HOUSEHOLD RECORD OF BARANGAY INHABITANTS

REGION: CARAGA PROVINCE: SURIGAO DEL NORTE CITY/MUNICIPALITY: SURIGAO CITY BARANGAY: LIPATA
Business/House No. ____________ Lighting System:
Dialect: ( ) Electricity ( ) Kerosene ( ) Solar ( ) Others: ______
Type of House: ( ) Concrete ( ) Semi-concrete ( ) wood/bamboo Source of Information:
( ) 1 story ( ) 2 stories ( ) 3 stories ( ) 4 stories ( ) 5 stories ( ) Radio ( ) Internet ( ) TV ( ) Newspaper ( ) Others: ___
Land Tenure/Ownership: ( ) Owned ( ) others: _______ Communication Services:
House: ( ) Owned ( ) Rented ( ) Caretaker ( ) Others: ____ ( ) Telephone ( ) Cellular Phone ( ) Internet ( ) Others: ____
Approximate income of the Family: _________________

NAME S A
E G PLACE OF BIRTH DATE OF BIRTH
FAMILY NAME FIRST NAME MIDDLE NAME X E

Prepared by: Certified Correct:

___________________________
Name of Household Head/Member AILEEN L. BARCENAS
(Signature over Printed Name) Barangay Secretary
ARANGAY: LIPATA PUROK: ________________
Water System:
s: ______ ( ) Spring ( ) Deep Well ( ) SMWD
Toilet Facilities:
) Others: ___ ( ) Open Pit ( ) Flush ( ) Others: _______
Means of Transportation:
( ) Others: ____ ( ) PUB ( )PUJ ( ) Motorcycle ( ) Private Car

HIGHEST Registered Voters

CIVIL STATUS OCCUPATION EDUCATIONAL (Yes)
ATTAINMENT (No)

Validated by:

HON. LOEL JOY O. MESIAS

Punong Barangay