BUS Form 5 V3_2023

Beneficiary Data Update Request Form

Date Filed: ____________
Instructions: 1. The household grantee shall properly fill-out this form. Fill out only the section that is applicable.
2. Please refer to Types of Updates at the back for the details of the supporting documents.
3. Updates related to payments should be prioritized for updating. This is to ensure the maximum amount of grants will be received by the household.
4. Ensure to secure a copy of Acknowledging Receipt once this form submitted to the Pantawid Personnel.

PART I - TO BE FILLED OUT BY THE HOUSEHOLD GRANTEE

A. HOUSEHOLD AND PERSONAL DATA
LAST NAME FIRST NAME MIDDLE NAME EXTENSION NAME

HOUSEHOLD ID NUMBER: GRANTEE NAME:

HOUSE NO. STREET/PUROK/SITIO BARANGAY CITY/MUNICIPALITY PROVINCE REGION
ADDRESS:
B. DATA CHANGE/CORRECTION/UPDATING
1 NEWBORN AND/OR ADDITIONAL HOUSEHOLD MEMBER
8 LAST NAME FIRST NAME MIDDLE NAME EXTENSION NAME

NAME OF CHILD:
DATE OF BIRTH (MM/DD/YYYY): SEX: DISABLED? No Yes, if YES please specify Type/s of Disability:
LAST NAME, FIRST NAME MIDDLE NAME EXTENSION NAME

NAME OF PARENT IN THE FAMILY ROSTER: RELATIONSHIP TO HH HEAD:

ATTENDING SCHOOL? Yes No, Reason for Not Attending:
NAME OF SCHOOL: ADDRESS OF SCHOOL:
NAME OF HEALTH FACILITY: ADDRESS OF HEALTH FACILITY:
2 TRANSFER OF ADDRESS FROM TO
3 REGION:
PROVINCE:
CITY/MUNICIPALITY:
BARANGAY:
STREET/PUROK/SITIO:
4 UPDATE ON HEALTH FACILITY FROM TO
1. NAME OF MEMBER: ATTENDING: Yes No, Reason for Not Attending:
LAST NAME, FIRST NAME
MIDDLE NAME EXTENSION NAME NAME OF FACILITY:
FACILITY ADDRESS:
TYPE OF FACILITY:
2. NAME OF MEMBER: ATTENDING: Yes No, Reason for Not Attending:
LAST NAME, FIRST NAME
MIDDLE NAME EXTENSION NAME NAME OF FACILITY:
FACILITY ADDRESS:
TYPE OF FACILITY:
5 UPDATE ON EDUCATION INFORMATION FROM TO
1. NAME OF MEMBER: ATTENDING: Yes No, Reason for Not Attending:
LAST NAME, FIRST NAME
MIDDLE NAME EXTENSION NAME NAME OF SCHOOL:
SCHOOL ADDRESS:
GRADE LEVEL:
IF SENIOR HIGH SCHOOL, please specify track and strand:
Academic: Technical-Vocational-Livelihood: Sports Arts and Design
Accountacy, Business, Management (ABM) Agricultural-Fishery
Humanities and Social Sciences (HUMSS) Home Economics
Science, Technology, Engineering, Mathematics (STEM) Information and Communications Technology (ICT)
General Academic Industrial Arts
Pre-Baccalaureate Maritime TVL Maritime

IF SENIOR HIGH SCHOOL GRADUATE, please specify received award:

Classroom Awards: Grade-level Awards
Conduct Awards Award for Outstanding Performance in Specific Disciplines, please specify below:
Academic Excellence Award
Academic Excellence Award
Leadership Award Athletics Science
Recognition for Perfect Attendance
Award for Work Immersion Arts Social Sciences
Special Recognition, please specify: Award for Research or Innovation Communication Arts Technical-Vocational Education
Mathematics

IF COLLEGE GRADUATE, please specify Latin Honors if any:

Summa Cum Laude Magna Cum Laude Cum Laude Specify other awards and honors (e.g. Graduation with Honors):
BAR EXAM PASSER if BOARD LICENSURE/EXAM PASSER please specify PROFESSION below (e.g. Accountacy, Architecture, Engineering, etc.):

