidavit declaring that the solo parent is not cohabiting with a partner or OTHER REMINDERS
co-parent and has sole parental care and support of the child or children:
Provided, that for purposes of issuance of subsequent SPIC and booklet, only the * Submit 2 pcs 1x 1 ID Picturevery application and renewal
sworn affidavit shall be submitted every year; and * Bring original and photocopy of birth certificate/s of child/ren/dependent/s
5. Affidavit of a barangay official attesting that the solo parent is a resident of the * Applicant must personally apply
barangay and that the child or children is/are under the parental care and support * All new and renewal applicants for interview and homevisit, if needs further assessment
of the solo parent.
6. Solo Parents Orientation Seminar Certificate of Attendance FOR LOSS SPIC:
* Affidavit of loss
* 1pc 1x1 ID picture
* Sworn affidavit
* Affidavit of barangay

a7 Abandonment by 1. Birth certificate/s of the child or children.

2. Marriage certificates or affidavit of the applicant solo parent.
the spouse: 3. Affidavit of two (2) disinterested persons attesting to the fact of abandonment
of the spouse.
4. Police or barangay record of the fact of abandonment.
5. Sworn affidavit declaring that the solo parent is not cohabiting with a partner or
co-parent, and has sole parental care and support of the child or children:
Provided, that for purposes of issuance of subsequent SPIC and booklet, only
sworn affidavit shall be submitted every year; and
6. Affidavit of a barangay official attesting that the solo parent is a resident of the
barangay and that the child or children is/are under the parental care and support
of the solo parent.
7. Solo Parents Orientation Seminar Certificate of Attendance