CHARITABLE AND SOCIAL INSTITUTION (Archdiocese of Palo Annual General Statistics)

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Name of Institution: *

Address: *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Mobile Number *

Phone Number

Fax Number

Number of women/girls assisted:

Number of men/boys assisted:

TOTAL number of persons assisted: *

Other Programs Carried-out

Kindly Specify other carried–out programs rendered by this institution, i.e. Street Children (Daily/Weekly feeding; General Dispensary; Catechesis, among others indicating therein: PROGRAM NAME, NUMBER OF WOMEN/GIRLS ASSISTED, NUMBER OF MEN/BOYS ASSISTED, TOTAL NUMBER OF PERSONS ASSISTED

Prepared by: *

First

Middle

Last

Signature: *

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Date of Completion *

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