BUS From 5 V.2.
2017
Beneficiary Data Update Request Form Pantawid Pamilyang
Pilipino Program
Date Filed: _________________
Instructions: 1. The household grantee shall properly fill-out this form. Fill out only the section that is applicable.
2. Please refer to types of Updates at the back for the details fo the supporting documents.
3. Upates related to payments should be prioritized for updating. This is to ensure the maximum amount of grants will be received by the household.
4. Ensure to secure a copy of Acknowledging Receipt once this form submitted to the Pantawid Personnel.
PART I - TO BE FILLED OUT BY THE HOUSEHOLD GRANTEE
A. HOUSEHOLD AND PERSONAL DATA
LAST NAME FIRST NAME MIDDLE NAME EXTENSION NAE
GRANTEE NAME
HOUSE NO, STREET/PUROK/SITIO
HOUSEHOLD ID NUMBER ADDRESS
BARANGAY CITY/MUNICIPALITY PROVINCE REGION
ADDRESS
B. DATA CHANGE/CORRECTION/UPDATING
NEWBORN AND/OR ADDITIONAL HOUSEHOLD MEMBER .
LAST NAME FIRST NAME MIDDLE NAME EXTENSION NAE
1 NAME OF CHILD:________________________________________________________________________________________________________________
8 DATE OF BIRTH (MM/DD/YYYY): SEX: DISABLED? Yes No
NAME OF PARENT IN THE FAMILY ROSTER: RELATIONSHIP TO HH HEAD:
ATTENDING SCHOOL? Yes No, Reason for Not Attending:
NAME OF SCHOOL: ADDRESS OF SCHOOL:
NAME OF HEALTH FACILITY: ADDRESS OF HEALTH FACILITY:
CHANGE OF ADDRESS FROM TO
2 REGION:
3 PROVINCE:
CITY/MUNICIPALITY:
BARANGAY:
STREET/PUROK/SITIO:
CHANGE OF HEALTH FACILITY FROM TO
4 NAME OF MEMBER: ATTENDING: Yes No, Reason for Not Attending:
NAME OF FACILITY:
ADDRESS:
TYPE OF FACILITY:
NAME OF MEMBER: ATTENDING: Yes No, Reason for Not Attending:
NAME OF FACILITY:
ADDRESS:
TYPE OF FACILITY:
CHANGE OF EDUCATION INFORMATION
(Last Name, First Name, Middle Name, Extension Name)
5 1. NAME OF CHILD WITH CORRECTION OF EDUCATION INFORMATION:
ATTENDING SCHOOL? Yes No, Reason for Not Attending:
FROM TO
NAME OF SCHOOL:
ADDRESS OF SCHOOL:
GRADE LEVEL:
(Last Name, First Name, Middle Name, Extension Name)
2. NAME OF CHILD WITH CORRECTION OF EDUCATION INFORMATION:
ATTENDING SCHOOL? Yes No, Reason for Not Attending:
FROM TO
NAME OF SCHOOL:
ADDRESS OF SCHOOL:
GRADE LEVEL:
(Last Name, First Name, Middle Name, Extension Name)
3. NAME OF CHILD WITH CORRECTION OF EDUCATION INFORMATION:
ATTENDING SCHOOL? Yes No, Reason for Not Attending:
FROM TO
NAME OF SCHOOL:
ADDRESS OF SCHOOL:
GRADE LEVEL:
...
Beneficiary’s Copy Date Filed: City/Municipal Link’s Copy Date Filed:
ACKNOWLEDGEMENT RECEIPT ACKNOWLEDGEMENT RECEIPT
Name of Beneficiary : HH ID No.: Name of Beneficiary : HH ID No.:
Type of Update Field Updated Change To Type of Update Field Updated Change To Remarks
Signature Over Printed Signature Over Printed Date Received Signature Over Printed Signature Over Printed Date Received
Name of Grantee Name of DSWD Personnel Name of Grantee Name of DSWD Personnel
(Thumb mark if the Grantee cannot write) Representative and Designation (Thumb mark if the Grantee cannot write) Representative and Designation
6 CHANGE OF HH GRANTEE FROM TO
NAME OF GRANTEE:
NEW GRANTEE’S INFORMATION:
MOTHER’S MAIDEN NAME: DATE OF BIRTH (MM/DD/YYYY): RELATIONSHIP TO HH HEAD:
GUARDIAN’S NAME (For Minor grantee only): Relationship to the Minor Grantee:
REASON FOR CHANGE: Long Absence Deceased Sickly or Old Age
7 DECEASED
NAME (Last Name, First Name, Middle Name, Extension Name) SEX RELATIONSHIP TO HH HEAD DATE OF BIRTH (MM/DD/YYYY) FOR REPLACEMENT
1 YES NO
2 YES NO
(If for replacement, please facilitate the deselection using Update Type 11 with reason as decease then proceed to the selection of the replacement child of the husehold)
9 CAPTURING/CORRECTION OF BASIC INFORMATION FROM TO
NAME (Last Name, First Name, Middle Name, Extension Name):
DATE OF BIRTH (MM/DD/YYY):
RELATIONSHIP TO HH HEAD:
MARITAL STATUS:
SEX:
DISABLED?: YES NO SOLO PARENT: YES NO OCCUPATION:
NAME (Last Name, First Name, Middle Name, Extension Name):
DATE OF BIRTH (MM/DD/YYY):
RELATIONSHIP TO HH HEAD:
MARITAL STATUS:
SEX:
DISABLED?: YES NO SOLO PARENT: YES NO OCCUPATION:
NAME (Last Name, First Name, Middle Name, Extension Name):
DATE OF BIRTH (MM/DD/YYY):
RELATIONSHIP TO HH HEAD:
MARITAL STATUS:
SEX:
DISABLED?: YES NO SOLO PARENT: YES NO OCCUPATION:
10 CAPTURING/CORRECTION OF IP AFFILIATION
NAME (Last Name, First Name, Middle Name, Extension Name): FROM TO
