REVISED VERSION: 09-2019

ANI AT KITA CERTIFIED BY

2x2
RSBSA ENROLLMENT FORM DATE
PICTURE
REGISTRY SYSTEM FOR BASIC SECTORS IN AGRICULTURE (RSBSA)

PHOTO TAKEN
ENROLLMENT: New Existing WITHIN 6 MONTHS

Reference/Control No.:

PART I: PERSONAL INFORMATION

SURNAME FIRST NAME

MIDDLE NAME EXTENSION NAME SEX: Male Female

ADDRESS
HOUSE/LOT/BLDG. NO. STREET/SITIO/SUBDV. BARANGAY

MUNICIPALITY/CITY PROVINCE REGION

CONTACT NUMBER: HIGHEST FORMAL EDUCATION:

None Elementary High School

DATE OF BIRTH: PLACE OF BIRTH:
Vocational College Post Graduate
M M D D Y Y Y Y
PERSON WITH DISABILITY (PWD): Yes No
RELIGION:
4P’s Beneficiary? Yes No
CIVIL STATUS: Single Married
Widowed Separated
Member of an Indigenous Group? Yes No
NAME OF SPOUSE If yes, specify:
IF MARRIED:

MOTHER’S
With Government ID? Yes No
MAIDEN NAME:
Specify ID number if yes:
HOUSEHOLD HEAD? Yes No Member of any Farmers Association/Cooperative? Yes No
If no, name of household head:
If yes, specify:
Relationship:
PERSON TO NOTIFY IN
CASE OF EMERGENCY:
No. of living household members:

No. of male: No. of female: CONTACT NUMBER:

PART II: FARM PROFILE

MAIN LIVELIHOOD FARMER FARMWORKER/LABORER FISHERFOLK

For farmers: For farmworkers: For fisherfolk:

Type of Farming Activity The Lending Conduit shall coordinate with the Bureau of
Kind of Work
Fisheries and Aquatic Resources (BFAR) in the issuance of
Rice a certification that the fisherfolk-borrower under PUNLA/
Land Preparation PLEA is registered under the Municipal Fisherfolk
Registration (FishR)
Corn Planting/Transplanting
Type of Fishing Activity
Other crops, Cultivation Fish Capture Fish Processing
please specify:
Harvesting Aquaculture Fish Vending
Livestock, Gleaning
please specify: Others, please specify:
Others, please specify:
Poultry,
please specify:

Gross Annual Income Last Year: Farming: Non-farming:


Registry System for Basic Sectors in Agriculture (RSBSA)
ENROLLMENT CLIENT’S COPY CERTIFIED BY

DATE
Reference/Control No.:

SURNAME FIRST NAME

MIDDLE NAME EXTENSION NAME

THIS FORM IS NOT FOR SALE

 No. of Farm Parcels: Agrarian Reform Beneficiary (ARB): Yes No
CROP/COMMODITY
(Rice/Corn/HVC/ NO. OF
FARM Livestock/Poultry/ HEAD ORGANIC
FARM TYPE
PARCEL FARM LAND DESCRIPTION Agri-fishery) SIZE (ha) (For Livestock PRACTITIONER
**
NO. and Poultry) (Y/N)
For Livestock & Poultry
(specify type of animal)

Location (Barangay & Municipality):

Total Farm Area: ___________________ha

*Ownership Document No: _______________

1
Registered Owner Others: ________________________________
Tenant
(Name of Land Owner: ___________________________________________________ )
Lessee
(Name of Land Owner: ___________________________________________________ )

Location (Barangay & Municipality):

Total Farm Area: ___________________ha

*Ownership Document No: _______________

2
Registered Owner Others: ________________________________
Tenant
(Name of Land Owner: ___________________________________________________ )
Lessee
(Name of Land Owner: ___________________________________________________ )

Location (Barangay & Municipality):

Total Farm Area: ___________________ha

*Ownership Document No: _______________

3
Registered Owner Others: ________________________________
Tenant
(Name of Land Owner: ___________________________________________________ )
Lessee
(Name of Land Owner: ___________________________________________________ )

OWNERSHIP DOCUMENT * 6. Agricultural sales patent FARM TYPE **

1. Certificate of Land Transfer 7. Homestead patent
1 - Irrigated
2. Emancipation Patent 8. Free Patent
3. Individual Certificate of Land 9. Certificate of Title or Regular Title 2 - Rainfed Upland
Ownership Award (CLOA) 10. Certificate of Ancestral Domain Title 3 - Rainfed Lowland
4. Collective CLOA 11. Certificate of Ancestral Land Title
5. Co-ownership CLOA 12. Tax Declaration (NOTE: not applicable to agri-fishery)

I hereby declare that all information indicated above are true and correct, and that they may be used by Department of Agriculture for the purposes of
registration to the Registry System for Basic Sectors in Agriculture (RSBSA) and other legitimate interests of the Department pursuant to its mandates.

DATE PRINTED NAME OF APPLICANT SIGNATURE OF APPLICANT THUMBMARK

VERIFIED TRUE AND CORRECT BY:

SIGNATURE ABOVE PRINTED NAME / DATE SIGNATURE ABOVE PRINTED NAME / DATE SIGNATURE ABOVE PRINTED NAME / DATE
BARANGAY CHAIRMAN CITY/MUNICIPAL AGRICULTURE OFFICE CAFC/MAFC CHAIRMAN
DATA PRIVACY POLICY
The collection of personal information is for documentation, planning, reporting and processing purposes in availing agricultural related interventions.
Processed date shall only be shared to partner agencies for planning, reporting and other use in accordance to the mandate of the agency. This is in
compliance with the Date Sharing Policy of the department.
You have the right to ask for a copy of your personal data that we hold about you as well as to ask for it to be corrected if you think it is wrong. To
do so, please contact <Contact Person and Contact Details>.

THIS FORM IS NOT FOR SALE

VERIFIED TRUE AND CORRECT BY:

SIGNATURE ABOVE PRINTED NAME / DATE SIGNATURE ABOVE PRINTED NAME / DATE SIGNATURE ABOVE PRINTED NAME / DATE
BARANGAY CHAIRMAN CITY/MUNICIPAL AGRICULTURE OFFICE CAFC/MAFC CHAIRMAN