Annex A

LGU CENSUS AND TAGGING OF INFORMAL SETTLER FAMILIES (ISF)/ILLEGAL

STRUCTURES/ENCROACHMENTS WITHIN EASEMENT AREAS OF MANILA BAY-REGION 3 WATERWAYS

Control No: 2021-______________

Province:_____________________
City/Municipality: _____________
Barangay: ___________________________________________________________________________
Purok/Sitio: __________________________________________________________________________
Name of Waterway: ___________________________________________________________________
Coordinates: _________________________________________________________________________

Name of Household Head: ____________________ _______________

First Middle Last
Meiden Name Incase the head of the Family is female: _________________________________________
Civil Status: Date of Birth: Place of Birth:
Name of Spouse (Maiden Name):
First Middle Last
Date of Birth: Place of Birth:

( ) Employed ( ) Self –Employed ( ) Unemployed

Pls. Specify_______ Pls. Specify Monthly Salary/Income:________________

FAMILY COMPOSITION

Name: Relationship: Age: Source of Income (if applicable)

_
_
_ _
_
_ _

Date of Occupancy: Type of Structure: ( )Concrete ( )Semi-Concrete ( )Light Material

Tenurial Status: (Please Check)

( ) Owned ( ) Renter/Caretaker
___ Titled ___ Rights Specify owner: ________________________

Existing Housing Grant: ( ) Previously Granted ( ) Pending Application ( ) None

Liquid Waste Disposal: ( ) Direct Discharge ( ) Indirect Discharge

*without toilet septic tank *with toilet septic tank

Relocation preference ( ) Balik-Probinsya ( ) Resettlement Site

Remarks:

Respondent:

_
Name Age (18 and above) Relationship to HH head Signature Date

Interviewer:

Signature over Printed Name Position Date of Interview

Noted by:

Signature over Printed Name

Barangay Chairmain