IF WITH TECHNICAL-VOCATIONAL EDUCATION AND TRAINING (TVET) CERTICATION, please specify below (e.g. Computer Systems Servicing NC II):

2. NAME OF MEMBER: ATTENDING: Yes No, Reason for Not Attending:

LAST NAME, FIRST NAME
MIDDLE NAME EXTENSION NAME NAME OF SCHOOL:
SCHOOL ADDRESS:
GRADE LEVEL:
IF SENIOR HIGH SCHOOL, please specify track and strand:
Academic: Technical-Vocational-Livelihood: Sports Arts and Design
Accountacy, Business, Management (ABM) Agricultural-Fishery
Humanities and Social Sciences (HUMSS) Home Economics
Science, Technology, Engineering, Mathematics (STEM) Information and Communications Technology (ICT)
General Academic Industrial Arts
Pre-Baccalaureate Maritime TVL Maritime

IF SENIOR HIGH SCHOOL GRADUATE, please specify received award:

Classroom Awards: Grade-level Awards:
Conduct Awards Academic Excellence Award Award for Outstanding Performance in Specific Disciplines, please specify below:
Academic Excellence Award Leadership Award Athletics Science
Recognition for Perfect Attendance Award for Work Immersion Arts Social Sciences
Award for Research or Innovation Communication Arts Technical-Vocational Education
Special Recognition, please specify: Mathematics

IF COLLEGE GRADUATE, please specify Latin Honors if any:

Summa Cum Laude Magna Cum Laude Cum Laude Specify other awards and honors (e.g. Graduation with Honors):
BAR EXAM PASSER if BOARD LICENSURE/EXAM PASSER please specify PROFESSION below (e.g. Accountacy, Architecture, Engineering, etc.):

IF WITH TECHNICAL-VOCATIONAL EDUCATION AND TRAINING (TVET) CERTICATION, please specify below (e.g. Computer Systems Servicing NC II):

Beneficiary's Copy Date Filed: City/Municipal Link's Copy Date Filed:

ACKNOWLEDGEMENT RECEIPT ACKNOWLEDGEMENT RECEIPT
Name of Beneficiary:
Name of Beneficiary:
Household ID No.:
Household ID No.:
Type of Update Field Updated Change to Type of Update Field Updated Change to Remarks

Signature Over Printed Signature Over Printed Date Received Signature Over Printed Signature Over Printed Date Received
Name/Thumbmark of Grantee/ Name of DSWD Personnel Name/Thumbmark of Grantee/ Representative Name of DSWD Personnel
Representative Representative and Designation Representative and Designation

1
 BUS Form 5 V3_2023

6 CHANGE OF HOUSEHOLD GRANTEE FROM TO

NAME OF GRANTEE (LAST NAME, FIRST NAME MIDDLE NAME EXTENSION NAME):
NEW GRANTEE'S INFORMATION:
MOTHER'S MAIDEN NAME:
DATE OF BIRTH (MM/DD/YYYY): RELATIONSHIP TO HOUSEHOLD HEAD:
GUARDIAN'S NAME (for minor grantee only): RELATIONSHIP TO MINOR GRANTEE:
REASON FOR CHANGE: DEATH GRIEVANCE REDRESS-RELATED ISSUES GENDER-BASED VIOLENCE LONG ABSENCE PARENTAL AUTHORITY SUSPENDED

CAPTURING OF DECEASED MEMBER/S (MEMBER STATUS)

NAME (LAST NAME, FIRST NAME MIDDLE NAME EXTENSION NAME): SEX RELATIONSHIP TO HOUSEHOLD HEAD DATE OF BIRTH (MM/DD/YYYY) FOR REPLACEMENT
1 YES NO
2 YES NO
(If for replacement, please facilitate the deselection using Update Type 11 with reason as deceased then proceed to the selection of the replacement child of the household)
9 CAPTURING/CORRECTION OF BASIC INFORMATION FROM TO
1. NAME (LAST NAME, FIRST NAME MIDDLE NAME EXTENSION NAME):

DATE OF BIRTH (MM/DD/YYYY):

