ANNEX “A”

BOIS Form Revised 2022

Republic of the Philippines

Department of the Interior and Local Government 1X1
DILG-NAPOLCOM Center, EDSA corner Quezon Avenue, Quezon City
ID Picture
BARANGAY OFFICIAL’S INFORMATION SHEET
REGION : VII CITY/MUN : MANJUYOD

PROVINCE : NEGROS ORIENTAL BARANGAY : SACSAC

ELECTIVE AND APPOINTIVE POSITION

Punong Barangay Barangay Treasurer
Sangguniang Barangay Member Barangay Secretary
Rank (1, 2, 3, 4, 5, 6, 7) SK Treasurer
SK Chairperson SK Secretary
SK Member (Rank 1, 2, 3, 4, 5, 6, 7) IPMR
Relationship with the Appointing Authority: __________________

TERM IN THE PRESENT POSITION: Other Appointive Barangay Official:

st nd rd
1 2 3 ___________________________________

PERSONAL INFORMATION
5401-7532-0630-7493

(PhilSys Card No.)

QUILIOPE WELLA MAE CADIZ

(Last Name) (Suffix e.g. Jr., I, II, III) (First Name) (Middle Name)

02-27-2001 SACSAC, MANJUYOD F S IFI

(Birth Date: mm/dd/yyyy) (Birth Place) (Sex) (Civil Status) (Religion)

BRGY. SACSAC, MANJUYOD NEGROS ORIENTAL NONE

(Residence Address) (Residence Telephone No.)

0961-087-0536 NONE wellamaequiliope@gmail.com

(Mobile Number) (Barangay Hall Telephone Number) (E-mail Address)

HIGHEST EDUCATIONAL ATTAINMENT: ELEMENTARY HIGH SCHOOL COLLEGE POST GRAD VOCATIONAL

Please specify: Graduate Under Graduate

OCCUPATION: Call Center Agent HONORARIUM: P530.00

BENEFICIARIES: (optional for the other appointive barangay officials)
NAME DATE OF BIRTH RELATIONSHIP

1. MELVIN QUILIOPE 05-16-1975 FATHER

2. WINNIE QUILIOPE 06-26-1973 MOTHER
3.

4.
(Please use additional Sheet if necessary)

I hereby certify that the above information are true and correct to the best of my knowledge. I understand that for the DILG to carry out its
mandate they must necessarily process my personal information. Therefore, I grant my consent and recognize the authority of the DILG to
process my personal information, pursuant to the Philippine Data Privacy Act of 2012.

WELLA MAE C. QUILIOPE

(Signature over Printed Name) (Date Accomplished)

Verified and validated by:

AVA SHERYL T. CATAPUSAN-TAN

 CD/CLGOO/MLGOO Date
(Signature over Printed Name)
ANNEX “A”
BOIS Form Revised 2022

Republic of the Philippines

Department of the Interior and Local Government 1X1
DILG-NAPOLCOM Center, EDSA corner Quezon Avenue, Quezon City
ID Picture
BARANGAY OFFICIAL’S INFORMATION SHEET
REGION : VII CITY/MUN : MANJUYOD

PROVINCE : NEGROS ORIENTAL BARANGAY : SACSAC

ELECTIVE AND APPOINTIVE POSITION

Punong Barangay Barangay Treasurer
Sangguniang Barangay Member Barangay Secretary
Rank (1, 2, 3, 4, 5, 6, 7) SK Treasurer
SK Chairperson SK Secretary
SK Member (Rank 1, 2, 3, 4, 5, 6, 7) IPMR
Relationship with the Appointing Authority: __________________

TERM IN THE PRESENT POSITION: Other Appointive Barangay Official:

1st 2nd 3rd ___________________________________

PERSONAL INFORMATION

(PhilSys Card No.)

