CHED-Scholarship Application Form

ANNEX "A"
2019 version (NOT FOR
SALE) Office of the President of the Philippines
COMMISSION ON HIGHER EDUCATION
REGIONAL OFFICE 1

2X2
ID PICTURE
CHED STUDENT FINANCIAL ASSISTANCE PROGRAMS (StuFAPs)
APPLICATION FORM
Instructions: Read General and Documentary Requirements. Fill in all the required information. Do not leave an item blank. If item is not applicable, indicate "N/A".
Application period: March 1 to May 31 of the current academic year
PERSONAL INFORMATION

1. Name (Last Name) Maiden Name

(First Name) (Middle Name)
put extension, if any: i.e. Jr., III (for Married Women)
2. Date of Birth (mm/dd/yy)
9. Present Address
3. Place of Birth
4. Sex Male 10. Zip Code
Female
Single Widowed
9. Permanent Address
5. Civil Status Married Separated

Annulled Others 10. Zip Code

6. Citizenship 1 1 . Name of School Last Attended
7. Mobile Number 12. School Address
8. E-mail Address
13. School Sector: ( )Public ( )Private 15. Type of Disability (if applicable)
14. Highest Attained Grade/Year Level 16. IP affiliation (if applicable)

FAMILY BACKGROUND
Father: ( ) Living ( )Deceased Mother: ( ) Living ( ) Deceased Legal Guardian
17. Name
18. Address
19. Contact Number
20. Occupation
21. Name of Employer
22. Employer Address
23. Highest Educational Attainment
24. No. of Siblings in the family 18 years old and below
24. Total Parents Taxable Income
25. Is your family a beneficiary of the DSWD's pantawid Pamilyang Pilipino Program (4Ps)? ( ) Yes ( ) No

26. School Intended to enroll or enrolled in:

27. School Address:
28. Type of School: ( ) Public ( ) Private
29. Degree Program: ______________________________________________________________________________
Type Grantee Institution/Agency
30. Are you enjoying other sources of educational/financial assistance? ( ) Yes or ( ) No If yes, please specify 1. .
2. .
I hereby certify that foregoing statements are true and correct. Any misinformation or witholding of information will automatically disqualify me from the CHED Scholarship Program. I am willing to
refund the financial benefits received if such information is discovered after acceptance of the award.
I hereby express my consent for the Commission on Higher Education to collect, record, organize, update or modify, retrieve, consult, use, consolidate, block, erase or destruct my personal data as part
of my information. I hereby affirm my right to be informed, object to processing, access and rectify, suspend or withdraw my personal data and be indemnified in case of damages pursuant to
the provisions of the Republic Act No. 10173 of the Philippines, Data Privacy Act of 2012 and its corresponding Implementing Rules and Regulations.

(Signature overPrinted Name of Applicant) Date Accomplished

Note: Fully accomplished form to be submitted to the CHEDRO
DO NOT FILL-OUT THIS PORTION (FOR CHED USE ONLY)

Belongs to: (any of the following groups) Documents Attached:

dependent of solo parent 1. Academic
senior citizens ( ) Report Card ( ) Copy of Grades: Grade 11 or 1st semester of Grade 12
2. Financial
persons with disabilities please specify type of disability
( ) ITR ( ) Tax Exemption ( ) Certifcate of Indigency
indigenous and ethnic peoples please specify membership
( ) Case Study DSWD ( ) OFW Contract
3. Others
( ) Solo Parent ( ) Senior Citizen ( ) IPs ( ) PWD
School intended to enrol in
School address
Type of School ( ) Public ( ) Private
Course ( ) Priority ( ) Non-Priority

Evaluated/Processed by:

CHED StuFAP Coordinator Date

CRITERIA OF ELIGIBILITY per CMO s. 2 0 1 9 DOCUMENTARY REQUIREMENTS per CMO s. 2 0 1 9
1. Filipino citizen; Academic Requirements - anyone of the following:
2. Graduating high school students/High school graduate 1 . Highschool report card
( )
3 General Weighted Average (GWA) of at least 90% or above.
( ) 2. Duly certified true copy of grades for Grade 11 or 1st semester of Grade 12 for graduating highschool
students
4 Combined annual gross income of parents/guardian not to exceed Four Hundred Thousand

Pesos (PhP400,000.00) or solo parent/guardian whose annual gross income does not Income Requirements - any one of the following :
exceed the said amount;
( ) 1. Latest ITR of parents or guardian if employed

In highly exceptional cases where income exceeds Php400,000.00, the CHEDRO StuFAPs ( ) 2. Certificate of Tax Exemption from the BIR
Committee shall determine the merits of the application ( ) 3. Certificate of Indigency from their Barangay
5 Avail of only one government funded financial assistance program. ( ) 4. Certificate/Case Study from DSWD

( ) 5. Latest copy of contractor proof of income for children of Overseas Filipino Workers (OFW) and seafarers.
NOTE:
Beneficiaries of free higher education under RA 10931 can only
receive stipend under this program