1
2
3
Applicable to all household members
11 SELECTION/REPLACEMENT OF CHILD-BENEFICIARY (IES) FOR EDUCATION (PLEASE USE THE UPDATE TYPE 4 AND/OR 5 TO UPDATE HEALTH AND/OR EDUCATION INFORMATION OF REPLACEMENT CHILD)
Name of Child Selection Deselection Reason Replacement Child for Selection
12 CAPTURING OF PREGNANCY STATUS
NAME (LAST NAME, FIRST NAME, MIDDLE NAME, EXTENSION NAME) SEX AGE PREGNANCY STATUS LAST MENSTRUAL PERIOD RELATIOSHIP TO HOUSEHOLD HEAD
Signature Over Printed Name of Grantee Signature Over Printed Name of Parent Leader Signature Over Printed Name of DSWD Personnel
(Thumbmark if the grantee does not know how to write) Representative and Designation
PART II - TO BE FILLED OUT BY THE CBDO AND ENCODER
(Do not transmit this Form to the RBDO/POO if supporting documents are not complete)
Reviewed by: Encoded by:
Date Reviewed: Date Encoded:
POO Remarks: Remarks of Encoder (if any):
IF NOT ENCODED, THIS FORM WITH THE ATTACHED DOCUMENTS WILL BE RETURNED TO POO/ C/MOO BECAUSE OF THE FOLLOWING REASONS:
( ) Lacking or inconsistent supporting documents. Specify lacking documents/s
( ) ML to verify the correct name of school/health facilities with exact address then prepare request to the RITO for the addition of new facility in the library.
( ) Not in the family roster
( ) Othera (specify)
TYPES OF UPDATES SUPPORTING DOCUMENTS
1. Newborn Birth Cerficate from National Statistics Office (NSO) or Local Civil Registry Office (LCRO), Health Certificate form RHU/BHS and Medical Certificate (if PWD)
Applicable when the whole housenold moves to a new address, not for a single household member. Copy of Case Folder shall be endorsed to the new C/ML..
A. Transferring Within Barangay - Certificate from the Barangay Captain
B. Transferring to Other Barangay within the City/Municipality - Certificate of Residency from Old/New Address issued by the Barangay Captain
2. Change of Address C. Other Area within the Region - Certificate of Residency from Old/New Address issued by the Barangay Captian when the request was emanated; Case Assessment Report
D. Other Area outside the Region - Certificate of Residency from Old/New Address issued by the Barangay Captain where the request was emanated ; Case Assessment Report
(Note: When the household moves out of the area with or without prior notice to C/MLand without appying for change of address within 60 days, the household will be tagged as Code 12- Moed out of the
Area Without Notice)
3. Moving out ot the area to non-Pantawid Area Barangay Certificate of old and new address and C/ML Certificae2. Change of Address
4. Update of Heath Facility RHU/BHS Certificate from the new facility
5. Update of Education School Certificate issued by the school wher the child is enrolled; Filled up BUS Form 6
Death Certificate Certification by C/ML stating reason for long absence: Medical Cartificate; Letterfrom the Old grantee; Filled out LBP form (if applicable), Social Case
6. Change of Grantee Study Report; Senior Citizen ID or Certification from OSCA or C/MSWDO
7. Deceased Death Certificate or Certification from the tribal Leader or Chiettain
Birth Certificate from National Statistics Office(NSO) or Local Civil Registry Office(LCRO); School Certificate Issued by the school where the child is enrolled(if 3-18yeats old):
8. Additional Household Member Health Certificate (if 0-6years Old) Medical Certificate (ifdisabled); RHU/BHS Certificate where the member is availing heath services; Letter from the household grantee;
Birth Certificate from National Statistics Office (NSO) or Local Civil Registry Office (LCRO), Marriage Certificate; Medical Certificate; Certificate of Employment or
9. Correction of Basic Information Barangay Certificate, indicating the present occupayion of the household member; Solo Parent ID
10. Update of IP/Tribal Afiliation Certificate of tribal membership from the Tribal Leader/Chieftain; NCIP Certificate
Death Certificate(if Deceased); Medical Certificate (for differently-abled chid-beneficiary certifying the disability and incapacity to attend school) Letter form the
11. Selection/Deselection of Child/ren for CV parent of the child-beneficairy/ grantee stating the request to select or reason to deselect the chil-beneficiary; Certificate of Emrollment of child for selection
monitoring replacement child.
