PROTECTIVE SERVICES DIVISION

CRISIS INTERVENTION SECTION/ FIELD OFFICE 10

DSWD-PMB-GF-011 | REV 02 | 08 JAN 2024

GENERAL INTAKE SHEET

MAARING MAGPATULONG SUMAGOT SA DSWD PERSONNEL

QN: PCN: Date: 2024

MM DD YYYY
✘ New Returning On-site Walk-in ✘ Referral Off-site
Part I: To be filled out by Client
IMPORMASYON NG KINATAWAN (Client’s Identifying Information)

Apelyido (Last Name) Unang Pangalan (First Name) Gitnang Pangalan (Middle Name) Ext. (Sr,Jr,I,II)

House No./Street/Purok (Ex 123 Sun) Barangay (Ex. Batasan) City/Municipality (Ex. Quezon City) Region (Ex. NCR)

Numero ng Telepono (Mobile No.) Kapanganakan (Birthdate) Edad (Age) Kasarian (Sex) Civil Status (Katayuang Sibil)
MM-DD-YYYY Trabaho (Occupation) Buwanang Kita (Monthly Salary)

Relasyon sa Benepisyaryo (Relationship to the Beneficiary)

IMPORMASYON NG BENEPISYARYO (Beneficiary’s Identifying Information)

Unang Pangalan (First Name) Gitnang Pangalan (Middle Name) Ext. (Sr,Jr,I,II)

House No./Street/Purok (Ex 123 Sun) Barangay (Ex. Batasan) City/Municipality (Ex. Quezon City) Province/District (Ex. Dist III) Region (Ex. NCR)

Numero ng Telepono (Mobile No.) Kapanganakan (Birthdate) Edad (Age) Kasarian (Sex) Civil Status (Katayuang Sibil) Trabaho (Occupation) Buwanang Kita (Monthly Salary)
MM-DD-YYYY
KOMPOSISYON NG PAMILYA (Family Composition) Note: Gamitin ang Likurang bahagi ng papel kung kinakailangan
Buong Pangalan Relasyon sa Benepisyaryo Edad Trabaho Buwanang kita
(Complete Name) (Age) (Occupation) (Monthly Salary

Part II: To be Filled out by DSWD Personnel

Client Category Social worker's Assessment
Target Sector: Specify Sub-Category
FHON CLIENT IS EXPERIENCING FINANCIAL DIFFICULTIES IN PROVIDING THE DAILY
Solo Parents KIA/WIA NEEDS AND EXPENSES. FAMILY HAS NO REGULAR SOURCE OF INCOME AND
A
SC Indigenous People HAS MEAGER INCOME THAT CANNOT SUFFICE THE NEED OF THE FAMILY ‘S
WEDC Recovering Person who used drugs EXPENSES CONSIDERING THE DEMANDING NEEDS AND OR INFLATION RATE
YNSP 4PS DSWD Beneficiary OF COMMODITIES AND BASIC NEEDS AMIDTS FINANICIAL CRISIS FACING BY
THE FAMILY CAUSED BY THE UNEXPECTED CIRCUMSTANCES SUCH AS
PWD Street Dwellers SUDDEN LOSE OF LIVELIHOOD AND ALSO THIS MONTH OF RAMADHAN THAT
PLHIV Psychosocial/Mental/Learning Disability NORMAL FOR THE MUSLIMS BROTHERS TO INCREASED EXPENSES AND NEED
CNSP Stateless Person/Asylum Seekers/Refugees INTENDED FOR IETHER TRADITIONAL, SPIRITUAL AND FAITH BASED
PRACTICIES.
Others:

✘ Financial Assistance: Material Assistance: Psychosocial Support: Referral:

Medic ✘ Food Assistance Psychosocial First _________
Family Food Packs
Funera
al Cash Relief Aid (PFA) _________
Other Food Items
l Assistance
Transportation Hygiene/Sleeping Kits _________
Emergency Cash Social Work Counseling
Educational Assistive Device & Technologies
Transfer-AICS
Provided Amount Fund Source
0 AUGMENT ON THE DAILY NEEDS EXPENSES 2,000.00 PSP 2024
2

We are committed to protect and respect the privacy of our clients

and beneficiaries and we will only collect, record, store, process
and use personal information in accordance with Republic Act No. Interviewed by: Reviewed & Approved by:
10173 or the Data Privacy Act of 2012. By signing this form you
are giving your consent to the DSWD and hereby agree to the
terms and conditions set herein and with the applicable Data
Privacy Policy of the Department.

