Department of Social Welfare and Development Department of Social Welfare and Development

DISASTER ASSISTANCE FAMILY ACCESS CARD (DAFAC) DISASTER ASSISTANCE FAMILY ACCESS CARD (DAFAC)

Region: _________________________________Serial no. :______________________ Region: _________________________________Serial no. :______________________

Province /District: ________________________ BENEFICIARY’S COPY Province /District: ________________________ SOCIAL WORKER’S COPY
City /Mun./Brgy.: ______________________________ Sex : □ Male □ Female City /Mun./Brgy.: ______________________________Sex : □ Male □ Female
Civil Status
Evacuation Center/Site: _____________________________________ □Single Civil Status
Evacuation Center/Site: _____________________________________ □Single
□Widowed □Married □Widowed □Married
HEAD OF THE FAMILY □Others:_____________ HEAD OF THE FAMILY □Others:_____________
Date of Birth: ____________________ age: ____ Religion:_________________ Date of Birth: ____________________ age: ____ Religion:_________________
Surname First Name Middle Name Last Name First Name Middle Name
_______________________ ______________________ ______________________ _______________________ ______________________ ______________________
Occupation: _________________________ Monthly Net Income:_____________ Occupation: _________________________ Monthly Net Income:_____________
4p’s Beneficiary IP- Type of Ethnicity: ____________________________ 4p’s Beneficiary IP- Type of Ethnicity: ____________________________
Relationship BIRTH DATE Civil Relationship BIRTH DATE Civil
Occupational Occupational
Family Members to Family Age Gender Status Education Remarks Family Members to Family Age Gender Status Education Remarks
Skills Skills
Head Head

House & lot owner Code: □ A: Old Person □B: Lactating Mother □C: PWD House & lot owner Code: □ A: Old Person □B: Lactating Mother □C: PWD
□ Rented house & lot □ Rented house & lot
House owner & lot renter Housing Condition: ________________________________ House owner & lot renter Housing Condition: ________________________________
□ House owner’s, rent-free lot with owner’ Partially Damaged Totally Damaged □ House owner’s, rent-free lot with owner’ Partially Damaged Totally Damaged
consent Casualty : 01- Dead 03 Missing consent Casualty : 01- Dead 03 Missing
House owner’s, rent free lot w/o consent of the 02- Injured 04 with illness House owner’s, rent free lot w/o consent of the 02- Injured 04 with illness
owner Health Condition:__________________________________ owner Health Condition:__________________________________
Rent-free house & lot with owner’s consent ________________________________________________ Rent-free house & lot with owner’s consent ________________________________________________
Rent-free house & lot w/o owner’s consent _________________________________________________ Rent-free house & lot w/o owner’s consent _________________________________________________

_____________________________ ___________________________ _____________________________ ___________________________

Signature/thumbmark of Family Head Name Signature of Brgy. Captain Signature/thumbmark of Family Head Name Signature of Brgy. Captain

_____________________________ SHALYMAR R. DE LEON,RSW__ _____________________________ SHALYMAR R. DE LEON,RSW

Date Registered Name Signature of LSWDO Date Registered Name Signature of LSWDO
 FAMILY ASSISTANCE RECORD FAMILY ASSISTANCE RECORD
Date Name of Assistance Provided During Recipient’s Date Name of Assistance Provided During Recipient’s
Receiving Family Kind /type Qty. Cost Provider Signature/ Receiving Family Kind /type Qty. Cost Provider Signature/
Member Thumbmark Member Thumbmark