ANDAYA TERY CONTAD

(Last Name) (Suffix e.g. Jr., I, II, III) (First Name) (Middle Name)

03-21-2003 BAIS CITY, NEG. OR. F S ASSEMBLY OF GOD

(Birth Date: mm/dd/yyyy) (Birth Place) (Sex) (Civil Status) (Religion)

BRGY. SACSAC, MANJUYOD NEGROS ORIENTAL NONE

(Residence Address) (Residence Telephone No.)

0963-218-4159 NONE quiliope035@gmail.com

(Mobile Number) (Barangay Hall Telephone Number) (E-mail Address)

HIGHEST EDUCATIONAL ATTAINMENT: ELEMENTARY HIGH SCHOOL COLLEGE POST GRAD VOCATIONAL

Please specify: Graduate Under Graduate

OCCUPATION: NONE HONORARIUM: P530.00

BENEFICIARIES: (optional for the other appointive barangay officials)
NAME DATE OF BIRTH RELATIONSHIP

1 JAMES ANTHONY QUILIOPE 12-16-2001 LIVE-IN PARTNER

3. THERESE RAIAH QUILIOPE 12-28-2021 DAUGHTER

3.

4.
(Please use additional Sheet if necessary)

I hereby certify that the above information are true and correct to the best of my knowledge. I understand that for the DILG to carry out its
mandate they must necessarily process my personal information. Therefore, I grant my consent and recognize the authority of the DILG to
process my personal information, pursuant to the Philippine Data Privacy Act of 2012.

TERY C. ANDAYA

(Signature over Printed Name) (Date Accomplished

Verified and validated by:
 AVA SHERYL T. CATAPUSAN-TAN

CD/CLGOO/MLGOO Date
(Signature over Printed Name)
ANNEX “A”
BOIS Form Revised 2022

Republic of the Philippines

Department of the Interior and Local Government 1X1
DILG-NAPOLCOM Center, EDSA corner Quezon Avenue, Quezon City
ID Picture
BARANGAY OFFICIAL’S INFORMATION SHEET
REGION : VII CITY/MUN : MANJUYOD

PROVINCE : NEGROS ORIENTAL BARANGAY : SACSAC

ELECTIVE AND APPOINTIVE POSITION

Punong Barangay Barangay Treasurer
Sangguniang Barangay Member Barangay Secretary
Rank (1, 2, 3, 4, 5, 6, 7) SK Treasurer
SK Chairperson SK Secretary
SK Member (Rank 1, 2, 3, 4, 5, 6, 7) IPMR
Relationship with the Appointing Authority: __________________

TERM IN THE PRESENT POSITION: Other Appointive Barangay Official:

st nd rd
1 2 3 ___________________________________

PERSONAL INFORMATION

(PhilSys Card No.)

ZAMORA REXTER BLAZA

(Last Name) (Suffix e.g. Jr., I, II, III) (First Name) (Middle Name)

09-28-2000 MANJUYOD NEG. OR. M S IFI

(Birth Date: mm/dd/yyyy) (Birth Place) (Sex) (Civil Status) (Religion)

BRGY. SACSAC, MANJUYOD NEGROS ORIENTAL NONE

(Residence Address) (Residence Telephone No.)

0905-644-8636 NONE zamorarexter28@gmail.com

(Mobile Number) (Barangay Hall Telephone Number) (E-mail Address)

HIGHEST EDUCATIONAL ATTAINMENT: ELEMENTARY HIGH SCHOOL COLLEGE POST GRAD VOCATIONAL

Please specify: Graduate Under Graduate

OCCUPATION: NONE HONORARIUM: P530.00

BENEFICIARIES: (optional for the other appointive barangay officials)
NAME DATE OF BIRTH RELATIONSHIP

1. DIOVELYN B. ZAMORA 08-15-1971 MOTHER

2. GILBRT C. ZAMORA 08-25-1962 FATHER

3.

4.
(Please use additional Sheet if necessary)

I hereby certify that the above information are true and correct to the best of my knowledge. I understand that for the DILG to carry out its
mandate they must necessarily process my personal information. Therefore, I grant my consent and recognize the authority of the DILG to
process my personal information, pursuant to the Philippine Data Privacy Act of 2012.

