1.

Items Purchased for Quantity Price Total

Repar/Reconstruction
Item 1 X X X
Item 2 X X X
Item 3 X X X
Item 4…. etc. x x x
Sub-Total Php 100,000 (or more)

This is to certify that SANTIAGO JACA, a resident of Barangay _______ has purchased the aforementioned
items/materials for the repair/reconstruction of his residence at __________ which was totally damaged/destroyed by
Super Typhoon Yolanda on November 8, 2013.

This certification is issued for purposes of claiming the emergency shelter assistance from the government through the
Local Water Utilities Administration and Leyte Metropolitan Water District and for whatever legal purpose it may serve.

Given this ___ day of January 2019 at ______ Brgy Hall, Tacloban City.

Beneficiary:

(Signature)

Santiago Jaca

Certified:

(Signature)

Brgy. Chairman

2. This is to certify that SANTIAGO JACA, a resident of Barangay _______ has been adversely affected by the onslaught
of Super Typhoon Yolanda during November 8, 2013 and that his residence at __________ was repaired/reconstructed
after having been totally damaged/destroyed by said typhoon.

This certification is issued for purposes of claiming the emergency shelter assistance from the government through the
Local Water Utilities Administration and Leyte Metropolitan Water District and for whatever legal purpose it may serve.

Given this ___ day of January 2019 at ______ Brgy Hall, Tacloban City.

(signature)

Brgy. Chairman

3. I, SANTIAGO JACA, a resident of ________ hereby certify that I am the sole recipient of the “emergency shelter
assistance fund” (Basta an ngaran han iyo makukuha, ESA or PSF ada adto) from the government through the Local
Water Utilities Administration and Leyte Metropolitan Water District and that no other government employee from my
family/household has availed of the same.

This certification is issued for the abovementioned purpose and for whatever legal interest it may serve.

Given this ___ day of January 2019 at ______ Tacloban City.

(signature)

Santiago Jaca

** PRINT EXTRA-COPIES para mayda ka imo la kopya. At least 2 copies should suffice.