Republic of the Philippines

Municipality of Daraga
BARANGAY BINITAYAN

HOUSEHOLD PROFILE

Date of Interview:
✘
I. DEMOGRAPHIC DATA
Surname First Name: Middle Name: Ext. (Sr., Jr.)
HEAD OF FAMILY
.
Date of Birth: Sex: Female
Contact No.: Gender: Female LGBTQIA+

Religion: Nationality: FILIPINO

Permanent Address: Temporary Addre
Si Common-Law Widowed Type of Living Shared Rent
Civil Status: (Check)
S Arrangement: Institutionalized
Primar
Secondary Vocational House Structure Concrete
y
Highest Educational Attainment: Te Toilet Facility Owned Shared
No Educational Attainment
Occupation: (Specify the type of employment)
Monthly Income:
PhilHealth Membership Number Direct Contributor
(PIN): Indirect Contributor

FAMILY COMPOSITION

Name - Relationship to Educational Occupation (Specify the type Monthly

Age Civil Status of employment ie. Permanent, JO, Self-
last name, first name, middle name- Patient Attainment employed) Income

. . . . -
. . . . -

Other Sources of Income:

(Specify below) Total Household
Per Capital Income: -
Income:
IN LAW
II. SOCIO ECONOMIC CLASSIFICATION
Financially Capable/ C 1. Artisanal Fishfolk
Main Classification Financially Incapable/ Inc 2. Farmer and Landless Rural Worker
Indigent (2,891 & belo 3. Urban Poor
4. IndIgenous Peoples
Listahanan 5. Senior Citizen
Membership 6. Formal Labor and Migrant Workers
to
Other NGOs ben 7. Workers in Informal Sector
Marginalized
8. PWD
DSWD assistance Others, please specify Sector
9. Solo Parent
10. Pregnant Women
11. ERPAT
12. Pala-Pala
Others: (Specify)
Estim
III. MONTHLY EXPENSES ated
Estimated Light Source Fuel Source Water Source
Month
Particulars Monthly Cost
ly Electric Gas Deep well
(Php)
House & Lot Cost - - Public
(Php)
Food & Water Kerosene Fire Wood Private
Education - - Water District
Clothing Candle Charcoal Commercial
Transportation - - - Residential
TOTAL: #VALUE!
Name of Pets kind / color leased/stray

VEHICLE/S:
Model Color Kind Plate Number

I swear under the penalty of perjury that all information written above are true and correct and in my
own free will.
Conforme:
_______
NAME AND SIGNATURE OF DECALARANT: NAME AND SIGNATURE OF INTERVIEWER