ABCDEFGHIJKLMNOPQRSTUVWXYZ
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Province of Batangas
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MUNICIPALIY OF ALITAGTAG
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MUNICPAL SOCIAL WELFARE & DEVELOPMENT OFFICE
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INTAKE SHEET
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Date Interview: November 28, 2016
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I. IDENTIFYING INFORMATION:
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Name
REYNALDO MARANAN
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Address:
Barangay Pinagkurusan, Alitagtag, Batangas
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Age:76Sex: MaleCivil Status:Married
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Educational Attaintment:
College
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Occupation:Monthly Salary
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Informant:ROEL MARANANRel. To Client:Son
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II. FAMILY COMPOSITION:
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NAMEAGESEXRel.to ClientCivil Educ.Occupation/
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StatusAttanmt.Income
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Reynaldo Marananclient
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Estrella Maranan70FWifeMarried H.S.None
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Ronaldo Maranan45MSonMarried Coll. LevelNone
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Roel Maranan44MSonMarried Coll. LevelNone
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Mayeth Pantoja42FDaughterMarried CollegeOFW
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Felix Maranan41MSonMarried Coll. LevelLaborer
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III. OTHER SOURCE OF INCOME:
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/ /Food Support from Relatives
/ /Backyard Livestock Raising
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/ /Backyard Garden
/ /Educational /Scholarship Grant
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Others: _____________________________________________________
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IV. PROBLEM PRESENTED:
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Roel is appealing for medical assistance for his father who was confiend
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and treated at BPH due to septic shock etc. Family is financially exhausted to
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support his cont. Medication
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V. BACKGROUND INFORMATION:
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A. Housing & Other Living Condition:
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1. Housing: / x / Owned / / Rented / / Shared / / Caretaker
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2. Housing Structure:
/ / Makeshift/displaced / / Light Materials
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/ / Concrete / x / Combined Heavy & Light Materials
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3. Lot:
/ / Owned / / Amortized / / Squatter / x /Sharer
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4. Lightings:
/ / Kerosene Lamp / x / Electricity / / Candle
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/ / Shared
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/ x / Owned
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B. Economic Condition:
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Individual Household Member Monthly per Capita Income
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/ x / Within Poverty Threshold Level ( P 1,500.41)
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/ / Below Poverty Threshold Level
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/ x / Within Food Threshold Level ( P 918.58)
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/ / Below Food Threshold
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C. If Medical Case:
/ x /
in patient
/ / out-patient
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If in patient, Name of Hospital: BATANGAS PROVINCIAL HOSPITAL
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D. Name of Health Insurance:
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/ x / Employed/Regular
/ / Self- Employed
/ / Indigent ( pantwid)
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/ / Lifetime Member
/ / Not a Member
/ X / Senior Citizens
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I hereby Certify that the above Informations are true and correct to the best of my knowledge
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and belief.
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________________________
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Client/ Informant Signature
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Contact No. ______________
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VI. EVALUATION & RECOMMENDATION:
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Based on the above information, the herein client is found eligible for:
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/ X / Medical
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/ / Educational
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/ / Transportation
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/ / Burial
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and hereby recommended to avail of ________________________________________
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( P ______________).
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Prepared by:
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ANGELYN C. ADAN - Mendoza
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Approved by:
 DCW1
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SYLVIA A. CATANYAG, RSW
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MSWDO
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