GRIEVANCE FORM

TRACKING #:_____________

PASUYONG PAKIKUMPLETO ANG MGA SUMUSUNOD NA DETALYE AT PAKIMARKAHAN NG “X” ANG MGA KAHON NA NAANGKOP SA INYONG KASAGUTAN.
I.IMPORMASYON PATUNGKOL SA NAGREREKLAMO (COMPLAINANT INFORMATION)
COMPLAINANT Beneficiary Non-beneficiary MCCT CONFIDENTIAL? OO HINDI PETSA:
TYPE
Household ID #: SET: CLIENT STATUS:
Pangalan: (First, Middle, Last) KASARIAN: IP AFFILIATION:

Address: (Street, Brgy, City/Muni,Province, Region) CONTACT #:

II. IMPORMASYON UKOL SA REKLAMO/HINAING (GRIEVANCE INFORMATION)
I-TSEK ( ) ANG MGA KAHON NA NAAANGKOP SA INYONG REKLAMO O HINAING.
1.Payment Issue 5. Misbehavior
YEAR:202_
P1 (Feb) P4 (Aug) Beneficiary Fraudulence
Vices
P1 (Mar) P4 (Sep)
P2 (Apr) P5 (Oct)
Gambling Collection of any kind
P2 (May) P5 (Nov)
P3 (Jun) P6 (Dec)
Pawning Disinformation
P3 (Jul) P6 (Jan)
Misrepresentation
Persuasion

No payment

Underpayment

SSI payment issues

Overpayment

2. Card Issue 6. Implementer Issue

2.1 Inaccessible cards 6.1 Implementer issues that affect beneficiary experience and
Perforated card integrity of the program
No card
Imposition of additional conditions
Captured card
Inaccessible account Discourtesy
Locked/Hot card
Collection of any kind
No top-ups
Inaction to requests
Blocked card Implementer fraudulence
2.2 Delayed issuance of and/or
Delayed fund transfer 6.2 Implementer issues that affect correct and timely receipt of
inaccessible replacement cards
Delayed card cash grants
Lost card Incorrect reporting of compliance data
Delayed action to requests
Stolen cardcard Delayed name matching
Damaged
3. Inclusion Request 7. Appeal

Transient poor Appeal for reactivation

Chronic poor Appeal for reinstatement
Extreme poor
4. Disqualification 9. Facility Issue

With Regular Income Inadequate education services and/or facilities

With High-Value Property Inadequate health services and/or facilities

With relative abroad

PAKISULAT ANG KUMPLETONG DETALYE NG INYONG REKLAMO/HINAING.GAMITIN ANG LIKOD NG PAHINA PARA SA MGA KARAGDAGANG IMPORMASYON.
(PLEASE DESCRIBE THE COMPLAINT HERE. USE THE BACK PAGE FOR ADDITIONAL DETAILS.)

III. IMPORMASYON UKOL SA RESOLUSYON NG REKLAMO (INFORMATION ON THE GRIEVANCE RESOLUTION)

TO BE COMPLETED BY PANTAWID PAMILYA STAFF/GRIEVANCE OFFICER/CITY/MUNICIPAL LINK.
Initial Resolution:
 This form has been thoroughly discussed with me and all information disclosed herein should not be used against me.
Complainant’s signature: Assisted by:
_____________________________________
Signature over printed name
Date: Date Assisted:
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THIS SERVES AS YOUR GRIEVANCE STUB. DATE FILED:
Name: HH ID #: Address:
Type of grievance filed: STATUS: On-going Resolved:
Payment issue Misbehavior Remarks:

Card issue Implementer issue

Inclusion request Appeal

Disqualification Facility issue

For follow-up, please contact:

Name: Designation: Contact #:

COMPLAINT DESCRIPTION

RESOLUTION DETAILS

For Pantawid Pamilya staff use only. Updates on the filed grievances may be provided here

Date Updates Updated by: