FORM A

INDIVIDUAL RECORD OF BARANGAY INHABITANT

REGION: 1 HOUSEHOLD NUMBERR (HN) : _____

PROVINCE: P A N G A S I N A N
MUNICIPALITY: B A U T I S T A
BARANGAY: A R T A C H O
PERSONAL INFORMATION
LAST NAME: QUALIFIER:
FIRST NAME:
MIDDLE NAME:
ADDRESS: Z
O N E 2 A R T A C H O
No. Street Barangay
B A U T I S T A P A N G A S I N A N
City/Municipality Province
DATE OF BIRTH: / /
(mm-dd-yyyy)

PLACE OF
BIRTH:
SEX: Male: Female:

CIVIL STATUS: Single: Married: Widow/er: Separated: Common Law:

OCCUPATION:
CITIZENSHIP:
RELATION 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

21-Jun-20
Attested by: Date Accomplished

JOMAR P. SAMOY
Barangay Secretary
FORM A
INDIVIDUAL RECORD OF BARANGAY INHABITANT

REGION: 1 HOUSEHOLD NUMBERR (HN) : _____

PROVINCE: P A N G A S I N A N

MUNICIPALITY: B A U T I S T A

BARANGAY: A R T A C H O
PERSONAL INFORMATION
LAST NAME: QUALIFIER: X

FIRST NAME:

MIDDLE NAME:

ADDRESS: Z
O N E 2 A R T A C H O
No. Street Barangay
B A U T I S T A P A N G A S I N A N
City/Municipality Province

DATE OF BIRTH: / /
(mm-dd-yyyy)

PLACE OF
BIRTH:

SEX: Male: Female:

CIVIL STATUS: Single: Married: Widow/er: Separated: Common Law:

OCCUPATION:

CITIZENSHIP:

RELATION 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

Attested by: Date Accomplished

 JOMAR P. SAMOY
Barangay Secretary
FORM A
INDIVIDUAL RECORD OF BARANGAY INHABITANT

REGION: 1 HOUSEHOLD NUMBERR (HN) : _____

PROVINCE: P A N G A S I N A N
MUNICIPALITY: B A U T I S T A
BARANGAY: A R T A C H O
PERSONAL INFORMATION
LAST NAME: QUALIFIER:
FIRST NAME:
MIDDLE NAME:
ADDRESS: Z
O N E A R T A C H O
No. Street Barangay
B A U T I S T A P A N G A S I N A N
City/Municipality Province
DATE OF BIRTH: / /
(mm-dd-yyyy)

PLACE OF
BIRTH:
SEX: Male: Female:

CIVIL STATUS: Single: Married: Widow/er: Separated: Common Law:

OCCUPATION:
CITIZENSHIP:
RELATION 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

21-Jun-20
Attested by: Date Accomplished

JOMAR P. SAMOY
Barangay Secretary
FORM A
INDIVIDUAL RECORD OF BARANGAY INHABITANT

REGION: 1 HOUSEHOLD NUMBERR (HN) : _____

PROVINCE: P A N G A S I N A N

MUNICIPALITY: B A U T I S T A

BARANGAY: A R T A C H O
PERSONAL INFORMATION
LAST NAME: QUALIFIER:

FIRST NAME:

MIDDLE NAME:

ADDRESS: Z
O N E A R T A C H O
No. Street Barangay
B A U T I S T A P A N G A S I N A N
City/Municipality Province

DATE OF BIRTH: / /
(mm-dd-yyyy)

PLACE OF
BIRTH:

SEX: Male: Female:

CIVIL STATUS: Single: Married: Widow/er: Separated: Common Law:

OCCUPATION:

CITIZENSHIP:

RELATION 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

21-Jun-20
Attested by: Date Accomplished
 JOMAR P. SAMOY
Barangay Secretary