Annex A.

: Disaster Assistance Family Access Card (DAFAC)

DEPARTMENT OF SOCIAL WELFARE AND DEVELOPMENT DEPARTMENT OF SOCIAL WELFARE AND DEVELOPMENT
DISASTER ASSISTANCE CARD (DAC) DISASTER ASSISTANCE CARD (DAC)

Region CARAGA Serial No. Region CARAGA

Province/ SURIGAO DEL SUR BENEFICIARY'S COPY Province/ SURIGAO DEL SUR

District District
TANDAG CITY TANDAG CITY
City/ Municipality City/ Municipality

MAITOM MAITOM
Barangay/ Evacuation Barangay/ Evacuation
Center/Site Center/Site 0

HEAD OF THE FAMILY M ✘ F 27 Age HEAD OF THE FAMILY

Err:509 #REF! #REF! Err:509 #REF!

SURNAME FIRST NAME MIDDLE NAME SURNAME FIRST NA
1995-03-15 1995-03-15
Date of Birth (YYYY-MM-DD) Occupation Monthly Net Income Date of Birth (YYYY-MM-DD) Occupati

4Ps Beneficiary IP – Type of Ethnicity 4Ps Beneficiary IP – Type of Ethnicity

Occupational Health Status/ Remarks

Family Members Relation to Family Head Date of Birth Age Sex Education Family Members Relation to Family Head Date of Birth
Skills Casualty (See Code)

0 0 0
0 0 0

House & lot owner Code: House & lot owner

A - Elderly D - Pregnant
House/room and lot renter B - PWD E - Lactating Mother House/room and lot renter
House owner & lot renter C - With Children below 5 House owner & lot renter
House owner, rent-free lot with owner's consent House owner, rent-free lot with owner's consent
House owner, rent-free lot w/o consent of owner Housing Condition Partially Damaged House owner, rent-free lot w/o consent of owner
Totally Damaged
Health Condition 01 - Dead 03 - Missing
02 - Injured 04 - With Illness

Name/Signature of Family Head Name/Signature of Brgy. Captain Name/Signature of Family Head

T

Ser 0
SOCIAL WORKER'S COPY

M F 27 Age

#REF! #REF!
FIRST NAME MIDDLE NAME

Occupation Mothly Net Income

Occupational Health Remarks

Age Sex Education Status/
Skills Casualty (See Code)

0 0 0 0 0 0
0 0 0 0 0 0

Code:
A - Elderly D - Pregnant
B - PWD E - Lactating Mother
C - With Children below 5

Housing Condition Partially Damaged

Totally Damaged
Health Condition 01 - Dead 03 - Missing
02 - Injured 04 - With Illness

ad Name/Signature of Brgy. Captain

Annex A.: Disaster Assistance Family Access Card (DAFAC)

DEPARTMENT OF SOCIAL WELFARE AND DEVELOPMENT DEPARTMENT OF SOCIAL WELFARE AND DEVELOPMENT
DISASTER ASSISTANCE CARD (DAC) DISASTER ASSISTANCE CARD (DAC)

Region CARAGA Serial No. Region CARAGA

Province/ BENEFICIARY'S COPY Province/ SURIGAO DEL SUR

SURIGAO DEL SUR
District District

City/ Municipality TANDAG CITY City/ Municipality TANDAG CITY

MAITOM MAITOM
Barangay/ Evacuation Barangay/ Evacuation
Center/Site Center/Site

HEAD OF THE FAMILY M F 122 Age HEAD OF THE FAMILY

SURNAME FIRST NAME MIDDLE NAME SURNAME

December 30, 1899

Date of Birth (MM-DD-YYYY) Occupation Monthly Net Income Date of Birth (MM-DD-YYYY)

4Ps Beneficiary IP – Type of Ethnicity 4Ps Beneficiary IP – Type of Ethnicity

Relation to Family Occupational Health Remarks Relation to Family

Family Members Date of Birth Age Sex Education Status/ (See Family Members Date of Birth
Head Skills Casualty Code) Head

, 122 0 , 0 0 0 December 30, 1899

, 122 0 , 0 0 0 December 30, 1899

, 122 0 , 0 0 0 December 30, 1899

, 122 0 , 0 0 0 December 30, 1899

, 122 0 , 0 0 0 December 30, 1899

, 122 0 , 0 0 0 December 30, 1899

House & lot owner Code: House & lot owner

A - Elderly D - Pregnant
House/room and lot renter B - PWD E - Lactating Mother House/room and lot renter
C - With Children below 5
House owner & lot renter House owner & lot renter
House owner, rent-free lot with owner's consent House owner, rent-free lot with owner's consent
House owner, rent-free lot w/o consent of owner Housing Condition Partially Damaged House owner, rent-free lot w/o consent of owner
Totally Damaged

Health Condition 01 - Dead 03 - Missing

02 - Injured 04 - With Illness

Name/Signature of Family Head Name/Signature of Brgy. Captain Name/Signature of Family Head

Annex A.: Disaster Assistance Family Access Card (DAFAC)

FAMILY ASSISTANCE RECORD FAMILY ASSIST

Assistance Provider
Recipient's
Date Name of Familily Member Signature/Thumbmark Date Name of Familily Member
Kind/Type Qty. Cost Provider Kind/Type
 Annex A.: Disaster Assistance Family Access Card (DAFAC)

FARE AND DEVELOPMENT

DAC)

Ser
SOCIAL WORKER'S COPY

M F 122 Age

0 0

FIRST NAME MIDDLE NAME

Occupation Mothly Net Income

P – Type of Ethnicity

Health Remarks (See

Date of Birth Age Sex Education Occupational Skills Status/
Casualty Code)

December 30, 1899 122 0 0 0 0 0

December 30, 1899 122 0 0 0 0 0

December 30, 1899 122 0 0 0 0 0

December 30, 1899 122 0 0 0 0 0

December 30, 1899 122 0 0 0 0 0

December 30, 1899 122 0 0 0 0 0

Code:
A - Elderly D - Pregnant
B - PWD E - Lactating Mother
C - With Children below 5

nt
ner Housing Condition Partially Damaged
Totally Damaged

Health Condition 01 - Dead 03 - Missing

02 - Injured 04 - With Illness

gnature of Family Head Name/Signature of Brgy. Captain

 Annex A.: Disaster Assistance Family Access Card (DAFAC)

FAMILY ASSISTANCE RECORD

Assistance Provider
Recipient's
Signature/Thumbmark
Kind/Type Qty. Cost Provider