BUS Form 5 v.2.

2017

Beneficiary Data Update Request Form

Date Filled: _______________

Instructions: 1. The household grantee shall properly fill-out this form. Fill out only the section that is applicable.
2. Please refer to Types of Updates at the back for the details of the supporting documents.
` 3.. Updates related to payments should be prioritized for updating. This is to ensure the maximum amount of grants will be received by the household.
4. Ensure to secure a copy of Acknowledging Receipt once this form submitted to the Pantawid Personnel.

PART I - TO BE FILLED OUT BY THE HOUSEHOLD GRANTEE

A. HOUSEHOLD AND PERSONAL DATA
LAST NAME FIRST NAME MIDDLE NAME EXTENSION NAME

GRANTEE NAME
HOUSE NO. STREET/PUROK/SITIO

HOUSEHOLD NUMBER ADDRESS

BARANGAY CITY/MUNICIPALITY PROVINCE REGION

ADDRESS
B. DATA CHANGE/ CORRECTION/ UPDATING
NEWBORN AND/OR ADDITIONAL HOUSEHOLD MEMBER
LAST NAME FIRST NAME MIDDLE NAME EXTENSION NAME
NAME OF CHILD:
DATE OF BIRTH (MM/DD/YYYY): SEX: ____________ DISABLED? Yes No
NAME OF PARENT IN THE FAMILY ROSTER: _____________________________________ RELATIONSHIP TO HH HEAD: _____________________
ATTENDING SCHOOL? Yes No, Reason for Not Attending: _________________________________________________________________
NAME OF SCHOOL: ________________________________________________ ADDRESS OF SCHOOL: ____________________________________
NAME OF HEALTH FACILITY: ________________________________________ ADDRESS OF HEALTH FACILITY: ___________________________
CHANGE OF ADDRESS FROM TO
REGION: ________________________________ ___________________________________
PROVINCE: ________________________________ ___________________________________
CITY/MUNICIPALITY: ________________________________ ___________________________________
BARANGAY: ________________________________ ___________________________________
STREET/PUROK/SITIO: ________________________________ ___________________________________
CHANGE OF HEALTH FACILITY FROM TO
NAME OF MEMBER: ATTENDING: Yes No, Reason for Not Attending: _______________________________________________
NAME OF FACILITY: _____________________________________ _________________________
ADDRESS: _____________________________________ _________________________
TYPE OF FACILITY: _____________________________________ _________________________
NAME OF MEMBER: ATTENDING: Yes No, Reason for Not Attending: _______________________________________________
NAME OF FACILITY: _____________________________________ _________________________
ADDRESS: _____________________________________ _________________________
TYPE OF FACILITY: _____________________________________ _________________________
CHANGE OF EDUCATION INFORMATION
(Last Name, First Name, Middle Name, Extension Name)
1. NAME OF CHILD WITH CORRECTION OF EDUCATION INFORMATION: ___________________________________________________________
ATTENDING SCHOOL? Yes No, Reason for Not Attending: ______________________________________________________________
FROM TO
NAME OF SCHOOL: ___________________________________________________ ______________________________________________
ADDRESS OF SCHOOL: ___________________________________________________ _______________________________________________
GRADE LEVEL: ___________________________________________________ ______________________________________________
(Last Name, First Name, Middle Name, Extension Name)
2. NAME OF CHILD WITH CORRECTION OF EDUCATION INFORMATION: ___________________________________________________________
ATTENDING SCHOOL? Yes No, Reason for Not Attending: ______________________________________________________________
FROM TO
NAME OF SCHOOL: ___________________________________________________ ______________________________________________
ADDRESS OF SCHOOL: ___________________________________________________ _______________________________________________
GRADE LEVEL: ___________________________________________________ ______________________________________________
(Last Name, First Name, Middle Name, Extension Name)
3. NAME OF CHILD WITH CORRECTION OF EDUCATION INFORMATION: ___________________________________________________________
ATTENDING SCHOOL? Yes No, Reason for Not Attending: ______________________________________________________________
FROM TO
NAME OF SCHOOL: ___________________________________________________ ______________________________________________
ADDRESS OF SCHOOL: ___________________________________________________ _______________________________________________
GRADE LEVEL: ___________________________________________________ ______________________________________________
—— —— ————————————————————————————————————————————————————————————
Beneficiary's Copy Date Filed: _________________ City/Municipal Link's Copy Date Filed: _____________

ACKNOWLEDGEMENT RECEIPT ACKNOWLEDGEMENT RECEIPT

Name of Beneficiary: __________________HH ID No.: Name of Beneficiary: HH ID No.:

Type of Update Field Updated Change To Type of Update Field of Update Change To Remarks

___________ ______________ __________ ___________ ___________________________________

 Date Received Date Received
Signature Over Printed Name of Signature Over Printed Name of Signature Over Printed Name Signature Over Printed Name of DSWD Personnel
Grantee DSWD Personnel of Grantee
(Thumb mark if the Grantee Representative and Designation (Thumb mark if the Grantee Representative and Designation
cannot write) cannot write)

last
6 CHANGE OF HH GRANTEE: FROM TO

NAME OF GRANTEE:

NEW GRANTEE'S INFORMATION:

MOTHER'S MAIDEN NAME: DATE OF BIRTH (MM/DD/YY): RELATIONSHIP TO HH HEAD:

GUARDIAN'S NAME (For Minor grantee only): RELATIONSHIP TO THE MINOR GRANTEE:
REASON FOR CHANGE: Long Absence Deceased Sickly or Old Age
7 DECEASED
NAME (Last Name, First Name, Middle Name, Extension Name) SEX RELATIONSHIP TO HH HEAD DATE OF BIRTH (MM/DD/YYYY) FOR REPLACEMENT
1 YES NO
2 YES NO
(If for replacement, please facilitate the deselection using Update Type 11 with reason as deceased then proceed to the selection of the replacement child of the household)
9 CAPTURING/CORRECTION OF BASIC INFORMATION FROM TO

