REPUBLIC OF THE PHILIPPINES

CALOOCAN CITY SOCIAL WELFARE DEPARTMENT

New
Renewal Solo Parent #: __________ Picture
Date___________
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
Poster Parent/Guardian
Husband / Wife in jail Husband / Wife PWD

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 :
 TO ALL APPLICANTS : PLEASE ASK THIS CERTIFICATION FROM YOUR BARANGAY

TO: BARANGAY _____

FROM: CALOOCAN CITY SOCIAL WELFARE OFFICE
RE: Solo Parent Certification
Date: _________2018
==================================================================================

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.

Thank you very much and More power!

MARILOU N. GALBAN, RSW

Caloocan City Social Welfare Officer
=======================================================================================================

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

Must be: Must be Single for a year already Must

¾ In case of widow/widower: submit death certificate
have children aged 18 years below
¾ In case of guardian / foster/adoption/parental case of
Requirements: for new applicants and renewal guardianship
New: a. Submit an affidavit (legal)
____1x1 picture applicant ‐ 1 PC for I.D.
____2x2 picture applicant – 2PC for CCSWD file
b. Brgy should indicate clearly the present situation
____Birth Certificate of child/children (Xerox) ¾ In case of wife/husband in jail
____Brgy certification (from barangay – see above a. Submit copy of court order
sample) 2 copies ¾ In case of wife/husband is a PWD
____Completely filled up
____Index Card size 1/2 a. Submit PWD id (Xerox)
Renewal: ¾ In case of child above 18 & a PWD
____new barangay Certification of Solo Parent a. Submit child PWD Id
____1x1 id picture, Xerox old Solo parent id back
To back

Unit I‐ II Unit III UNIT IV UNIT V UNIT VI

B1‐35,73,80 B1 81‐85 B179‐188 B165 – 175 Brgy176
B 36 – 72, 74‐79, 86‐131 132‐150, 151‐164 177‐178
Rose Marie Reyes‐ Focal Ms. Regina Embalsado: Ms.Mamerta Lucas Ms. Milagros Sampang Ms. Melanie Parrenas
Person Unit in Charge Unit In Charge Unit In Charge Unit In Ccharge
ToToJalocon– staf Zosima Sanchez ‐ staf Cecile Lopez ‐ staf MerlyBorlaza ‐ staf Femy ‐ staf
Marissa Reyes ‐ staf

3365705 277 2931