LGU Financial Asssitance

DSSD CRISIS INTERVENTION SECTION

DSSD

PETSA NGAYON ORAS NG PAG BILANG NG

(Date Today) PASOK (Time of Entry) KLIYENTE
MM DD YYYY HH MM

IMPORMASYON UKOL SA KLIYENTE (Client's Identifying Information)

PANGALAN:
(NAME) LAST NAME FIRST NAME MIDDLE NAME SUFFIX

PETSA NG KAPA EDAD: KASARIAN: Male

NGANAKAN (Birthday) (Age) (Sex)
Female

STATUS SIBIL Single Widowed

CONTACT
(Civil Status) Married Others
NUMBER

RELASYON SA BENEPISYARYO:
(Relatioship to the Beneficiary)

TIRAHAN:
(Address) Barangay Municipality/City Province

TRABAHO: SWELDO:
(Occupation) (Salary)

IMPORMASYON UKOL SA BENEPISYARYO (Beneficiary's Identifying Information)

PANGALAN:
(NAME) LAST NAME FIRST NAME MIDDLE NAME SUFFIX

PETSA NG KAPA EDAD: KASARIAN: Male

(Age) (Sex)
NGANAKAN (Birthday) Female

STATUS SIBIL Single Widowed

CONTACT
(Civil Status) Married Others
NUMBER

TIRAHAN:
(Address) Barangay Municipality/City Province

TRABAHO: SWELDO:
(Occupation) (Salary)

KOMPOSISYON NG PAMILYA:
PANGALAN EDAD RELASYON TRABAHO BUWANANG SAHOD

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 LGU Financial Asssitance
DSSD CRISIS INTERVENTION SECTION

CLIENT'S Family Head and Other Needy Adult

CATEGORY Men/Women in Especially Difficult Circumstances
Youth in Need of Special Protection
Child in Need on Special Protection
Senior Citizen

BENEFICIARY'S Family Head and Other Needy Adult

CATEGORY Men/Women in Especially Difficult Circumstances
Youth in Need of Special Protection
Child in Need on Special Protection Sub-Category
Senior Citizen Identify the category of Beneficiary

ASSESSMENT (use additional sheets as necessary)

PROBLEM PRESENTED:

SOCIAL WORKER'S ASSESSTMENT

RECOMMENDED SERVICES AND ASSISTANCE:

Counselling Legal Assistance Referral (Specifiy) Others (Specify)

✓ Financial Assistance Purpose Amount Mode of Assistance Fund Source

Livelihood Assistance Grant ✓ Cash LGU GEN FUND

Medical Needs Goods PAGCOR
Burial Needs Checks PCSO Trust Fund
Transporation Needs LGSF-SBDP
Educational Support
Food Subsidy
Non-food Items
Other Support Services

Interviewed by: Recommending Approval: Approved:

JUAN PAULO U. SAJO, RSW
Social Welfare Officer II
Reg. No. 0012302
Reg. Date. 11/2000
Valid Until: 07/11/2025
SALLY J. ABELARDE, RSW HON. ALFREO ABELARDO B. BENITEZ
City Gov't Asst. Dept. Head II City Mayor
Officer-in-Charge
Reg. No. 0005546
Reg. Date: 04/11/1984
Valid Until: 10/13/2026
 Republic of the Philippines
DEPARTMENT OF SOCIAL SERVICES AND DEVELOPMENT
3rd Floor New Government Center, Circumferential Road, Bacolod City
Tel. Nos. (034) 432-1602/435-7134

CERTIFICATE OF ELIGIBILITY

Source of Fund:
DSSD / EA Cliente Category
PCSO Trust Fund Family Head / Needy Adult
LGSF - SBDP Out of School Youth
Disabled and Special Group
WEDC
Victims of Disaster

This is to certify that ________________________________________________, ____ years old,

residing at __________________________________________ with the following members:

NAME AGE RELATIONSHIP

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"Has been eligible for _______________________________ from DSSD in the amount of

___________________ (Php ____________.00). Record of the case dated __________ are in the files
of the DSSD.")

Prepared by: Recommending Approval:

JUAN PAULO U. SAJO, RSW SALLY J. ABELARDE, RSW

Social Welfare Officer II City Gov't Asst. Dept. Head II
Reg. No. 0012302 Officer-in-Charge
Reg. Date. 11/2000 Reg. No. 0005546
Valid Until: 07/11/2025 Reg. Date: 04/11/1984
Valid Until: 10/13/2026

CERTIFICATION

I hereby certify that all information given above about me are true and correct and that all documents
submitted are original copies thereof or the faithful reproduction of the original.

(Client’s Signature over Printed Name)