REXTER B. ZAMORA

(Signature over Printed Name) (Date Accomplished)

Verified and validated by:
 AVA SHERYL T. CATAPUSAN-TAN

CD/CLGOO/MLGOO Date
(Signature over Printed Name)
ANNEX “A”
BOIS Form Revised 2022

Republic of the Philippines

Department of the Interior and Local Government 1X1
DILG-NAPOLCOM Center, EDSA corner Quezon Avenue, Quezon City
ID Picture
BARANGAY OFFICIAL’S INFORMATION SHEET
REGION : VII CITY/MUN : MANJUYOD

PROVINCE : NEGROS ORIENTAL BARANGAY : SACSAC

ELECTIVE AND APPOINTIVE POSITION

Punong Barangay Barangay Treasurer
Sangguniang Barangay Member Barangay Secretary
Rank (1, 2, 3, 4, 5, 6, 7) SK Treasurer
SK Chairperson SK Secretary
SK Member (Rank 1, 2, 3, 4, 5, 6, 7) IPMR
Relationship with the Appointing Authority: __________________

TERM IN THE PRESENT POSITION: Other Appointive Barangay Official:

st nd rd
1 2 3 ___________________________________

PERSONAL INFORMATION
4098-5701-9045-3967
(PhilSys Card No.)

KADUSALE JUDY AN BANJAO

(Last Name) (Suffix e.g. Jr., I, II, III) (First Name) (Middle Name)

09-28-2002 MANJUYOD NEG. OR. F S IFI

(Birth Date: mm/dd/yyyy) (Birth Place) (Sex) (Civil Status) (Religion)

BRGY. SACSAC, MANJUYOD NEGROS ORIENTAL NONE

(Residence Address) (Residence Telephone No.)

0936-205-3440 NONE kadusalejudyan28@gmail.com

(Mobile Number) (Barangay Hall Telephone Number) (E-mail Address)

HIGHEST EDUCATIONAL ATTAINMENT: ELEMENTARY HIGH SCHOOL COLLEGE POST GRAD VOCATIONAL

Please specify: Graduate Under Graduate

OCCUPATION: NONE HONORARIUM: P5,367.00

BENEFICIARIES: (optional for the other appointive barangay officials)
NAME DATE OF BIRTH RELATIONSHIP

1. LOGINA B. KADUSALE 12-19-1986 MOTHER

2.

3.

4.
(Please use additional Sheet if necessary)

I hereby certify that the above information are true and correct to the best of my knowledge. I understand that for the DILG to carry out its
mandate they must necessarily process my personal information. Therefore, I grant my consent and recognize the authority of the DILG to
process my personal information, pursuant to the Philippine Data Privacy Act of 2012.

JUDY AN B. KADUSALE

(Signature over Printed Name) (Date Accomplished)

Verified and validated by:
 AVA SHERYL T. CATAPUSAN-TAN

CD/CLGOO/MLGOO Date
(Signature over Printed Name)
ANNEX “A”
BOIS Form Revised 2022

Republic of the Philippines

Department of the Interior and Local Government 1X1
DILG-NAPOLCOM Center, EDSA corner Quezon Avenue, Quezon City
ID Picture
BARANGAY OFFICIAL’S INFORMATION SHEET
REGION : VII CITY/MUN : MANJUYOD

PROVINCE : NEGROS ORIENTAL BARANGAY : SACSAC

ELECTIVE AND APPOINTIVE POSITION

Punong Barangay Barangay Treasurer
Sangguniang Barangay Member Barangay Secretary
Rank (1, 2, 3, 4, 5, 6, 7) SK Treasurer
SK Chairperson SK Secretary
SK Member (Rank 1, 2, 3, 4, 5, 6, 7) IPMR
Relationship with the Appointing Authority: __________________

TERM IN THE PRESENT POSITION: Other Appointive Barangay Official:

st nd rd
1 2 3 ___________________________________

PERSONAL INFORMATION

(PhilSys Card No.)

