Republic of the Philippines Republic of the Philippines
Province of Leyte Province of Leyte
Municipality of Dagami Municipality of Dagami
Barangay SAN JOSE District 1 Barangay SAN JOSE District 1
Dagami, Leyte Dagami, Leyte
REQUEST FORM REQUEST FORM
NAME: _________________________________________ NAME: _________________________________________
AGE: ___________ SEX: ___________ AGE: ___________ SEX: ___________
BIRTHDATE: ____________________________________ BIRTHDATE: ____________________________________
ADDRESS: ______________________________________ ADDRESS: ______________________________________
MARITAL STATUS: (Please Check) MARITAL STATUS: (Please Check)
SINGLE MARRIED WIDOW WIDOWER SINGLE MARRIED WIDOW WIDOWER
CONTACT NO.: __________________________________ CONTACT NO.: __________________________________
ID PRESENTED: _________________________________ ID PRESENTED: _________________________________
OCCUPATION: ___________________________________ OCCUPATION: ___________________________________
TYPE OF SERVICES: (Please Check) TYPE OF SERVICES: (Please Check)
Barangay Clearance Barangay Clearance
Certificate of Indigency Certificate of Indigency
Barangay Certification Barangay Certification
Other Services (Please Specify) _________________ Other Services (Please Specify) _________________
PURPOSE: _________________________________ PURPOSE: _________________________________
REQUESTED BY: _________________________________ REQUESTED BY: _________________________________
RECEIVED BY: ___________________________________ RECEIVED BY: ___________________________________
DATE RECEIVED: ________________________________ DATE RECEIVED: ________________________________
TIME RECEIVED: _________________________________ TIME RECEIVED: _________________________________
Republic of the Philippines Republic of the Philippines
Province of Leyte Province of Leyte
Municipality of Dagami Municipality of Dagami
Barangay SAN JOSE District 1 Barangay SAN JOSE District 1
Dagami, Leyte Dagami, Leyte
REQUEST FORM REQUEST FORM
NAME: _________________________________________ NAME: _________________________________________
AGE: ___________ SEX: ___________ AGE: ___________ SEX: ___________
BIRTHDATE: ____________________________________ BIRTHDATE: ____________________________________
ADDRESS: ______________________________________ ADDRESS: ______________________________________
MARITAL STATUS: (Please Check) MARITAL STATUS: (Please Check)
SINGLE MARRIED WIDOW WIDOWER SINGLE MARRIED WIDOW WIDOWER
CONTACT NO.: __________________________________ CONTACT NO.: __________________________________
ID PRESENTED: _________________________________ ID PRESENTED: _________________________________
OCCUPATION: ___________________________________ OCCUPATION: ___________________________________
TYPE OF SERVICES: (Please Check) TYPE OF SERVICES: (Please Check)
Barangay Clearance Barangay Clearance
Certificate of Indigency Certificate of Indigency
Barangay Certification 1Barangay Certification
Other Services (Please Specify) _________________ Other Services (Please Specify) _________________
PURPOSE: _________________________________ PURPOSE: _________________________________
REQUESTED BY: _________________________________ REQUESTED BY: _________________________________
RECEIVED BY: ___________________________________ RECEIVED BY: ___________________________________
DATE RECEIVED: ________________________________ DATE RECEIVED: ________________________________
TIME RECEIVED: _________________________________ TIME RECEIVED: _________________________________