Name of Project: DOLE
DOLE Regional Office: 8
Province: LEYTE
Municipality: TACLOBAN CITY
Barangay:
Name of Beneficiary
Birthdate1
No. Extension
First Name Middle Name Last Name (YYYY/MM/DD)
Name
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
I hereby certify that the above list of beneficiaries are displaced workers, underemployed or self-employ
Further, I certify that they or any member of their families were verified are not Government Employees
Prepared and Certified true and Correct by:
LGU Authorized representative
Signature over Printed Name
Notes:
*Only the gray portion of this form should be submitted to concerned agencies, i.e DSWD for data matching/val
1 – Birthdate: Year/Month/Day (YYYY/MM/DD)
2 – Address: (Street
c. closure of No, Barangay,
company, City/Municipality, Province, District)
retrenchment
• PWDs, Senior
4 - Occupation citizens,
- Transport FormerVendors,
workers, rebels, Former Violent Extremist
Crop growers Groups,[Link]
(please specify, People Homebased
tobacco farmer),
• Others (please specify)
5 – Sex: F for female, M for Male
6 – Civil Status: S for single, M for married
7 – Dependent: Name of the Beneficiary of micro-insurance policy holder.
8 - Trainings: Agriculture crops production, Aquaculture, Automotive, Construction, Welding, Information and Co
LIST OF BENEFICIARIES
Address2
Type of ID
Barangay City/Municipality Province District (e.g. SSS, Voter's ID)
employed or self-employed workers that have lost their livelihood or whose earnings were affected by the COVID-19 pande
Government Employees (i.e. Local Government Units and Job Orders, are not Beneficiaries of (A) Department of Finance'
WD for data matching/validation.
ousfarmer),
co People Homebased worker (please specify, i.e sewer), Fisherfolks, Livestock/Poultry Raiser, Small transport drivers,
ding, Information and Communication Technology,Electrical and electronics, Furniture making, Garments and textiles, Foo
OF BENEFICIARIES
E-payment/Bank Account No.
Type of
ID Number Contact No. (indicate the type of account
Beneficiary3
and no. as applicable)
e affected by the COVID-19 pandemic.
ies of (A) Department of Finance's (DOF) Small Business Wage Subsidy (SBWS) program, (B) Social Security System (S
y Raiser, Small transport drivers, Laborer (please specify), Barangay Tanod, Barangay Health Workers
making, Garments and textiles, Food Processing, Cooking, Housekeeping, Tourism, Customer Services, Others (please sp
OSEC-FMS Form No. 4
Dependent7 (Name of
Occupation4 Sex5 Civil Status6 Age Beneficiary of the Micro-
insurance Holder)
(B) Social Security System (SSS) Unemployment Benefit and are not Barangay Health Workers and Barangay Tanod
Health Workers
er Services, Others (please specify)
Interested for If Yes,
Skills Training Indicate
(Y - Yes skills training
N - No) needed9
orkers and Barangay Tanod
