ANNEX B.

LIVELIHOOD ASSESSMENT FORM

For Target Recipients of the Capital Assistance Grant for
CULTURED VINEGAR

Kasalukyang lugar/tirahan ng
pamilya: BRGY.SAN RAFAEL DULAG, LEYTE
Pangalan at Member ID ng ALBERT SAMIANA CANONOY
Head of Family: 083718042-00276496
Pangalan at Member ID ng RICA ABRENIO REGODON
Grantee: 083718042-00276496

Bilang ng miyembro ng Pamilya: Bilang ng nagtatrabahong

60 years old and up: ____ 15-17 years old: ____ miyembro ng Pamilya: 03
50-59 years old:_______ 7-14 years old: 01
18-50 years old: 02 6 years old below:____ Bilang ng PWDs: 0
Kabuuang Bilang: _____
Karanasan sa kabuhayan ng
Pamilya: FARMER LABORER

Livelihood assets (Skills,

equipment, tools) ng pamilya: Store space, Funnel (Embutido), Hose, Galloons & Jug

Ano ang planong kabuhayan o

pagkakakitaan na nais gawin Cultured Vinegar
ng pamilya?

Bakit ito ang napiling Because the family has knowledge of selling “Culture Vinegar”
kabuhayan o pagkakakitaan ng and they have skill of producing cultured vinegar from coconut
pamilya? three, they also have existing business during pandemic but it
was closed due to crises brought by the pandemic. Tuba also is
a common drink during occasions in their Barangay.

RICA ABRENIO REGODON 083718042-00276496

Pangalan at Lagda Family/HH ID

MARIA ISABEL L. BIROS

PDO II/Municipal Link
Pangalan at Katungkulan ng Pantawid Worker
 ANNEX B.2 Department of Social Welfare and Development
Pantawid Pamilyang Pilipino Program

INDIVIDUAL GRANT PROPOSAL

Provision of Capital Assistance Grant for*
COCONUT WINE

A. BENEFICIARY’S INFORMATION

RICA ABRENIO REGODON

Name of Grantee and Family/HH ID
083718042-00276496

Name and Member ID of Family Member RICA ABRENIO REGODON

who will avail the Grant 083718042-00276496
Sex (Kasarian) [ ] MALE [ X ] FEMALE
Mobile Number
Current Address BRGY. SAN RAFAEL DULAG, LEYTE

B. GRANT PROCEEDS
Project Component Project Cost for ESSI funding
The Pantawid ESSI is designed to uplift the socio
economic status of the MCCT & RCCT households. One of
the beneficiaries served by the program in our MCCT-
FAMILIES IN NEEDS OF SPECIAL PROTECTION &
RCCT-REGULAR CONDITIONAL CASH TRANSFER and
they are eligible for the ESSI fund that shall develop their
skills and capacities through the seed capital livelihood
assistance. The program shall ensure MCCT-FNSP & 15,000.00
RCCT welfare and security as they are mainstreamed
communities.
The livelihood assistance chose by the beneficiary will
strengthen her participation based on her needs and
capacity to maximize her skills to augment the family’s
income through CULTURED VINEGAR. This is also to
ensure social protection to the beneficiary for quality life and
support the needs of the family.

TOTAL CAPITAL ASSISTANCE GRANTS REQUESTED 15,000.00

C. PROJECT DETAILS (STATE THE ANSWER IN ENGLISH)

Mga dahilan kung bakit ito
ang napiling paggagamitan
ng grant: 1. Mga kakayanan at karanasan tungkol sa ganitong kabuhayan.

The husband of Rica A. Regodon who’s raised from his father who’s
a tuba gatherer and also they learned the technique of making tuba
from their parents. They also have experience of selling tuba in their
Barangay during pandemic.

2. Lawak o mga lugar na dadalhan ng iyong mga produkto o serbisyo.

In their Barangay

3. Bilang ng ganitong mga produkto o serbisyo na meron na sa balak

mong merkado. Bilang ng mga taong posibleng bibili/tatangkilik ng
ganitong mga produkto/serbisyo.
Target consumers are the resident within their Barangay.
 4. Kasapatan ng raw materials o suplay para sa kabuhayan.
The raw material is always available in the Market of Dulag

5. Posibleng mga dahilan upang maging matagumpay ang ganitong

kabuhayan.
Less competitive of the product in the Barangay.
6. Posibleng mga dahilan ng pagkalugi.
If there is Typhoon that may affect their source of the Tuba on which
they produced it.

