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[Municipality/City]
[Province]
RBI FORM A

RECORD OF BARANGAY INHABITANTS BY HOUSEHOLD

A. REGION PSG
C
B. PROVINCE O
D
C. CITY/MUNICIPALITY E
S
D. BARANGAY
E. HOUSEHOLD
DATE ACCOMPLISHED:

NAME (1) ADDRESS (2)

NAME OF DATE OF CITIZEN-

SUBDIVISION/ZONE/ PLACE OF BIRTH SEX CIVIL OCCUPATION
LAST NAME FIRST NAME MIDDLE NAME EXT NO. STREET NAME BIRTH SHIP
SITIO/PUROK (if (3) (5) STATUS (6) (8)
(1.1) (1.2) (1.3) (1.4) (2.1) (2.2) (4) (7)
applicable)
(2.3)

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)