NORONSALAM A. DIMALUTANG RAIZ A. AMPASO

Buong Pangalan at Pirma Social Worker Approving Authority
(Signature over Printed Name) (Signature over Printed Name) (Signature over Printed Name)

Page 1 of 1

DSWD Field Office 10, Masterson Ave., Upper Carmen, Cagayan de Oro City, Philippines (9000)
Website: [Link] Tel Nos.: (088) 565 5795
 PROTECTIVE SERVICES DIVISION
(SWAD OFFICE - LANAO DEL NORTE)
DSWD-PMB-GF-013 | REV 01 / 30 SEPT 2022

CERTIFICATE OF ELIGIBILITY
(Financial Assistance)

PCN: Date:

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

Fem
Male
This is to certify that, , ale
Kumpletong Pangalan (First name, Middle name, Last name) Kasarian (Sex) 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

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

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

The Client is hereby recommended to receive FOOD assistance for AUGMENTATION TO DAILY NEEDS EXPENSES

in the amount of TWO THOUSAND PESOS ONLY Php 2,000.00 CHARGEBLE AGAINST: PSP 2024
(Year)

Conforme: Prepared by: Approved by:

___________________________ NORONSALAM A. DIMALUTANG

Beneficiary/Representative Social Worker
(Signature over Printed Name) (Signature over Printed Name)

Acknowledgement Receipt

Date:

✘ Financial Assistance Php

(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 SWO / ADMIN
(Signature over Printed Name) (Signature over Printed Name)

*E.O 163 series 2022

Page 1 of 1
DSWD Field Office 10, Masterson Avenue, Upper Carmen, Cagayan de Oro City, Philippines (9000)
Email:fo10@[Link] Nos.: (63) (88) 858-8134 Telefax: (63) (88) 858-6333
 PROTECTIVE SERVICES DIVISION
CRISIS INTERVENTION SECTION/ FIELD OFFICE 10
DSWD-PMB-GF-011 | REV 02 | 08 JAN 2024

GENERAL INTAKE SHEET

MAARING MAGPATULONG SUMAGOT SA DSWD PERSONNEL

QN: PCN: Date: 2024

MM DD YYYY
✘ New Returning On-site Walk-in ✘ Referral Off-site
Part I: To be filled out by Client
IMPORMASYON NG KINATAWAN (Client’s Identifying Information)

Apelyido (Last Name) Unang Pangalan (First Name)

PE RSO N
Gitnang Pangalan (Middle Name) Ext. (Sr,Jr,I,II)

F I R S T
House No./Street/Purok (Ex 123 Sun) Barangay
T FI L IN, IF
LCity/Municipality
(Ex. Batasan) (Ex. Quezon City) Region (Ex. NCR)

ON O
Numero ng Telepono (Mobile No.) N/A - D Edad
Kapanganakan
MM-DD-YYYY
Kasarian
(Birthdate) Civil Status
(Age) (Sex)
Trabaho
(Katayuang Sibil)
(Occupation) Buwanang Kita (Monthly Salary)

Relasyon sa Benepisyaryo (Relationship to the Beneficiary)

IMPORMASYON NG BENEPISYARYO (Beneficiary’s Identifying Information)

MALA MAMA MACADATO

Unang Pangalan (First Name) Gitnang Pangalan (Middle Name) Ext. (Sr,Jr,I,II)
POBLACION MARAWI CITY LDS BARMM
House No./Street/Purok (Ex 123 Sun) Barangay (Ex. Batasan) City/Municipality (Ex. Quezon City) Province/District (Ex. Dist III) Region (Ex. NCR)

9191234153 1/25/1974 50 MALE MARRIED LABORER 2,000

Numero ng Telepono (Mobile No.) Kapanganakan (Birthdate) Edad (Age) Kasarian (Sex) Civil Status (Katayuang Sibil) Trabaho (Occupation) Buwanang Kita (Monthly Salary)
MM-DD-YYYY
KOMPOSISYON NG PAMILYA (Family Composition) Note: Gamitin ang Likurang bahagi ng papel kung kinakailangan
Buong Pangalan Relasyon sa Benepisyaryo Edad Trabaho Buwanang kita
(Complete Name) (Age) (Occupation) (Monthly Salary