ANDAYA MIRAFLOR BLAZA

(Last Name) (Suffix e.g. Jr., I, II, III) (First Name) (Middle Name)

07-29-2000 MANJUYOD NEG. OR. F S ASSEMBLY OF GOD

(Birth Date: mm/dd/yyyy) (Birth Place) (Sex) (Civil Status) (Religion)

BRGY. SACSAC, MANJUYOD NEGROS ORIENTAL NONE

(Residence Address) (Residence Telephone No.)

NONE NONE Andayamiraflor2000@gmail.com

(Mobile Number) (Barangay Hall Telephone Number) (E-mail Address)

HIGHEST EDUCATIONAL ATTAINMENT: ELEMENTARY HIGH SCHOOL COLLEGE POST GRAD VOCATIONAL

Please specify: Graduate Under Graduate

OCCUPATION: HOUSEWIFE HONORARIUM: P530.00

BENEFICIARIES: (optional for the other appointive barangay officials)

NAME DATE OF BIRTH RELATIONSHIP

1. JELOU QUILIOPE. 03-03-1982 LIVE-IN PARTNER

2. JELMER QUILIOPE 02-18-2019 SON

3.
4.
(Please use additional Sheet if necessary)

I hereby certify that the above information are true and correct to the best of my knowledge. I understand that for the DILG to carry out its
mandate they must necessarily process my personal information. Therefore, I grant my consent and recognize the authority of the DILG to
process my personal information, pursuant to the Philippine Data Privacy Act of 2012.

MIRAFLOR B. ANDAYA

(Signature over Printed Name) (Date Accomplished)

Verified and validated by:
 AVA SHERYL T. CATAPUSAN-TAN

CD/CLGOO/MLGOO Date
(Signature over Printed Name)
ANNEX “A”
BOIS Form Revised 2022

Republic of the Philippines

Department of the Interior and Local Government 1X1
DILG-NAPOLCOM Center, EDSA corner Quezon Avenue, Quezon City
ID Picture
BARANGAY OFFICIAL’S INFORMATION SHEET
REGION : VII CITY/MUN : MANJUYOD

PROVINCE : NEGROS ORIENTAL BARANGAY : SACSAC

ELECTIVE AND APPOINTIVE POSITION

Punong Barangay Barangay Treasurer
Sangguniang Barangay Member Barangay Secretary
Rank (1, 2, 3, 4, 5, 6, 7) SK Treasurer
SK Chairperson SK Secretary
SK Member (Rank 1, 2, 3, 4, 5, 6, 7) IPMR
Relationship with the Appointing Authority: __________________

TERM IN THE PRESENT POSITION: Other Appointive Barangay Official:

st nd rd
1 2 3 ___________________________________

PERSONAL INFORMATION
2682-9750-3913-7693
(PhilSys Card No.)

EJERCITO JORINE RODRIGUEZ

(Last Name) (Suffix e.g. Jr., I, II, III) (First Name) (Middle Name)

04-28-2001 MANJUYOD NEG. OR. M S UCCP

(Birth Date: mm/dd/yyyy) (Birth Place) (Sex) (Civil Status) (Religion)

BRGY. SACSAC, MANJUYOD NEGROS ORIENTAL NONE

(Residence Address) (Residence Telephone No.)

0936-224-6413 NONE ejercitojorine@gmail.com

(Mobile Number) (Barangay Hall Telephone Number) (E-mail Address)
K

HIGHEST EDUCATIONAL ATTAINMENT: ELEMENTARY HIGH SCHOOL COLLEGE POST GRAD VOCATIONAL

Please specify: Graduate Under Graduate

OCCUPATION: NONE HONORARIUM: P530.00

BENEFICIARIES: (optional for the other appointive barangay officials)
NAME DATE OF BIRTH RELATIONSHIP

1. JUNIA EJERCITO 11-01-1967 MOTHER

2.

