Republic of the Philippines THIS CARD IS NOT FOR SALE Republic of the Philippines THIS CARD IS NOT FOR
Republic of the Philippines THIS CARD IS NOT FOR SALE
Department of Social Welfare and Development BENEFICIARY’S COPY Department of Social Welfare and Development SOCIAL WORKER’S COPY
FAMILY ASSISTANCE CARD IN OFFICIAL USE ONLY FAMILY ASSISTANCE CARD IN OFFICIAL USE ONLY
EMERGENCIES AND DISASTERS (FACED) SERIAL NUMBER: EMERGENCIES AND DISASTERS (FACED) SERIAL NUMBER:
LOCATION OF THE AFFECTED FAMILY LOCATION OF THE AFFECTED FAMILY
1. REGION ______________
III
4. DISTRICT _____________________
2 1. REGION ______________
III
4. DISTRICT _______________________
2
2. PROVINCE ______________
BATAAN
5. BARANGAY _____________________ 2. PROVINCE ______________
BATAAN
5. BARANGAY _______________________
3. CITY/ MUNICIPALITY ______________
BALANGA 6. EVACUATION CENTER/ SITE _____________________ 3. CITY/ MUNICIPALITY ______________
BALANGA 6. EVACUATION CENTER/ SITE _______________________
HEAD OF THE FAMILY HEAD OF THE FAMILY
7. LAST NAME __________________ 15. CIVIL STATUS _____________________ 7. LAST NAME __________________ 15. CIVIL STATUS _____________________
8. FIRST NAME __________________ 16. MOTHER’S MAIDEN NAME _____________________ 8. FIRST NAME __________________ 16. MOTHER’S MAIDEN NAME _____________________
9. MIDDLE NAME __________________ 17. RELIGION _____________________ 9. MIDDLE NAME __________________ 17. RELIGION _____________________
10. NAME EXT. _____________________ 10. NAME EXT. _____________________
__________________ 18. OCCUPATION __________________ 18. OCCUPATION
(Jr., Sr., I) (Jr., Sr., I)
11. BIRTHDATE _____________________ 11. BIRTHDATE _____________________
__________________ 19. MONTHLY FAMILY NET INCOME __________________ 19. MONTHLY FAMILY NET INCOME
(DD-Month-YYYY) (DD-Month-YYYY)
12. AGE __________________ 20. ID CARD PRESENTED _____________________ 12. AGE __________________ 20. ID CARD PRESENTED _____________________
13. BIRTHPLACE __________________ 21. ID CARD NUMBER _____________________ 13. BIRTHPLACE __________________ 21. ID CARD NUMBER _____________________
PRIMARY ALTERNATE PRIMARY ALTERNATE
14. SEX MALE FEMALE 22. CONTACT NUMBER 14. SEX MALE FEMALE 22. CONTACT NUMBER
23. PERMANENT ____________________________________________________________________________________________________
23. PERMANENT BALANGA CITY BATAAN 2100
BALANGA CITY BATAAN 2100 ____________________________________________________________________________________________________
ADDRESS ADDRESS
House/Block/Lot No. Street Subd./Village Barangay City/ Province Zip Code House/Block/Lot No. Street Subd./Village Barangay City/ Province Zip Code
Municipality Municipality
24. OTHERS 4Ps Beneficiary IP (Type of Ethnicity: ____________________________________) 24. OTHERS 4Ps Beneficiary IP (Type of Ethnicity: ____________________________________ )
25. FAMILY INFORMATION 25. FAMILY INFORMATION
RELATION HIGHEST RELATION HIGHEST
TYPE OF TYPE OF
FAMILY MEMBERS TO FAMILY BIRTHDATE AGE SEX EDUCATIONAL OCCUPATION FAMILY MEMBERS TO FAMILY BIRTHDATE AGE SEX EDUCATIONAL OCCUPATION
VULNERABILTY VULNERABILTY
HEAD ATTAINMENT HEAD ATTAINMENT
ACCOUNT INFORMATION ACCOUNT INFORMATION
Note: In case the family head does not have a bank or an e-wallet account, any of the family members with a Note: In case the family head does not have a bank or an e-wallet account, any of the family members with a
validated account can be indicated. validated account can be indicated.
26. BANK/E-WALLET ____________________ 28. ACCOUNT TYPE _______________________ 26. BANK/E-WALLET ____________________ 28. ACCOUNT TYPE _______________________
27. ACCOUNT NAME ____________________ 29. ACCOUNT NUMBER _______________________ 27. ACCOUNT NAME ____________________ 29. ACCOUNT NUMBER _______________________
30. HOUSE OWNERSHIP 31. SHELTER DAMAGE CLASSIFICATION 30. HOUSE OWNERSHIP 31. SHELTER DAMAGE CLASSIFICATION
OWNER RENTER SHARER PARTIALLY DAMAGED TOTALLY DAMAGED OWNER RENTER SHARER PARTIALLY DAMAGED TOTALLY DAMAGED
_______________________________________________________________ _________________________________ _______________________________________________________________ _________________________________
Signature/ Thumbmark of Family Head Name/ Signature of Barangay Captain Signature/ Thumbmark of Family Head Name/ Signature of Barangay Captain
_______________________________________________________________ __________________________________
LALAINE R. DE LEON, RSW _______________________________________________________________ __________________________________
LALAINE R. DE LEON, RSW
Date Registered Name/Signature of LSWDO Date Registered Name/Signature of LSWDO
Right Thumbmark Right Thumbmark
32. DATA PRIVACY DECLARATION 32. DATA PRIVACY DECLARATION
All data and information indicated herein shall be used for identification purposes for the implementation of disaster All data and information indicated herein shall be used for identification purposes for the implementation of disaster
risk reduction and management (DRRM) programs, projects, and activities and its disclosure shall be in compliance risk reduction and management (DRRM) programs, projects, and activities and its disclosure shall be in compliance
to Republic Act 10173 (Data Privacy Act of 2012). to Republic Act 10173 (Data Privacy Act of 2012).
Republic of the Philippines THIS CARD IS NOT FOR SALE
BENEFICIARY’S COPY Republic of the Philippines THIS CARD IS NOT FOR SALE
Department of Social Welfare and Development SOCIAL WORKER’S COPY
Department of Social Welfare and Development
FAMILY ASSISTANCE CARD IN OFFICIAL USE ONLY
FAMILY ASSISTANCE CARD IN OFFICIAL USE ONLY
EMERGENCIES AND DISASTERS (FACED) SERIAL NUMBER:
EMERGENCIES AND DISASTERS (FACED) SERIAL NUMBER:
35. FAMILY ASSISTANCE RECORD
35. FAMILY ASSISTANCE RECORD
NAME OF ASSISTANCE PROVIDED NAME OF ASSISTANCE PROVIDED
RECEIVING SIGNATURE/
DATE EMERGENCY THUMBMARK RECEIVING SIGNATURE/
FAMILY ASSISTANCE UNIT QUANTITY COST PROVIDER DATE EMERGENCY THUMBMARK
/ DISASTER FAMILY ASSISTANCE UNIT QUANTITY COST PROVIDER
MEMBER / DISASTER
MEMBER
