DISTRICT:

BARANGAY:

ELECTED BARANGAY OFFICIALS SEX ASSIGNED AT BIRTH

STATUS (PLEASE MARK X YOUR GENDER (PLEASE MARK X YOUR PREFERENCE) Please indicate
# NAME POSITION AGE CONTACT NUMBER PREFERENCE) HETEROSEXU TRANSGEND if Senior or RELIGION T SHIRT SIZE
NEWLY ELECTED RE-ELECTED MALE FEMALE GAY LESBIAN OTHERS PWD
AL/ STRAIGHT ER
1 PUNONG BARANGAY
2 BARANGAY KAGAWAD
3 BARANGAY KAGAWAD
4 BARANGAY KAGAWAD
5 BARANGAY KAGAWAD
6 BARANGAY KAGAWAD
7 BARANGAY KAGAWAD
8 BARANGAY KAGAWAD
9 SK CHAIRPERSON
10 SK KAGAWAD
11 SK KAGAWAD
12 SK KAGAWAD
13 SK KAGAWAD
14 SK KAGAWAD
15 SK KAGAWAD
16 SK KAGAWAD

DISTRICT:
BARANGAY:

APPOINTED BARANGAY PERSONNEL: (All barangay personnel should be included in the list) SEX ASSIGNED AT BIRTH
STATUS (PLEASE MARK X YOUR GENDER (PLEASE MARK X YOUR PREFERENCE) Please indicate
# NAME POSITION AGE CONTACT NUMBER PREFERENCE) HETEROSEXU TRANSGEND if Senior or RELIGION T SHIRT SIZE
NEWLY APPOINTEDRE-APPOINTED MALE FEMALE GAY LESBIAN OTHERS PWD
AL/ STRAIGHT ER
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
 DISTRICT:
BARANGAY:

ELECTED BARANGAY OFFICIALS WITH OTHER INSURANCE SPONSORED BY THE

SSS MEMBER
BARANGAY
# NAME POSITION (PLEASE MARK X YOUR PREFERENCE) SSS NUMBER INSURANCE COMPANY/PROVIDER
YES NO (IF SSS MEMBER) (COCOLIFE
YES NOT INCLUDED)
NO
1 PUNONG BARANGAY
2 BARANGAY KAGAWAD
3 BARANGAY KAGAWAD
4 BARANGAY KAGAWAD
5 BARANGAY KAGAWAD
6 BARANGAY KAGAWAD
7 BARANGAY KAGAWAD
8 BARANGAY KAGAWAD
9 SK CHAIRPERSON
10 SK KAGAWAD
11 SK KAGAWAD
12 SK KAGAWAD
13 SK KAGAWAD
14 SK KAGAWAD
15 SK KAGAWAD
16 SK KAGAWAD

DISTRICT:
BARANGAY:

APPOINTED BARANGAY PERSONNEL: (All barangay personnel should be included in the list) WITH OTHER INSURANCE SPONSORED BY THE
SSS MEMBER
BARANGAY
# NAME POSITION (PLEASE MARK X YOUR PREFERENCE) SSS NUMBER INSURANCE COMPANY/PROVIDER
YES NO (IF SSS MEMBER) (COCOLIFE
YES NOT INCLUDED)
NO
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20