RELATIONSHIP TO HOUSEHOLD HEAD:
MARITAL STATUS:
SEX
DISABLED: NO YES, if YES please specify type of DISABILITY: Psychosocial Chronic Illness Learning Visual Orthopedic Mental
SOLO PARENT: YES NO Intellectual Hearing Speech
EMPLOYMENT INFORMATION
EMPLOYED: NO YES, if YES please specify type of employer Government Private
TYPE OF EMPLOYMENT: Regular Project Seasonal Casual Fixed-Term
Please specify OCCUPATION (e.g. employee): PHILSys ID No.:
0 - Special Occupations 6 - Farmers, Forestry Workers and Fishermen
1 - Officials of government and special interest orgs, corporate executives, managers, managing proprietors and supervisors
2 - Professionals 7 - Craft and related trades workers
3 - Technicians and Associate Professionals 8 - Plant and Machine Operators and Assemblers
4 - Clerks 9 - Laborers and Unskilled Workers
5 - Service Workers and Shop and Market Sales Workers
2. NAME (LAST NAME, FIRST NAME MIDDLE NAME EXTENSION NAME):

DATE OF BIRTH (MM/DD/YYYY):

RELATIONSHIP TO HOUSEHOLD HEAD:
MARITAL STATUS:
SEX
DISABLED: NO YES, if YES please specify type of DISABILITY: Psychosocial Chronic Illness Learning Visual Orthopedic Mental
SOLO PARENT: YES NO Intellectual Hearing Speech
EMPLOYMENT INFORMATION
EMPLOYED: NO YES, if YES please specify type of employer Government Private
TYPE OF EMPLOYMENT: Regular Project Seasonal Casual Fixed-Term
Please specify OCCUPATION (e.g. employee): PHILSys ID No.:
0 - Special Occupations 6 - Farmers, Forestry Workers and Fishermen
1 - Officials of government and special interest orgs, corporate executives, managers, managing proprietors and supervisors
2 - Professionals 7 - Craft and related trades workers
3 - Technicians and Associate Professionals 8 - Plant and Machine Operators and Assemblers
4 - Clerks 9 - Laborers and Unskilled Workers
5 - Service Workers and Shop and Market Sales Workers
10 CAPTURING/CORRECTION OF IP AFFILIATION
NAME (LAST NAME, FIRST NAME MIDDLE NAME EXTENSION NAME) FROM TO
1
2
Applicable to all household members
11 SELECTION/REPLACEMENT OF CHILD-BENEFICIARY/IES FOR EDUCATION (PLEASE USE THE UPDATE TYPE 4 AND/OR 5 TO UPDATE HEALTH AND/OR EDUCATION INFORMATION OF REPLACEMENT CHILD)
NAME OF CHILD (LAST NAME, FIRST NAME MIDDLE NAME EXTENSION NAME): SELECTION DESELECTION REASON REPLACEMENT CHILD FOR SELECTION
1
2

12 CAPTURING OF PREGNANCY STATUS

NAME (LAST NAME, FIRST NAME MIDDLE NAME EXTENSION NAME) SEX AGE PREGNANCY STATUS LAST MENSTRUAL PERIOD RELATIONSHIP TO HOUSEHOLD HEAD
1
2

DATA PRIVACY CONSENT: In compliance with the Data Privacy Act (DPA) of 2012, and its Implementing Rules and Regulations (IRR) effective since September 9, 2016, I allow the Pantawid Pamilyang
Pilipino Program (4Ps) to enter and store my household data within the Department's authorized storage system and will only be accessed by the 4Ps Authorized personnel. The 4Ps has instituted appropriate
organizational technical and physical security measures to ensure the protection of personal data.By submitting this BUS Form, you consent to the collection, generation, use, processing, storage and retention
of your household data by the Program for the purpose of updating your beneficiary information in the Pantawid Pamilya Information System. I understand that I am given the rights under the Data Privacy Act,
including the right to object to process my data, the right to access my data, the right to correct any inaccurate data and the right to erasure or blocking of data. For more information on these rights, and for
requests to review the Data, to withdraw consent to the use of the Data for any of the purpose stated above, and/or to correct or update the Data, I am to contact the 4P's Project Development Officers at
4ps_bdmd@dswd.gov.ph.

