RBI FORM A

RECORD OF BARANGAY INHABITANTS BY HOUSEHOLD

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

NAME OF DATE OF CIVIL

LAST NAME FIRST NAME MIDDLE NAME EXT. SITIO/PUROK/ADDRESS PLACE OF BIRTH SEX STATUS CITIZENS OCCUPATION
BIRTH HIP

Prepared by: Certified Correct: Validated by:

________________________________ ___________________________ _______________________________

Barangay Health Worker Barangay Secretary Punong Barangay
(Signature over Printed Name) (Signature over Printed Name) (Signature over Printed Name)