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REPUBLIC OF THE PHILIPPINES
CALOOCAN CITY SOCIAL WELFARE DEPARTMENT
New
Renewal Solo Parent #: __________
Date___________ Picture
APPLICATION FOR SOLO PARENT
Barangay_____UNIT ___DISTRICT_____
Name:__________________________________________ Age:_____ Sex:______
Date of Birth :_____________________Place of Birth:_____________________
Address:____________________________________________________ ______
Educational Attainment:________________________________________
Philhealth3 4Ps member
Children : ( 18 and below)
Name Relationship Age Status Educational Attainment Birthdate
I. Classification / Circumstances of Being a Solo parent (pls check one)
Unwed Separated Widow Abandoned Annulled
Husband / Wife in jail Husband / Wife PWD Poster Parent/Guardian
II. Circumstances: ( state situation )
___________________________________________________________________________________
___________________________________________________________________________________
III. Needs and problems of Solo parent(financial/job/legal/counseling/ NHA/ Educational)
___________________________________________________________________________________
IV. Family Resources
Unemployed
Source of Income : Kind of Work:________________________________
Employed ‐ Contractual Permanent Seasonal
5,000 – 10,000
10,000 – 20,000
20,000 – 30,000
30,000 – 40,000
V. Name / Address of Company/ tel no.:__________: ____________________________________
I HEREBY CERTIFY THAT THE INFORMATION GIVEN ARE TRUE AND CORRECT. I FURTHER UNDERSTAND THAT
ANY MISINTERPRETATION THAT MAY HAVE MADE WILL SUBJECT ME TO CRIMINAL AND CIVIL LIABILITIES
PROVIDED FOR BY EXISTING LAWS.
DATE:________________ Signature:____________________Contact NO.:_____________________
Interviewed by:______________________________Unit ______
Application Received by:___________________________________ Date:____________________
Assistance:_______________________________________________________________________
Remarks :
We believe that your office could help us identify the authenticity of Solo Parents Applicant. Hereby, may we respectfully request
your kind assistance to help us validate their present status by issuing them a certification certified by the Barangay Captain.
It is very important that applicant has minor children and no present relationship for him/ her to be considered a single parent.
In addition, may we also request your continued support on advocating this Solo Parent under Republic Act 8972.
Benefits of employed Solo Parent is the additional seven days leave credits with pay. And for those unemployed, our city Government
has livelihood trainings , job placements to offer.
Attached herewith, the sample of Certification with detailed information that will be very helpful for the approval of his/ her
application.
SAMPLE ONLY: (with barangay logo)
This is to certify that _______________________, _____years old, presently residing at____________________________ of this
Barangay is a Single Parent. MR. /MS._______________________ is___________________.
( kindly state the status of the applicant: see below categories of single parent) . His/ Her children, namely____________________________ is/
are under her /his custody.
Upon, verification , he/she is not involved into a new relationship up to present which gives her consideration to be a certified solo
parent.
This certification is being issued upon the request of Mr./Ms____________ for authentication of client’s present status to qualify
to be a Solo Parent.
Issued this day of___________.
Barangay Captain
Witnesses :
____________________________________________ ____________ ________ __________
Name address contact number signature
________________ ____________ ________ ______________________________________
Name address contact number signature