Republic of the Philippines
Province of Negros Oriental
CITY OF CANLAON
SOCIAL WELFARE AND DEVELOPMENT OFFICE
Canlaon City, Negros Oriental
BA FORM 200
Application for Financial Assistance
Application No.: CA-2025-001
Date: Jan 15, 2025
I. CLIENT INFORMATION
| Name of Client: | JUAN SANTOS DELA CRUZ |
| Age: | 42 years old |
| Address: | 123 Rizal Street, Canlaon City, Negros Oriental |
| Barangay: | Panubigan |
| Contact No.: | 09171234567 |
II. TYPE OF ASSISTANCE
| Type of Assistance: | MEDICAL ASSISTANCE |
| Nature of Disaster: | Medical Emergency |
| Date of Occurrence: | Jan 10, 2025 |
| Amount Requested: | ₱ 5,000.00 |
III. FAMILY COMPOSITION / DEPENDENTS
| No. | Name | Relationship | Age |
|---|
| 1 | Maria Dela Cruz | Wife | 39 |
| 2 | Jose Dela Cruz | Son | 15 |
| 3 | Ana Dela Cruz | Daughter | 12 |
IV. REMARKS / OBSERVATIONS
Hospitalized for surgery. Family unable to cover hospital expenses.
V. CERTIFICATION
I hereby certify that the above information is true and correct to the best of my knowledge and belief.
JUAN SANTOS DELA CRUZ
Applicant's Signature over Printed Name
MARIA T. ESCOBAR
Social Welfare Officer II
SWDO, City of Canlaon
VI. ACTION TAKEN / APPROVAL
| Status: | RELEASED |
| Approved by: | Engr. Ronald B. Tuballa |
| Date Approved: | Jan 17, 2025 |
ENGR. RONALD B. TUBALLA
City Mayor
City of Canlaon
SWDO — City of Canlaon · Negros Oriental · BA Form 200 · May 11, 2026