INDIVIDUAL RECORD OF BARANGAY INHABITANTS

Household number:_______

REGION
BARANGAY

PERSONAL DATA
LAST NAME QUALIFIER
FIRST NAME
MIDDLE NAME
ADDRESS

No. Street Name of Subdivision/zone

City/Municipality Province
DATE OF BIRTH - -
(mm-dd-yyyy)
PLACE OF BIRTH

SEX: Male FEMALE ____

CIVIL STATUS : SINGLE ____ MARRIED _____ WIDOW/ER____ SEPARATED ____
OCCUPATION
CITIZENSHIP
Relationship to
household Head

I hereby certify that the above information are true and correct to the best of my knowledge

_______________________________________
Name/Signature of Person Accomplishing this form

______________________________
Date Accomplished

Attested By: v

_________________________________
Barangay Secretary left Thumbmark Right Thumbmark
(in case inhabitant is unable to read and write)

Note: The HN shall be filled up by the Barangay Secretary