ANALYN WIFE 63 NONE

NONE
Part II: To be Filled out by DSWD Personnel
Client Category Social worker's Assessment
Target Sector: Specify Sub-Category
FHON CLIENT IS EXPERIENCING FINANCIAL DIFFICULTIES IN PROVIDING THE DAILY
✘ Solo Parents KIA/WIA NEEDS AND EXPENSES. FAMILY HAS NO REGULAR SOURCE OF INCOME AND
A
SC Indigenous People HAS MEAGER INCOME THAT CANNOT SUFFICE THE NEED OF THE FAMILY ‘S
WEDC Recovering Person who used drugs EXPENSES CONSIDERING THE DEMANDING NEEDS AND OR INFLATION RATE
YNSP 4PS DSWD Beneficiary OF COMMODITIES AND BASIC NEEDS AMIDTS FINANICIAL CRISIS FACING BY
THE FAMILY CAUSED BY THE UNEXPECTED CIRCUMSTANCES SUCH AS
PWD Street Dwellers SUDDEN LOSE OF LIVELIHOOD AND ALSO THIS MONTH OF RAMADHAN THAT
PLHIV Psychosocial/Mental/Learning Disability NORMAL FOR THE MUSLIMS BROTHERS TO INCREASED EXPENSES AND NEED
CNSP Stateless Person/Asylum Seekers/Refugees INTENDED FOR IETHER TRADITIONAL, SPIRITUAL AND FAITH BASED
PRACTICIES.
Others:

✘ Financial Assistance: Material Assistance: Psychosocial Support: Referral:

Medic ✘ Food Assistance Psychosocial First _________
Family Food Packs
Funera
al Cash Relief Aid (PFA) _________
Other Food Items
l Assistance
Transportation Hygiene/Sleeping Kits _________
Emergency Cash Social Work Counseling
Educational Assistive Device & Technologies
Transfer-AICS
Provided Amount Fund Source
0 AUGMENT ON THE DAILY NEEDS EXPENSES 2,000.00 PSP 2024
2

We are committed to protect and respect the privacy of our clients

and beneficiaries and we will only collect, record, store, process
and use personal information in accordance with Republic Act No. Interviewed by: Reviewed & Approved by:
10173 or the Data Privacy Act of 2012. By signing this form you
are giving your consent to the DSWD and hereby agree to the
terms and conditions set herein and with the applicable Data
Privacy Policy of the Department.

MAMA M. MALA NORONSALAM A. DIMALUTANG RAIZ A. AMPASO

Buong Pangalan at Pirma Social Worker Approving Authority
(Signature over Printed Name) (Signature over Printed Name) (Signature over Printed Name)

Page 1 of 1

DSWD Field Office 10, Masterson Ave., Upper Carmen, Cagayan de Oro City, Philippines (9000)
Website: [Link] Tel Nos.: (088) 565 5795
 PROTECTIVE SERVICES DIVISION
(SWAD OFFICE - LANAO DEL NORTE)
DSWD-PMB-GF-013 | REV 01 / 30 SEPT 2022

CERTIFICATE OF ELIGIBILITY
(Financial Assistance)

PCN: Date:

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

Fem
MAMA MACADATO MALA ✘ Male
This is to certify that, , ale 50
Kumpletong Pangalan (First name, Middle name, Last name) Kasarian (Sex) AGE

and presently residing at POBLACION, MARAWI CITY

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

N/A 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

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

The Client is hereby recommended to receive FOOD assistance for AUGMENTATION TO DAILY NEEDS EXPENSES

in the amount of TWO THOUSAND PESOS ONLY Php 2,000.00 CHARGEBLE AGAINST: PSP 2024
(Year)

Conforme: Prepared by: Approved by:

MAMA MACADATO MALA NORONSALAM A. DIMALUTANG RAIZ A. AMPASO

Beneficiary/Representative Social Worker Approving Authority
(Signature over Printed Name) (Signature over Printed Name)

Acknowledgement Receipt

Date:

✘ Financial Assistance Php

(Amount in words)

Medical Assistance Transportation Assistance ✘ Food Assistance

Funeral Assistance Educational Assistance Cash Assistance for Support Services

Tinanggap ni: Binayaran ni: Sinaksihan ni:

MAMA MACADATO MALA

Beneficiary/Representative SWO / ADMIN
(Signature over Printed Name) (Signature over Printed Name)

*E.O 163 series 2022

Page 1 of 1
DSWD Field Office 10, Masterson Avenue, Upper Carmen, Cagayan de Oro City, Philippines (9000)
Email:fo10@[Link] Nos.: (63) (88) 858-8134 Telefax: (63) (88) 858-6333