Mga gastusin ng proyekto

kung saan magagamit ang 15,000 (WRITE ONLY THE TOTAL COSTS)
grant
Magkano ang kikitain kada
buwan mula sa proyektong
ito? 26,640.00 (WRITE ONLY THE PROJECTED INCOME)

D. BUDGETARY REQUIREMENTS (PLEASE COPY AND PASTE THE COMPUTATION

TABLE FROM THE SLP PROPOSAL HERE. PLEASE SEE THE TABLES BELOW)

a) Raw materials (Mga kinakailangang sangkap/materyales)

Raw Material Quantity Unit Unit Frequency of
Total Cost
(sangkap/materyales) (Bilang) (Yunit) Price Production
        Every days -
        Every days -
        Every days -
        Every days -
        Every days -
        Every days -
        Every days -
Grand Total Cost -

b) Available Manpower and Required Labor (Mga tauhan at mga kinakailangang manggagawa)
Daily
Name of Workers in Specific Task in the Work day/s Total Wage/ Salary per
Wage/
the Microenterprise Microenterprise per Cycle Production Cycle
Salary
        -
        -
        -
        -
        -
        -
        -
        -
        -
        -
        -
        -
        -
        -
        -
        -
Total wage based on production or business cycle -

c) Tools and Equipment (Mga kinakailangang kagamitan)

 Tool/ Salvage Life Span in days Production Depreci
Total
Equipmen Quantity Unit Unit Price Value of tools/ Cycle in ation
Cost
t per Unit equipment days Cost

          -   - -

          -   - -

          -   - -

          -   - -

          -   - -

          -   - -

          -   - -

          -   - -

          -   - -

          -   - -

          -   - -

          -   - -

          -   - -

          -   - -

          -   - -

          -   - -

Grand Total -     -

d) Other Expenses (Iba pang gastusin)

Regular Operational Expense (regular na Frequency Capital Expense for 1 Production
pinagkakagastusan) of Payment Required Cycle
Work space rent (Upa) Every days -
-
Every days -
Electricity (kuryente) -
Every days -
Water (tubig) -
Every days -
Transportation cost (Pamasahe) -
Every days -
Permit to operate -
  Every days -
-
Every days -
  -
Every days -
  -
Every days -
  -
  Every days -
 -
Every days -
  -
Every days -
  -
Every days -
  -
Every days -
Miscellaneous expenses -
-
Grand Total -

e) Gross sales per production cycle (Pangunahing kita mula sa puhunan para sa mga
sangkap/materyales)
Sale Price
Product (produkto) Quantity Unit Total Sales
per unit
        -
        -
        -
        -
        -
        -
        -
        -
        -
        -
        -
        -
        -
        -
        -
        -

f) Net profit per production cycle (Kabuuang kikitain sa bawat paggawa ng produkto o serbisyo)
ITEMS COST

Gross Sales (inaasahang kita mula sa isang “production cycle”) -

Less: Raw materials -

Gross Profit -
Less:  
Manpower available and labor
  required -    

  Depreciation Cost -    

  Other Expenses -    

Total Operating Expense -

Net Income -
This grant proposal for the Provision of Capital Assistance Grant
(CAG) amounting to Fifteen Thousand Pesos (15,000.00) only wherein Fifteen Thousand Pesos
(15,000.00) will be sourced from 4Ps funds is hereby recommended for funding:

Prepared by
RICA ABRENIO REGODON / 083718042-00276496 Date signed: ___________
Name and Signature of Recipient / Family/HH ID

__ MARIA ISABEL L. BIROS Date signed: __________

Name and Signature of CF/CW/M/City Link
Recommending
Approval __ PAULA B. UNAY Date signed: __________
Chief, Pantawid Pamilyang Pilipino Program
Certified as to __
Availability of Funds: MARK LORBEN E. VICUÑA Date signed: __________
Administrative Officer V
Approved/
Disapproved __ GRACE Q. SUBONG Date signed: ___________
Regional Director
 ANNEX B.3
Department of Social Welfare and Development
Pantawid Pamilyang Pilipino Program

Kasunduan sa Pagtanggap ng Capital Assistance Grant

Ako si, RICA ABRENIO REGODON , 32 taong gulang, nakatira sa

Pangalan Edad

BRGY. SAN RAFAEL DULAG, LEYTE ay isa sa nakatanggap ng

Capital Assistance Grant mula sa Pantawid Pamilyang Pilipino Program (4Ps) ng

Department of Social Welfare and Development (DSWD) , sa halagang

FIFTEEN THOUSAND PESOS ONLY (P15, 000.00)

ay nangangako na gagamitin ang halagang nabanggit na naaayon sa pinag-usapan

at pananagutan ko ang hindi pagtupad dito ayon sa mga itinakdang kondisyon ng

4Ps at DSWD.

RICA ABRENIO REGODON

Lagda sa Ibabaw ng Buong Pangalan

HH ID: 083718042-00276496

Petsa : _____________________

Saksi/Witness:

______________________________
Lagda sa Ibabaw ng Buong Pangalan