RBI FORM A

RECORD OF BARANGAY INHABITANTS BY HOUSEHOLD

A. REGION: PSG
C
B. PROVINCE: O
D
C. CITY/MUNICIPALITY: E
S
D. BARANGAY:
E. HOUSEHOLD NO. DATE ACCOMPLISHED:

NAME (1) ADDRESS (2)

NAME OF CIVIL CITIZEN-
LAST NAME FIRST NAME MIDDLE NAME EXT NO. STREET NAME SUBDIVISION/ZONE/ PLACE OF BIRTH DATE OF SEX STATUS SHIP OCCUPATION
[1.1] [1.2] [1.3] [1.4] [2.1] [2.2] SITIO/PUROK (If [3] BIRTH [5] [6] [7] [8]
application [4]
[2.3]

Prepared by: Certified Correct: Validated by:

______________________________ _________________________ __________________________

Name of household Head/Member Barangay Secretary Punong Barangay
(Signature over Printed Name) (Signature over Printed Name) (Signature over Printed Name)
CRISANTA D. ANTENOR LOLITA B. AGUILAR
GUILAR