Name of Project: TUPAD OSEC-FMS Form No.

4
DOLE Regional Office:
Province: RIZAL
Municipality: ANTIPOLO
Barangay: STA. CRUZ
LIST OF BENEFICIARIES

Name of Beneficiary Birthdate1 Address2

Type of ID Civil Dependent6 (Name of Beneficiary Contact No.
No. ID Number Type of Beneficiary3 Sex4 Age
ExtN. City/ (e.g. SSS, Voter's ID) Status5 of the Micro-insurance Holder)
First Name Middle Name Last Name (YYYY/MM/DD) Barangay Province
Name Municipality
BNS
68 REA IBARBIA DIZON 9/5/1985 STA. CRUZ ANTIPOLO RIZAL VOTERS ID 5802-0706B F M 36 WILSON MONTOYA 09506106275
62 MYRNA ISIDRO OSIANO 5/27/1963 STA. CRUZ ANTIPOLO RIZAL VOTERS ID 5802-0708B F M 58 HILARIO M. OSIANO 09322836795
ROWENA ROMERO MAGBANUA 6/29/1974 STA. CRUZ ANTIPOLO RIZAL VOTERS ID 5802-0707C F S 47 MA. HERA M. DOMINGO 9616196162
JOSE MARIE HEMENTIZA 8/1/2000 STA. CRUZ ANTIPOLO RIZAL BRGY. ID 0770-21 M S 21 ROSEMARIE HEMENTIZA 9071120393

BHW
RIZZA BAUYON BASILA 12/30/1973 STA. CRUZ ANTIPOLO RIZAL VOTERS ID 5802-0607F F M 48 RENZ ISIDRO BASILA 9128829594
JOSEPHINE LAMER CAJUCOM 8/10/1974 STA. CRUZ ANTIPOLO RIZAL TIN ID 381-246-815-000 F M 47 JASMIN L. CAJUCOM 9511588777
ANITA GIGANIA LIQUIRAN 8/7/1961 STA. CRUZ ANTIPOLO RIZAL VOTERS ID 5802-0707C F M 60 ROMEO LIQUIRAN 9632837479
MILDRED COMIDA LLENAS 5/28/1989 STA. CRUZ ANTIPOLO RIZAL VOTERS ID 5802-0693C F M 32 MARLON B. LLENAS 9477300516
MELODINA RAFAEL ORTEGA 7/17/1969 STA. CRUZ ANTIPOLO RIZAL VOTERS ID 5802-0708B F M 51 JOMEL ORTEGA 9304419480
MARLYN CASIMERO OBEDA 3/9/1959 STA. CRUZ ANTIPOLO RIZAL VOTERS ID 5802-0708B F M 62 JOHN REIMAR OBEDA 9284345640
MARYANN BAGRO COSTA 10/10/1964 STA. CRUZ ANTIPOLO RIZAL VOTERS ID 5802-0700A F M 57 ROMEO COSTA 9073442594
ELENITA BERNARDO BENIPAYO 10/19/1962 STA. CRUZ ANTIPOLO RIZAL VOTERS ID 5802-0707A F M 59 JESUS BENIPAYO 9501414858
RICKY SAMSON CALUMA 7/26/1964 STA. CRUZ ANTIPOLO RIZAL BRGY. ID 6358-21 M S 57 JOSH CALUMA 9095096368
 61 LIZA DIMITIMAN GARROTE 10/25/1968 STA. CRUZ ANTIPOLO RIZAL VOTERS ID 5802-0714A F M 52 CRISANTO D. GARROTE JR. 09123622762
62 MYRNA ISIDRO OSIANO 5/27/1963 STA. CRUZ ANTIPOLO RIZAL VOTERS ID 5802-0708B F M 58 HILARIO M. OSIANO 09322836795
63 ANITA GIGANIA LIQUIRAN 8/7/1961 STA. CRUZ ANTIPOLO RIZAL VOTERS ID 5802-0707C F M 60 ARREN JAY LIQUIRAN 09632837479
64 RIZZA BAUYON BASILA 12/30/1972 STA. CRUZ ANTIPOLO RIZAL UMID ID 0111-7237081-6 F W 48 SHAN CEDRICK B. BASILA 09070185144
65 JOSEPHINE LAMER CAJUCOM 8/10/1974 STA. CRUZ ANTIPOLO RIZAL TIN ID 381-246-815-000 F M 47 JASMIN L. CAJUCOM 09511588777
66 RAQUEL CALUMA JUANSON 2/27/1973 STA. CRUZ ANTIPOLO RIZAL UMID ID CRN 006-0099-6934-0 F M 48 RACEL CLOUIE C. JUANSON 09263313500
67 MILDRED COMIDA LLENAS 5/28/1989 STA. CRUZ ANTIPOLO RIZAL VOTERS ID 5802-0693C F M 32 MARLON B. LLENAS 09678126820
68 REA IBARBIA DIZON 9/5/1985 STA. CRUZ ANTIPOLO RIZAL VOTERS ID 5802-0706B F M 36 WILSON MONTOYA 09506106275
69 ELENITA BERNARDO BENIPAYO 10/19/1962 STA. CRUZ ANTIPOLO RIZAL TIN ID 911-289-860-000 F M 58 JESUS D. BENIPAYO 09501414858
70 MARY ANN BAGRO COSTA 10/10/1964 STA. CRUZ ANTIPOLO RIZAL VOTERS ID 5802-0700A F M 57 ROMEO L. COSTA 09384351127
71 MELODINA RAFAEL ORTEGA 7/17/1969 STA. CRUZ ANTIPOLO RIZAL VOTERS ID 5802-0708B F M 51 JHOMEL R. ORTEGA 09304419480
72 MARILYN CASIMERO OBEDA 3/9/1959 STA. CRUZ ANTIPOLO RIZAL VOTERS ID 5802-0708B F M 60 JON REIMAR C. OBEDA 09304419480

