CRISIS INTERVENTION SECTION

FIELD OFFICE VI
DSWD-PMB-GF-013 | REV 01 / 30 SEPT 2022

CERTIFICATE OF ELIGIBILITY
(Financial Assistance)

QN: PCN: Date:

New Returning On-Site Walk-in Referral Off-Site

Mal Fem
This is to certify that, , e ale
Kumpletong Pangalan (First name, Middle name, Last name) Kasarian (Sex) Edad (Age)

and presently residing at

kumpletong Tirahan (Complete Address)

has been found eligible for assistance after the assessment and validation conducted, for his/herself or through the representation of his/her

SELF
Relasyon ng Kinatawan sa Benepisyaryo (Relationship of the Representative to Beneficiary) Buong Pangalan ng Benepisyaryo (Name of Beneficiary)

Records of the case such as the following are confidentially filed at the Crisis Intervention Division (CID)

✘ General Intake Sheet Medical Certificate/Abstract Discharge Summary Death Summary

Laboratory
✘ Valid I.D. Presented Prescriptions
Request
Referral Letter
Statement of Account Charge Slip Social Case Study Report
4PS DSWD I.D. Treatment Protocol Funeral Contract ✘ Others Cert. of Indigency
Justification Quotation Death Certificate

The Client is hereby recommended to receive Food assistance for Daily Expenses

in the amount of Two Thousand Pesos Only Php. 2,000 CHARGEBLE AGAINST: PSP 2024
(Year)

Conforme: Prepared by: Approved by:

MYLENE B. DEMONTEVERDE
Beneficiary/Representative Social Worker Approving Authority
(Signature over Printed Name) (Signature over Printed Name) (Signature over Printed Name)

Acknowledgement Receipt

Date:

Two Thousand Pesos Only Php 2,000

✘ Financial Assistance
(Amount in words)

Medical Assistance Transportation Assistance ✘ Food Assistance

Funeral Assistance Educational Assistance Cash Assistance for Support Services

Tinanggap ni: Binayaran ni: Sinaksihan ni:

Beneficiary/Representative RDO / SDO SWO / ADMIN

(Signature over Printed Name) (Signature over Printed Name) (Signature over Printed Name)

*E.O 163 series 2022

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DSWD Field Office VI, M.H. delPilar St., Molo, Iloilo City, Philippines
Website: www.fo6.dswd.gov.ph Email: fo6@dswd.gov.ph Tel No: (033) 337 6221 Telefax: (033) 337 6221