Name of client MARY GOLD O.
MANCAO Age 34 Date
Address P-7 REXAN, NAPNAPAN, PANTUKAN, DAVAO DE ORO
Birthplace DRMC-APOKON, TAGUM, DAVAO DEL NORTE
Birthdate October 11, 1989
Name Relationship Age Civil Stat Educ. Status
Family Members 1 DANILO T. MANCAO JR. SAPOUSE 35 M COLLEGE LEVEL
2 CHYMEA BLISS O. MANCAO DAUGHTER 13 S HIGH SCHOOL
3
4
5
6
Problem presented
(up to 4 lines)
Initial Assessment
Recommendation As per interview and assessment conducted, the client is eligible to avail the financial assistance amounting to 1,000.00
Financial/Program to augment and defray the transporation expenses of the client.
Social Worker
Payment of: LIMITED FINANCIAL ASSISTANCE
Type: MEDICAL ASSISTANCE 1
Acct. Code 20201050 2
F.P.P. 3
Amount 4
Signatory 10 5
Position PG Department - PSWDO 6
Charges: TRUST FUND-AICS 7
Cash Voucher No. 2024Med
Disbursing Officer MHELANIE B. URBANO
CASHIER I
Documents 1
1 Certificate of eligibility 2
2 General intake sheet 3
3 Medical certificate 4
4 Hospital Billing
5 barangay certification
6
7
DATE PREPARED :
BURIAL / FILE no intake sheet
June 27, 2024
Source of Income
LABOR
NONE
ng to 1,000.00 under Trust Fund
CHECKLIST OF DOCS (MEDICAL)
Certificate of eligibility
General intake sheet
certificate of confinement
certificate of indigency
barangay certification
Barangay Certificate (Residency)
Certificate of indigency
death certificate
certificate of eligibility
`
35
PROVINCE OF COMPOSTELA VALLEY
PROVINCIAL SOCIAL WELFARE & DEVELOPMENT OFFICE
GENERAL INTAKE SHEET
I. IDENTIFYING INFORMATION
1 Name of Client : MARY GOLD O. MANCAO
2 Address : P-7 REXAN, NAPNAPAN, PANTUKAN, DAVAO DE ORO
3 Birthplace : DRMC-APOKON, TAGUM
4 Birthdate : October 11, 1989
5 Category : ICS Evacuee
x Others Disaster Victim
6 Source of Referral (specify nameof agency, others)
Address :
II. FAMILY COMPOSITION
Age
Relationship to Civil Educ'l
Family Members Status
Client Status Attainment
1 DANILO T. MANCAO JR. SPOUSE 35 M COLLEGE
2 CHYMEA BLISS O. MANCAO DAUGHTER 13 S HIGH SCHOOL -
3 -
4 -
6 - 0 0 0 -
78 -- 00 00 00 00 --
III. Problem Information:
1
2 Initial Assessment (Initial impression of worker about the problem & its causes)
3 Plan of Action/Recommendation:
The client is eligible for financial assistance under the Trust Fund Financial Program in the amoun
of Php 1,000.00 to assist with their daily food needs, as determined by the results of the completed
assessment and interview.
-
Name of Social Welfare and Dev. Worker Signature or Thumbmark of Client
DDO-PSWDO-PSD Form01
12:20:5211/02/2024 D:\jerry\ObR.dbf
E
AVAO DE ORO
Source of
Income
LABOR
NONE
0
00
cial Program in the amount
e results of the completed
Thumbmark of Client
DO-PSWDO-PSD Form01
12:20:5211/02/2024 D:\jerry\ObR.dbf
12:20:5211/02/2024 D:\jerry\ObR.dbf
PROVINCIAL SOCIAL WELFARE AND DEVELOPMENT OFFICE
CERTIFICATE OF ELIGIBILITY
THIS IS TO CERTIFY THA MARY GOLD O. MANCAO , 34 yrs. old and a
resident of P-7 REXAN, NAPNAPAN, PANTUKAN, DAVAO DE ORO , after having been
interviewed is found eligible for MEDICAL ASSISTANCE
the Trust Fund Assistance-AICS. Recommended amount of
Records and the case study report dated June 27, 2024
confidential file at the Provincial Social Welfare and Development Office.
Assessed by:
0
0
Recommending Approval:
PRECIOSA BH. TOLEDO
Social Welfare Officer IV
Approved:
JOSEPHINE M. FRASCO
PG Department Head
DDO-PSWDO-PSD Form02
yrs. old and a
fter having been
under
- .
are in
0
0 P
DO-PSD Form02
Payee MARY GOLD O. MANCAO Account Code: 20201050
Allotment Class: 402
Trust Fund
Function Code:
Address: P-7 REXAN, NAPNAPAN, PANTUKAN, DAVAO DE ORO 402
EXPLANATION AMOUNT
PAYMENT OF
LIMITED FINANCIAL ASSISTANCE -
AS PER SUPPORTING DOCUMENTS HERETO ATTACHED AND MADE PART
OF THIS VOUCHER IN THE AMOUNT OF …………………………………..
SUPPORTING DOCUMENTS:
/ Barangay Certificate of Residency
/ Certificate of Eligibility
/ General Intake Sheet
/ Qoutation/Prescription/Statement of Account
Medical Certificate/Medical Abstract
/ -
0
P -
A. RECOMMENDING APPROVAL: C. RELEASED PAYMENT:
JOSEPHINE M. FRASCO MHELANIE B. URBANO
PSWD - PG Department Head CASHIER I
B. APPROVED FOR PAYMENT: RECEIVED PAYMENT:
DOROTHY P. MONTEJO-GONZAGA PRINTED NAME
Governor OR/OTHER JEV NO.
DOCUMENTS
20201050
402
Trust Fund
402
AMOUNT
9 `
B. URBANO
HIER I
DATE
DATE
