RBI FORM A

RECORD OF BARANGAY INHABITANTS BY HOUSEHOLD

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

NAME (1) ADDRESS

(2) PLACE OF DATE OF CIVIL CITIZENS
NAME OF BIRTH BIRTH SEX STATUS HIP OCCUPATION
SUBD/SITIO/PU
LAST NAME FIRST NAME MIDDLE NAME EXT NO. STREET NAME
ROK (If Applicable)
(1.1) (1.2) (1.3) (1.4) (2.1) (2.2) (2.3) (3) (4) (5) (6) (7) (8)

Prepared by: Certified Correct: Validated by:

Name of Household Head/Member Barangay Secretary Punong Barangay

(Signature Over Printed Name) (Signature Over Printed Name) (Signature Over Printed
Name)