SOCIO-ECONOMIC PROFILE FORM FOR DDOSP APPLICANT

Name of Applicant:_____________________________________________ Control No: ________________

Address: ________________________________________ Sex: _________ Contact No: ________________

Age: ______ Course: ________________________ School: _______________________________________

A. EDUCATION
1. How many are you in the household?

Kindly fill-out the necessary information needed corresponding to the number in the household. (Start with the head of the family first down to the youngest member of the household.)

No. Full Name Age Civil Status Highest Educational School Type (Public/Private) Status Salary Range for Working
(Working/Studying)
Attainment Siblings

1.

2.

3.

4.

5.

6.

7.

B. INCOME
Father’s Occupation: ____ Mother’s Occupation: ______

Annual Income Range Annual Income Range

P 129,999 and below P 129,999 and below

P 130,000 – P 179,999 P 130,000 – P 179,999

P 180,000 – P 229,999 P 180,000 – P 229,999

P 230,000 – P 279,999 P 230,000 – P 279,999

P 280,000 – P 329,999 P 280,000 – P 329,999

P 330,000 and above P 330,000 and above

C. HOUSING CHARACTERISTICS (Please check.)

1. Type of building occupied by your household: ________ P1,101 and above
________ a. single house (bungalow, nipa hut, two-storey, barong-barong) 7. Have water source? ________ Yes ________ No
________ b. duplex 8. Type of fuel household used for cooking:
________ c. apartment / rowhouse ________ a. Electricity
________ d. condominium / condotel ________ b. Kerosene
________ e. relocation area / housing ________ c. LPG
2. Number of Bedrooms: ________ ________ d. Charcoal
3. Main construction material of the roof: ________ e. Wood
________ a. Galvanized iron / aluminum ________ f. Palay husk / wood shavings
________ b. Concrete / clay tile 9. Presence of household conveniences / information & communications technology (ICT) devices /
________ c. Half-galvanized iron & half concrete vehicles (If present, kindly specify number)
________ d. Wood / bamboo A. Household Conveniences
________ e. Cogon / nipa / anahaw ________ Refrigerator/freezer
________ f. Asbestos ________ Stove with Oven/Gas Range
________ g. Makeshift / salvaged / improvised material ________ Induction Cooker
4. Construction materials of the outer walls ________ Air Fryer
________ a. Concrete/brick/stone ________ Microwave Oven
________ b. Wood ________ Washing machine
________ c. Half concrete/brick/stone & half wood ________ Air conditioner
________ d. Galvanized iron / aluminum ________ Electric fan & other cooling equipment
________ e. Bamboo/cogon/nipa B. ICT Devices
________ f. Glass ________ Radio/radio cassette (AM, FM & Transistor)
________ g. Makeshift / salvaged / improvised material ________ Television
________ h. Concrete hollow blocks ________ CD/DVD/VCD Player
5. Materials of the floor of the housing unit ________ Audio component/stereo set/karaoke/videoke
________ a. Ceramic tile/marble/granite ________ Landline/wireless telephone
________ b. Cement/brick/stone ________ Cellular phone
________ c. Wood plank ________ Tablet
________ d. Wood tile ________ Personal computer (desktop, laptop, notebook, netbook & others)
________ e. Vinyl/carpet tile C. Vehicles
________ f. Linoleum ________ car
________ g. None ________ jeep
6. Have electricity? ________ Yes ________ No ________ motor cycle / motor scooter
Monthly Billing Range: ________ tricycl
________ Below P300 ________ pedicab
________ P301 to P500 ________ van
________ P501 to P700 ________ truck
________ P701 to P900 ________ bicycle
________ P901 to P1,100 ________ boat (M/N

Source: CBMS of PSA

10. List down ownership of livestock, herds, poultry & other farm animals: _________________________________________

Insert photo of the house (outside)

Insert photo of the house (inside)

Remarks :

Name and signature of validator :

Date :
Source: CBMS of PSA