3.

4.
(Please use additional Sheet if necessary)

I hereby certify that the above information are true and correct to the best of my knowledge. I understand that for the DILG to carry out its
mandate they must necessarily process my personal information. Therefore, I grant my consent and recognize the authority of the DILG to
process my personal information, pursuant to the Philippine Data Privacy Act of 2012.

JORINE R. EJERCITO

(Signature over Printed Name) (Date Accomplished)

Verified and validated by:
 AVA SHERYL T. CATAPUSAN-TAN

CD/CLGOO/MLGOO Date
(Signature over Printed Name)
ANNEX “A”
BOIS Form Revised 2022

Republic of the Philippines

Department of the Interior and Local Government 1X1
DILG-NAPOLCOM Center, EDSA corner Quezon Avenue, Quezon City
ID Picture
BARANGAY OFFICIAL’S INFORMATION SHEET
REGION : VII CITY/MUN : MANJUYOD

PROVINCE : NEGROS ORIENTAL BARANGAY : SACSAC

ELECTIVE AND APPOINTIVE POSITION

Punong Barangay Barangay Treasurer
Sangguniang Barangay Member Barangay Secretary
Rank (1, 2, 3, 4, 5, 6, 7) SK Treasurer
SK Chairperson SK Secretary
SK Member (Rank 1, 2, 3, 4, 5, 6, 7) IPMR
Relationship with the Appointing Authority: __________________

TERM IN THE PRESENT POSITION: Other Appointive Barangay Official:

st nd rd
1 2 3 ___________________________________

PERSONAL INFORMATION

(PhilSys Card No.)

CADIENTE HANNAH JANE PALUMAR

(Last Name) (Suffix e.g. Jr., I, II, III) (First Name) (Middle Name)

06-27-2005 MANJUYOD NEG. OR. F S IFI

(Birth Date: mm/dd/yyyy) (Birth Place) (Sex) (Civil Status) (Religion)

BRGY. SACSAC, MANJUYOD NEGROS ORIENTAL NONE

(Residence Address) (Residence Telephone No.)

0912-105-6998 NONE hannahjane062005@gmail.com

(Mobile Number) (Barangay Hall Telephone Number) (E-mail Address)

HIGHEST EDUCATIONAL ATTAINMENT: ELEMENTARY HIGH SCHOOL COLLEGE POST GRAD VOCATIONAL

Please specify: Graduate Under Graduate

OCCUPATION: NONE HONORARIUM: P530.00

BENEFICIARIES: (optional for the other appointive barangay officials)
NAME DATE OF BIRTH RELATIONSHIP

3. GANE CADIENTE 09-07-1963 FATHER

4. FEDERITA CADIENTE 09-25-1965 MOTHER

3.

4.
(Please use additional Sheet if necessary)

I hereby certify that the above information are true and correct to the best of my knowledge. I understand that for the DILG to carry out its
mandate they must necessarily process my personal information. Therefore, I grant my consent and recognize the authority of the DILG to
process my personal information, pursuant to the Philippine Data Privacy Act of 2012.

HANNAH JANE P. CADIENTE

(Signature over Printed Name) (Date Accomplished)

Verified and validated by:
 AVA SHERYL T. CATAPUSAN-TAN

CD/CLGOO/MLGOO Date
(Signature over Printed Name)
ANNEX “A”
BOIS Form Revised 2022

Republic of the Philippines

Department of the Interior and Local Government 1X1
DILG-NAPOLCOM Center, EDSA corner Quezon Avenue, Quezon City
ID Picture
BARANGAY OFFICIAL’S INFORMATION SHEET
REGION : VII CITY/MUN : MANJUYOD

PROVINCE : NEGROS ORIENTAL BARANGAY : SACSAC

ELECTIVE AND APPOINTIVE POSITION

Punong Barangay Barangay Treasurer
Sangguniang Barangay Member Barangay Secretary
Rank (1, 2, 3, 4, 5, 6, 7) SK Treasurer
SK Chairperson SK Secretary
SK Member (Rank 1, 2, 3, 4, 5, 6, 7) IPMR
Relationship with the Appointing Authority: __________________

TERM IN THE PRESENT POSITION: Other Appointive Barangay Official:

st nd rd
1 2 3 ___________________________________

PERSONAL INFORMATION
2613-9253-8578-4182
(PhilSys Card No.)

