INDIVIDUAL RECORD OF BARANGAY INHABITANTS

Region __ __ __ __ __ __ __ __ __ HOUSEHOLD NUMBER(HN)___________

Barangay __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

PERSONAL INFORMATION
Last Name __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
First Name __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
Middle Name __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
Address __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

Date of Birth __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

Sex: Male Female

Civil Status Single Married Separated Widow/er

Occupation __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
Citizenship __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

Relationship to Household Head __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

I hereby certify that the above information are true and correct to the best of my knowledge.

_________________________________________________
Name/Signature of Person Accomplishing this Form

_________________________
Date Accomplished

Attested by:
Left Right

( In case inhabitant is unable to read and write)

ALEXANDER V. RUIZ
Barangay Secretary
Note: The HN shall be filled up by the Barangay Secretary