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:

PLACE OF DATE OF CIVIL CITIZENS

NAME (1) ADDRESS (2) SEX OCCUPATION
BIRTH BIRTH STATUS HIP
NAME OF
LAST NAME FIRST NAME MIDDLE NAME EXT NO. STREET NAME SUBD/SITIO/PUR
OK (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)