SMARTApplicationForm
2023version (NOTFORSALE) ANNEX1
OfficeofthePresidentofthePhilippines
COMMISSIONONHIGHEREDUCATION
2X2
IDPICTURE
STUDENT MONETARY ASSISTANCE FOR RECOVERY AND TRANSITION (SMART)
APPLICATION FORM
Instructions:ReadGeneral andDocumentaryRequirements.Fill inall therequiredinformation.Donot leaveanitemblank.If itemisnot applicable,indicate"N/A".
PERSONALINFORMATION
GARCIA AYESSA MANAPAT
1. Name
(LastName) MaidenName(for
(FirstName) (Middle Name)
put extension, if any: i.e. Jr., III MarriedWomen)
9.PermanentAddress
2.DateofBirth(mm/dd/yy)
08/18/2000 167 Army Road Veterans Village Holy Spirit Q.C.
3.PlaceofBirth
Malabon City
10.PresentAddress 167 Army Road Veterans Village Holy Spirit Q.C.
4.Sex Male Female
5.CivilStatus
Single
6.Citizenship Filipino 11.NameofSchool
Quezon City University
M3QV+MM5, Batasan Rd, Quezon City, Metro Manila
7.Mobile Number 12. SchoolAddress
09455475351
8.E-mailAddress 13.DegreeProgram
[email protected] Bachelor of Science in Entrepreneurship
PERSONALINFORMATION
Father:() Living ()Deceased Mother:()Living()Deceased Legal Guardian
14.Name
Gilbert Garcia Mercilina Garcia
15.Address
n/a 167 Army Road Veterans Village Holy Spirit Q.C.
16.Occupation
n/a House helper
17.NameofEmployer n/a n/a
18.EmployerAddress
n/a n/a
19.TotalParentsTaxableIncome
n/a 8,000
20. Isyourfamily abeneficiaryoftheDSWD'sPantawidPamilyangPilipino Program (4Ps)? ()Yes()No 21. No. of Siblingsin the family
3
22.Areyouenjoyingothersourcesofedu ()Yesor()No Type GranteeInstitution/Agency
cational/financialassistance?
Ifyes,please specify: 1.
2.
I herebycertifythat foregoing statements are true and correct. Anymisinformation or witholding of information will automatica llydisqualifyme from the
CHEDScholarship Program. I am willing to refund the financial benefits received if such information is discovered after acceptance of the awa rd.
I hereby express my consent for the Commission on Higher Education to collect, record, organize, update or modify, retrieve, consult, use, consolidate,
block,erase or destruct my personal data as part of my information. I hereby affirm my right to be infor med, object to processing, access and rectify, suspend
orwithdraw mypersonal data and be indemnified in case of damages pursuant to the provisions of the Republic Act No. 10173 of the Philippines, Data
PrivacyActof 2012 and its corresponding Implementing Rules and Regulations.
Ayessa M. Garcia 09/15/2023
(SignatureoverPrintedNameof Applicant) Date Accomplished
Note:FullyaccomplishedformtobesubmittedtoCHEDOSDS
DONOTFILL-OUTTHISPORTION(FORCHEDUSEONLY)
Belongs to:(anyof the following groups) DocumentsAttached:
dependentofsoloparent 1.Academic
seniorcitizens ()CertifiedTrueCopy(CTC)ofCertificateofRegistration/Enrolment(CORs/COEs)
personswithdisabilities pleasespecifytypeofdisability 2.Financial
indigenousandethnicpeoples pleasespecifymembership ()ITR()TaxExemption()CertifcateofIndigency()CaseStudyReport
3.PhotocopyofSchoolIDCardoranygovernmenrtissuedID
Evaluated/Processedby:
09/15/2023
NameandSignatureofCHEDEvaluator Date
