Republic of the Philippines

QUEZON CITY
Office for the Senior Citizens’ Affairs
Gate 3, Quezon City Hall Complex, Kalayaan Ave., Quezon City
Telephone No. 8-703-2843

QC Ordinance 2544, S 2016

QC DEATH BENEFIT WELFARE ASSISTANCE
(DBWA) ₱ 5,000.00 Control No: _____________
(Moratorium: Exemption to 3 months period; Death from Dec. 1, 2019 –Dec. 31, 2020)
Due to Pandemic period Covid-19
PERIOD TO CLAIM
Only claims for Death Benefit Welfare Assistance submitted within three (3) months
from date of death senior citizen shall be processed.
NAME OF DECEDENT: ___________________________________________________ SC.ID NO.___________
Pangalan ng Senior na namatay

DATE OF DEATH: ____________________________________________________________________________

Petsa ng kamatayan

COMPLETE ADDRESS: ___________________________________________________________ DIST.: ______

Kumpletong tirahan (Paki sketch o iguhit ang direksyon ng tirahan sa likod ng aplikasyon) Distrito

NAME OF CLAIMANT: ________________________________________________________________________

Pangalan ng humihiling

CONTACT NO.: _______________________________________________________________________________

Numero ng kontak

RELATIONSHIP WITH DECEDENT: _____________________________________________________________

Relasyon sa namatay
REQUIREMENTS TO BE SUBMITTED
SENIOR CITIZEN ID OF DECEDENT (Original ID & 2 xerox copies)
Civil Registry or PSA Certified True Copy of Decedent Death Certificate
(1 Original & 1 xerox copy)
Valid ID of Claimant (2 xerox copies)
And other requirements if he or she:

SURVIVING SPOUSE:
• PSA Marriage Certificate (2 xerox copies)

CHILD/CHILDREN*
• PSA Claimant Birth Certificate (2 xerox copies)
• *Affidavit of Undertaking Form downloadable (1 original & 1 xerox copy)

PARENTS
• See the following requirements above

BROTHER OR SISTER –SIBLINGS*

• PSA Decedent Birth Certificate (2 xerox copies)
• PSA Claimant Birth Certificate (2 xerox copies)
• *Affidavit of Undertaking Form downloadable (1 original & 1 xerox copy)

Note: All bereaved claimant must be registered residents of Quezon City.

After the verification of the documents submitted, applicant will be asked
to wait for further information for approval.

SUBMITTED BY: ______________________________________