Signature Over Printed Name/Thumbmark Signature Over Printed Name/Thumbmark Signature Over Printed Name of DSWD Personnel
of Grantee/ Representative of Parent Leader Representative and Designation

PART II - TO BE FILLED OUT BY THE CBDO AND ENCODER

(Do not transmit this Form to the RBDO/POO if supporting documents are not complete)
Reviewed by: Date Reviewed: Encoded by: Date Encoded:
POO Remarks: Remarks of Encoder (if any):
IF NOT ENCODED, THIS FORM WITH THE ATTACHED DOCUMENTS WILL BE RETURNEDTO POO/ C/MOO BECAUSE OF THE FOLLOWING REASONS:

Lacking or inconsistent supporting documents. Specify lacking document/s:

ML to verify the correct name of school /health facilities with exact address, then prepare request to the RITO for the addition of new facility in the library .
Not in the family roster
Others (specify)
TYPES OF UPDATES SUPPORTING DOCUMENTS
1. Newborn (a) Birth Certificate/Local Civil Registry Office; (b) Health Certificate from RHU/BHS; (c) Medical Certificate (if PWD)

2. Change of Address (a) Barangay Certificate and/or Certificate of Residency from old and new address of the transferring household; (b) Social Case Study Report/Case Assessment Report whichever is
3. Moving out of the area to non-Pantawid area applicable; (Note:When the household noves out of the area with or without prior notice to C/ML and without applying for change of address within 60 days, th household will be tagged as Code
12 - Moved out of the Area without Notice)
4. Update of Health Facility (a) RHU/BHS Certificate; (b) Social Case Study Report if applicable.
5. Update of Education (a) School Certificate issued by the school where the child is enrolled; Note: If BUS Form 6 is used by education partners, school certificate is not required; (b)
Social Case Study Report if applicable; (c) Letter of declarationfor Senior High School and College Graduates.

6. Change of Grantee (a) Death Certificate; (b) PWD ID or Cetificate from OSCA or C/MSWDO Certificate; (c) Medical Certificate; (d) NCIP/Tribal Chieftain's Certification; (e) Barangay Certificate; (f) Social Case
Study Report/Case Assessment Report whichever is applicable; (g) Valid ID of proposed guardian, if applicable; (h) Birth Certificate of minor grantee; Note: In case of minor grantee (17 years
old and below), a request for a Parental Capability Assessment (PCA) shall be secured from the LSWDO.
Capturing of Deceased Members (a) Death Certificate; (b) Certification from the Tribal Leader or Chieftain

8. Additional Household Member
9. Correction of Basic Information
(a) Birth Certificate/Local Civil Registry; (b) Marriage Certificate; (c) Barangay Certificate; (d) Health Certificate from RHU/BHS; (e) Social Case Study Report/Case Assessment Report
whichever is applicable; (f) Declaration of the Household Head or Grantee.
(a) Birth Certificate/Local Civil Registry; (b) Marriage Certificate; (c) Solo Parent ID or C/MSWDO Certificate; (d) PWD ID or Cetificate from OSCA or C/MSWDO Certificate; (e) Medical
Certificate; (f) NCIP/Tribal Chieftain's Certification; (g) Affidavit of Acknowledgement of Paternity; (h) Case Assessment Report, as deemed necessary; (i) Certificate of Employment or
Barangay Certificate, indicating the present occupation of the household member; (j) PHILSys ID

10. Update of IP/Tribal Affiliation (a) NCIP/Tribal Chieftain's Certification

11. Selection/Deselection of Child/ren (a) Death Certificate (if Deceased); (b) Medical Certificate (for differently-abled child-beneficiary certifying the disability and incapacity to attend school); (c) Letter from the parent of the
for CV monitoring child-beneficiary/ grantee stating the request to select or resaon to deselect the child-beneficiary; (d) Certificate of Enrollment of child for selection or replacement child.

12. Capturing of Pregnancy Status (a) RHU/BHS Certificate from the health facility of the pregnant household member