MARTINEZ MARK KEVIN GUIMARAS

(Last Name) (Suffix e.g. Jr., I, II, III) (First Name) (Middle Name)

01-18-2001 DUMAGUETE CITY NEG. OR. M S WORD OF LIFE

(Birth Date: mm/dd/yyyy) (Birth Place) (Sex) (Civil Status) (Religion)

BRGY. SACSAC, MANJUYOD NEGROS ORIENTAL NONE

(Residence Address) (Residence Telephone No.)

0931-913-5228 NONE martinezmarkkevin44@gmail.com

(Mobile Number) (Barangay Hall Telephone Number) (E-mail Address)

HIGHEST EDUCATIONAL ATTAINMENT: ELEMENTARY HIGH SCHOOL COLLEGE POST GRAD VOCATIONAL

Please specify: Graduate Under Graduate

OCCUPATION: NONE HONORARIUM: P5,367.00

BENEFICIARIES: (optional for the other appointive barangay officials)
NAME DATE OF BIRTH RELATIONSHIP

1 OLIVER MARTINEZ 10-30-1979 FATHER

2. JASMIN MARTINEZ 11-14-1978 MOTHER

3.

4.
(Please use additional Sheet if necessary)

I hereby certify that the above information are true and correct to the best of my knowledge. I understand that for the DILG to carry out its
mandate they must necessarily process my personal information. Therefore, I grant my consent and recognize the authority of the DILG to
process my personal information, pursuant to the Philippine Data Privacy Act of 2012.

MARK KEVIN G. MARTINEZ

(Signature over Printed Name) (Date Accomplished)

Verified and validated by:
 AVA SHERYL T. CATAPUSAN-TAN

CD/CLGOO/MLGOO Date
(Signature over Printed Name)
ANNEX “A”
BOIS Form Revised 2022

Republic of the Philippines

Department of the Interior and Local Government 1X1
DILG-NAPOLCOM Center, EDSA corner Quezon Avenue, Quezon City
ID Picture
BARANGAY OFFICIAL’S INFORMATION SHEET
REGION : VII CITY/MUN : MANJUYOD

PROVINCE : NEGROS ORIENTAL BARANGAY : SACSAC

ELECTIVE AND APPOINTIVE POSITION

Punong Barangay Barangay Treasurer
Sangguniang Barangay Member Barangay Secretary
Rank (1, 2, 3, 4, 5, 6, 7) SK Treasurer
SK Chairperson SK Secretary
SK Member (Rank 1, 2, 3, 4, 5, 6, 7) IPMR
Relationship with the Appointing Authority: __________________

TERM IN THE PRESENT POSITION: Other Appointive Barangay Official:

st nd rd
1 2 3 ___________________________________

PERSONAL INFORMATION

(PhilSys Card No.)

JANDOG JENNIFER BALDOZ

(Last Name) (Suffix e.g. Jr., I, II, III) (First Name) (Middle Name)

12-05-2001 BINDOY NEG. OR. F M FOUR SQUARE

(Birth Date: mm/dd/yyyy) (Birth Place) (Sex) (Civil Status) (Religion)

BRGY. SACSAC, MANJUYOD NEGROS ORIENTAL NONE

(Residence Address) (Residence Telephone No.)

