JUAN MAGSASAKA

RSBSA ENROLLMENT FORM 2x2

REGISTRY SYSTEM FOR BASIC SECTORS IN AGRICULTURE (RSBSA) PICTURE

Reference No.: ________________

PART I: PERSONAL INFORMATION

SURNAME FIRST NAME MIDDLE NAME EXTENSION NAME

ADDRESS
HOUSE/LOT/BLDG. NO. STREET/SITIO/SUBDV. BARANGAY

MUNICIPALITY/CITY PROVINCE REGION

Contact Number: ___________________________________ Sex: Male Female Person with Disability (PWD): Yes No
Date of Birth: Religion: ___________________________________________ Highest Formal Education:
M M D D Y Y Y Y Civil Status: Single Married None Elementary High School
Place of Birth: ______________________________________ Widowed Separated Vocational College
Household Head?: Yes No No. of living household members: _________________ Member of an Indigenous Group? Yes No
If no, name of household head: _____________________
Relationship: _____________________ No. of male: ___________ No. of female: ____________ If yes, specify group: ________________________________

–
With Voter's ID?: Yes - ID#____________________
No
Name Position Signature Date

PART II: FARM PROFILE

MAIN LIVELIHOOD • FARMER FARMWORKER/LABORER FISHERFOLK
For farmers: For farmworkers:
Type of Farming Activity Kind of Work The Lending Conduit shall coordinate with the Bureau of
Fisheries and Aquatic Resources (BFAR) in the issuance of a
Rice irrigated rainfed upland rainfed lowland
Land Preparation
Corn PLEA is registered under the Municipal Fisherfolk
Planting/Transplanting
Other crops, Registration (FishR).
please specify: __________________________________ Cultivation
Type of Fishing Activity
Livestock, Harvesting Fish Capture
please specify: __________________________________
Others, please specify: Aquaculture
Poultry,
please specify: __________________________________ ___________________________________________________ Others, please specify:
___________________________
Other source of income: Farming, please specify: _________________________________ Non-farming, please specify: _________________________________

FARM DESCRIPTION No. of Farm Parcels: __________________________ Yes No

FARM LOCATION SIZE Ownership
CROP/COMMODITY Tenurial Status
PARCEL (Barangay & Municipality) (Hectare) Document*
1 Registered Owner Tenant Lessee Others _____________

2 Registered Owner Tenant Lessee Others _____________

3 Registered Owner Tenant Lessee Others _____________

4 Registered Owner Tenant Lessee Others _____________

5 Registered Owner Tenant Lessee Others _____________

LOCATION NO. OF * Please put appropriate number/s. See table below for reference.
LIVESTOCK/POULTRY
(Barangay & Municipality) HEAD Ownership Document
1 7. Homestead patent
2. Emancipation Patent 8. Free Patent
2

3 Ownership Award (CLOA)

4. Collective CLOA Title
4
5. Co-ownership CLOA
5 6. Agricultural sales patent 12. Tax Declaration
I hereby declare that all information indicated above are true and correct, and that they may be used by Department of Agriculture for
the purposes of registration to the Registry System for Basic Sectors in Agriculture (RSBSA) and other legitimate interests of the Department
pursuant to its mandates.

_________________________________________________________________________________________ _____________________
SIGNATURE ABOVE PRINTED NAME OF FARMER/FISHERFOLK-APPLICANT DATE

VERIFIED TRUE AND CORRECT BY: THUMBMARK

___________________________________________________________ ___________________________________________________________ DATE: ______________________

SIGNATURE ABOVE PRINTED NAME SIGNATURE ABOVE PRINTED NAME
MAFC CHAIRMAN MUNICIPAL AGRICULTURE OFFICE
MARO (for ARBs)
PCA (for coconut farmers/farmworkers)
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