I hereby certify that the above list of beneficiaries are displaced marginalized workers, underemployed or self-employed workers that have lost their livelihood or whose earnings were affected due to Enhanced Community Quarantine.

Further, I certify that they were verified to have not received cash assistance from the DSWD under the Assistance to Individuals in Crisis Situation (AICS) and the Enhanced Pantawid Pamilyang Pilipino Program (4Ps), DA's cash assistance for rice farmers, and DOF's Small Business Wage Subsidy Program; and that the total
amount of assistance received by the household of each beneficiary from various social amelioration programs shall not exceed P5,000.00 - 8,000.00 (amount ceiling varies across regions), as prescribed by the Inter-Agency Task Force for the Management of Emerging Infectious Diseases (IATF-EID).

Prepared and Certified true and Correct by:

 LGU or Authorized representative

Notes:
*Only the gray portion of this form should be submitted to DSWD. This will be used by DSWD in name-matching to avoid duplication of beneficiaries with the other social amelioration programs.
1 – Birthdate: Year/Month/Day (YYYY/MM/DD)
2 – Address: (Street No, Barangay, City/Municipality, Province)
3 – Type of Beneficiaries: Example: Crop growers (please specify), Vendors (please specify), Homebased worker (please specify), Fisherfolks, Livestock/Poultry Raiser, Alternative/Small transport drivers, Laborer (please specify), Person with Disability (PWDs), Others (please specify)
4 – Sex: F for female, M for Male
5 – Civil Status: S for single, M for married
6 – Dependent – Name of the Beneficiary of micro-insurance policy holder.

Note: Statement of Informed Consent

I understand the purpose of this profiling activity. I voluntarily and willfully give my consent to be part of this undertaking. I certify that the information that I will give are true and correct and that any misrepresentation and falsification of information may void their application to TUPAD #BKBK. I authorize the use, processing and sharing of
my personal data for the purpose that is intended for without prejudice to my rights stated in the Data Privacy Act of 2012.