NONE NONE jenniferbaldoz635@gmail.com

(Mobile Number) (Barangay Hall Telephone Number) (E-mail Address)

HIGHEST EDUCATIONAL ATTAINMENT: ELEMENTARY HIGH SCHOOL COLLEGE POST GRAD VOCATIONAL

Please specify: Graduate Under Graduate

OCCUPATION: HOUSEWIFE HONORARIUM: P530.00

BENEFICIARIES: (optional for the other appointive barangay officials)
NAME DATE OF BIRTH RELATIONSHIP

1. RAYMOND JANDOG 10-14-2002 HUSBAND

2. KATHLYN JANDOG 05-16-2023 DAUGHTER

3.

4.
(Please use additional Sheet if necessary)

I hereby certify that the above information are true and correct to the best of my knowledge. I understand that for the DILG to carry out its
mandate they must necessarily process my personal information. Therefore, I grant my consent and recognize the authority of the DILG to
process my personal information, pursuant to the Philippine Data Privacy Act of 2012.

JENNIFER B. JANDOG

(Signature over Printed Name) (Date Accomplished)

Verified and validated by:
 AVA SHERYL T. CATAPUSAN-TAN

CD/CLGOO/MLGOO Date
(Signature over Printed Name)
ANNEX “A”
BOIS Form Revised 2022

Republic of the Philippines

Department of the Interior and Local Government 1X1
DILG-NAPOLCOM Center, EDSA corner Quezon Avenue, Quezon City
ID Picture
BARANGAY OFFICIAL’S INFORMATION SHEET
REGION : VII CITY/MUN : MANJUYOD

PROVINCE : NEGROS ORIENTAL BARANGAY : SACSAC

ELECTIVE AND APPOINTIVE POSITION

Punong Barangay Barangay Treasurer
Sangguniang Barangay Member Barangay Secretary
Rank (1, 2, 3, 4, 5, 6, 7) SK Treasurer
SK Chairperson SK Secretary
SK Member (Rank 1, 2, 3, 4, 5, 6, 7) IPMR
Relationship with the Appointing Authority: __________________

TERM IN THE PRESENT POSITION: Other Appointive Barangay Official:

st nd rd
1 2 3 ___________________________________

PERSONAL INFORMATION

(PhilSys Card No.)

GARSULA LILIBEN CALIDGUID

(Last Name) (Suffix e.g. Jr., I, II, III) (First Name) (Middle Name)

10-091999 BAIS CITY NEG. OR. F S ROMAN CATHOLIC

(Birth Date: mm/dd/yyyy) (Birth Place) (Sex) (Civil Status) (Religion)

BRGY. SACSAC, MANJUYOD NEGROS ORIENTAL NONE

(Residence Address) (Residence Telephone No.)

0975-465-5612 NONE lilibengarsula2@gmail.com

(Mobile Number) (Barangay Hall Telephone Number) (E-mail Address)

HIGHEST EDUCATIONAL ATTAINMENT: ELEMENTARY HIGH SCHOOL COLLEGE POST GRAD VOCATIONAL

Please specify: Graduate Under Graduate

OCCUPATION: NONE HONORARIUM: P530.00

BENEFICIARIES: (optional for the other appointive barangay officials)
NAME DATE OF BIRTH RELATIONSHIP

1. LEVI GARSULA 08-13-1957 FATHER

2. OLBENCITA GARSULA 04-25-1972 MOTHER

3. CRISTY GARSULA 08-31-2008 SISTER

4.
(Please use additional Sheet if necessary)

I hereby certify that the above information are true and correct to the best of my knowledge. I understand that for the DILG to carry out its
mandate they must necessarily process my personal information. Therefore, I grant my consent and recognize the authority of the DILG to
process my personal information, pursuant to the Philippine Data Privacy Act of 2012.

LILIBEN C. GARSULA

(Signature over Printed Name) (Date Accomplished)

Verified and validated by:
AVA SHERYL T. CATAPUSAN-TAN

CD/CLGOO/MLGOO Date
(Signature over Printed Name)