Certificate of Indigency Form

Republic of the Philippines · Province of Batangas

Barangay Bolbok

Batangas City, Batangas · Tel: 043 980 0831 · contact@bolbok.gov.ph

CI-FORM-001

Rev. 01 · 2026

Certificate of Indigency — Request Form

Control No.: Date Filed:

Applicant Information

Last Name

First Name

Middle Name

Date of Birth

Age

Civil Status

Contact Number

Years of Residency in Barangay Bolbok

Complete Address in Barangay Bolbok

Household / Income Information

Number of Household Members

Monthly Household Income

Source of Income

Purpose of Request

Medical / Hospital Assistance

Educational Assistance

DSWD / Government Benefit

Legal Aid

Burial Assistance

Others (specify below)

Others / Specify

Valid ID Presented

Type of ID

ID Number

I hereby certify that all information stated above is true and correct. I understand that this certificate is issued for indigent residents only and that any false declaration shall subject me to applicable penalties under existing laws.

Applicant's Signature over Printed Name

Date: __________________________

Punong Barangay / Authorized Official

Barangay Bolbok, Batangas City

For Office Use Only

Verified By

Date Processed

Remarks

* This certificate is free of charge. Processing time: same day (Mon–Fri, 8:00 AM – 5:00 PM).