SOCIAL PENSION APPLICATION FORM

I. BASIC INFORMATION

APPLICANT’S NAME: _________________________________________ CITIZENSHIP: ______________

(Surname, First Name, Middle Name)

AGE: BIRTHDATE: BIRTHPLACE:

SEX: CIVIL STATUS: ( ) Single ( ) Married ( ) Separated ( ) Widowed

ADDRESS: No. of Years:

LIVING ARRANGEMENT: ( ) Living Alone ( ) Living with Relatives

( ) Owned House ( ) Rented

II. ECONOMIC STATUS

ARE YOU A PENSIONER? ( ) NO ( ) YES IF YES, HOW MUCH? _______________________

SOURCE: ( ) GSIS ( ) SSS ( ) PVAO ( ) AFPSLAI ( ) OTHERS

DO YOU HAVE A PERMANENT SOURCE OF INCOME? ( ) YES ( ) NONE

IF YES, FROM WHAT SOURCE?

DO YOU HAVE REGULAR SUPPORT FROM FAMILY? ( ) YES ( ) NONE

IF YES, SPECIFY TYPE OF SUPPORT: ( ) CASH? HOW MUCH _______________________________

( ) IN KIND? SPECIFY, ________________________________
HOW OFTEN? ______________________________________

III. HEALTH CONDITION

DO YOU HAVE EXISTING ILLNESS? ( ) YES ( ) NO

IF YES, SPECIFY TYPE OF ILLNESS _____________________________

HOSPITALIZED WITHIN THE LAST SIX MONTHS? ( ) YES ( ) NO

I hereby certify that the above mentioned information are true and correct to the best of my
knowledge.

___________________________________
Signature above printed name of Applicant

Interviewed by: Reviewed by:

_________________________ ____________________________
OSCA Head C/MSWDO

____________________________
Date Accomplished
 SOCIAL INTAKE FORM

(1) NAME _________________________________________ NHTS-PR HH NO. _______________

(Surname / First Name / Middle Name) ( To be filled by the RSPU)
(2) AGE
(3) SEX ( ) Male ( ) Female
(4) CIVIL STATUS ( ) Single ( ) Married ( ) Widowed ( ) Separated
(5) DATE OF BIRTH
(6) PLACE OF BIRTH
(7) ADDRESS
(8) CONTACT DETAILS: Landline: Mobile No.: Email:
(9) AFFILIATION, PLS CHECK: ( ) FSCAP ( ) COSE ( ) OTHERS, SPECIFY
(10)OSCA ID: ISSUED ON: ISSUED AT:
(11)LIVING ARRANGEMENTS ( ) LIVING ALONE ( ) LIVING WITH RESIDENCE
( ) OWNED HOUSE ( ) RENTED NO. OF YEARS
(12)PENSIONER ( )
(13)NON PENSIONER ( )
(14)IF PENSIONER, PLS SPECIFY ( ) GSIS ( ) SSS ( ) PRIVATE HOW MUCH?
(15)IF NON PENSIONER, ARE YOU RECEIVING SUPPORT FROM FAMILY / RELATIVES?( ) YES ( ) NO
IF YES, WHAT KIND? ( ) CASH ( ) IN KIND, SPECIFY

(16)HOW MANY MEALS DO YOU HAVE IN A DAY? ( ) THREE ( ) TWO ( ) ONE

(17)DO YOU HAVE DISABILITY? ( ) YES ( ) NO
(18)ARE YOU IMMOBILE? ( ) YES ( ) NO
(19)DEPENDENT ON ASSISTIVE DEVICE? ( ) YES ( ) NO
(20)DO YOU HAVE PRE-EXISTING ILLNESS? ( ) YES ( ) NO
IF YES, WHAT TYPE?

Interviewed by: Reviewed by:

_________________________ ____________________________
OSCA Head C/MSWDO

Date Filed:

___________________________