NAME (Last Name, First Name, Middle Name, Extension Name):

DATE OF BIRTH (MM/DD/YYYY):
RELATIONSHIP TO HH HEAD:
MARITAL STATUS:
SEX:
DISABLED?: YES NO SOLO PARENT: YES NO OCCUPATION:
NAME (Last Name, First Name, Middle Name, Extension Name):
DATE OF BIRTH (MM/DD/YYYY):
RELATIONSHIP TO HH HEAD:

MARITAL STATUS:
SEX:
DISABLED?: YES NO SOLO PARENT: YES NO OCCUPATION:
NAME (Last Name, First Name, Middle Name, Extension Name):
DATE OF BIRTH (MM/DD/YYYY):
RELATIONSHIP TO HH HEAD:
MARITAL STATUS:
SEX:
DISABLED?: YES NO SOLO PARENT: YES NO OCCUPATION:
10
CAPTURING/CORRECTION OF IP AFFILIATION
NAME (Last Name, First Name, Middle Name, Extension Name): FROM TO
1
2
3
Applicable to all household
11
SELECTION/REPLACEMENT OF CHILD-BENEFICIARY (IES) FOR EDUCATION (PLEASE USE THE UPDTAE TYPE 4 AND/OR 5 TO UPDATE HEALTH AND/OR EDUCATION INFORMATION OF REPLACEMENT CHILD)

Name of Child Selection Deselection Reason Replacement Child for Selection

12 CAPTURING OF PREGNANCY STATUS

NAME (LAST NAME, FIRST NAME, MIDDLE NAME, EXTENSION NAME) SEX AGE PREGNANCY STATUS LAST MENSTRUAL PERIOD RELATIONSHIP TO HOUSEHOLD HEAD

Signature Over Printed Name of Grantee Signature Over Printed Name of Grantee Signature Over Printed Name of Grantee

Thumbmark if grantee does not know how to write) Representative and Designation
PART II - TO BE FILLED-OUT BY THE CBDO AND ENCODER
(Do not transmit this Form to the RBDO/POO if supporting documents are not complete)
Reviewed by: Encoded by:
Date Reviewed: Date Encoded:
POO Remarks: Remarks of Encoder (if any):

IF NOT ENCODED, THIS FORM WITH THE ATTACHED DOCUMENTS WILL BE RETURNED TO POO/C/MOO BEACAUSE OF THE FOLLOWING REASONS:

( ) Lacking or inconsistent supporting documents. Specify lacking document/s

( ) ML to verify the correct name of school/health facilities with exact address, then prepare request to the RITO for the addition of new facility in the library.
( ) Not in the family roster
( ) Others (specify)
TYPES OF UPDATES SUPPORTING DOCUMENTS
1. Newborn
Birth Certificate from National Statistics Office (NSO) or Local Civil Registry Office (LCRO), Health Certificate from RHU/BHS and Medical Certificate (if PWD)
Applicable when the whole household moves to a new address, not for a single household member. Copy of Case Folder shall be endorsed to the new C/ML

A. Transferring Within Barangay - Certificate from the Barangay Captain

B. Transferring to Other Barangay within the City/Municipality - Certificate of Residency from Old/New Address issued by the Barangay Captain
2. Change of Address
C. Other Area within the Region - Certificate of Residency from Old/New Address issued by the Barangay Captain where the request was emanated; Case Assessment Report

D. Other Area outside the Region - Certificate of Residency from Old/New Address issued by the Barangay Captain where the request was emanated; Case Assessment Report

(Note: When the household moves out of the area with or without prior notice C/ML and without applying for the change of address within 60 days, the household will be tagged as Code 12 -
3. Moving out of the area to non-Pantawid area Barangay Certificate of old and new address and C/ML Certificate
4. Update of Health Facility RHU/BHS Certificate from the new facility
5. Update of Education School Certificate issued by the school where the child is enrolled; Filled up BUS Form 6

6. Change of Grantee Death Certificate; Certification of C/ML stating the reason for long absence; Medical Certificate; Letter from the old grantee; Filled out LBP from (if applicable); Social Care Study Report; Senior Citizen ID or
Certification from OSCA or C/MSWDO
7. Deceased Death Certificate or Certification from the Tribal Leader of Chieftain

8. Additional Household Member Birth Certificate from National Statistics Office (NSO) or Local Civil Registry Office (LCRO); School Certificate issued by the school where the child is enrolled (if 3-18) years Health Certificate (if 0-5 years old); Medical
Cerificate (if disabled); RHU/BHS Certificate where the member is availing health services; Letter from the household grantee
Birth Certificate from National Statistics Office (NSO) or Local Civil Registry Office (LCRO); Marriage Certificate; Medical Certificate; Certificate of Employment or Barangay Certificate, indicating the present
9. Correction of Basic Information occupation of the household member; Solo Parent ID

10. Update of IP/ Tribal Affiliation Certificate of tribal membership from the Tribal Leader/Chieftain; NCIP Certificate

Death Certificate (if Deceased); Medical Certificate (for differently-abled child-beneficiary certifying the disability and incapacity to attend school); Letter from the parent of the child-beneficiary grantee stating the
11. Selection/ Deselection of Children for CV monitoring request or reason to deselect the child-beneficiary; Certificate of Enrollment of child for selection or replacement child.

12. Capturing of Pregnancy Status RHU/BHS Certificate from the health facility of the pregnant household member