Environmental and Social Management Framework Attachment 3a & 3b for Support to Parcelization of Lands to Individual Titling (SPLIT) Project

of Department of Agrarian Reform

Sequence No. : CCLOA OCT/TCT NO. : CCLOA Number (SN) :

CCLOA Registration Date: Location:
ASP No. Date ASP Approved KOBO TOOLBOX STATUS

[3a] [3b] [ ] Encoded : (mm/dd/yyyy)

ESMF ATTACHMENT 3a (For ARBs Annotated in the CCLOA) (mm/dd/yyyy)
[3a] [3b] [ ] Finalized :
(mm/dd/yyyy)
(Check the ARB Masterlist if the respondent/interviewee is an ARB per annotated CLOA, otherwise proceed to 3b) (mm/dd/yyyy)
ARB Full Name : CARLOS D. NAPOLES Sex: MALE Civil Status : ____________DOB:
1
Lot # (Actual Tillage): 1
Lot Area of actual tillage (sqm): [ ] Individual [ ] Collective
2
Lot # (Actual Tillage): 2
Lot Area of actual tillage (sqm): [ ] Individual [ ] Collective
3
Lot # (Actual Tillage): 3
Lot Area of actual tillage (sqm): [ ] Individual [ ] Collective
4
Lot # (Actual Tillage): 4
Lot Area of actual tillage (sqm): [ ] Individual [ ] Collective
5
Lot # (Actual Tillage): 5
Lot Area of actual tillage (sqm): [ ] Individual [ ] Collective
ARB Still in possession? (Y/N) : N if “N” Reason for “No”: then proceed to ESMF Form 3B
ESMF ATTACHMENT 3b (For Actual Occupant)
Actual Occupant’s Full Name : CARLOS DE GRACIA NAPOLES Sex: MALE Civil Status : MARRIED
DOB of AO (mm/dd/yyyy):11/30/1974 Mode of Occupancy of AO (Tenurial Status) : BUYER (bought on NOV. 12, 2021)
Common Questions Between ESMF Form 3a and 3b (must be filled out regardless of form used)
Is the ARB/AO a member of any ARB Organization (Y/N)? N Educational Attainment of ARB/AO: HIGH SCHOOL GRADUATE
If Yes, please specify ARB Organization/s (DAR Assisted)
Are there support services from DAR currently being availed or have been availed by the ARB/AO (Y/N)? If Yes, select below (x):
1
Capacity Development 2Credit/Microfinance Assistance 3
Farm Tools/Equipment 4
Farmer Business School 5
Others
Please Specify According to Choice/s Above :

Is the ARB/ Actual Occupant (AO) a member of any ICC/IP Community (Y/N)? N
Is there an issue of overlap in the actual area of tillage/cultivation of the ARB (Y/N)? N
Name of Spouse of ARB/AO (Full Name): GENA A. NAPOLES Sex: FEMALE
Educational Attainment of Spouse of ARB/AO: COLLEGE GRADUATE
Is the Spouse (of ARB/AO) actually tilling the same Collective CLOA Parcel (Y/N)? N
Is the spouse engaged in off-farm/non farm activities (Y/N)? if Yes, Specify activity/work
Total Number of Children: 4 Specify details of Children below (Full Name, Age, Sex [M/F])
1. GENNAL A. NAPOLES / MALE/ 25
2. ABBEY JILL A. NAPOLES/ FEMALE/ 24
3. CARL LOALE A. NAPOLES / MALE/ 22
4.
5.
Are Any Children involve in Farm Activities? (Y/N) N, If Yes, specify Activity :
Are Any Children involve in Off-Farm Activities? (Y/N) , If Yes, specify Activity :

ARB or Actual Occupant’s Household Profile (must be filled out regardless of form used)
Is the ARB or Actual Occupant the head of Household (Y/N)? Y Total Number of Household Members: 2
Are there extended families living within the household (YN)? N If Yes, Total Count:
If Yes, Please specify Affinity :
Are there nursing mothers in the household (Y/N)? N If Yes, How Many?
Are there any senior citizens in the household (Y/N)? N If Yes, How Many?
Are there any single parent in the household (Y/N)? N If Yes, How Many?
Are there any PWD in the household (Y/N)? N If Yes, How Many?
If Yes, Please Specify Type of Disability(ies):
Is there anyone in the household with lingering health condition/illness (Y/N)? N If Yes, How Many?
If Yes, Please specify type of illness/es :
Location of Home (x)?: Within actual tillage orüOutside Actual Tillage, Specify Address: BLK. 3. LOT 12 VETERANS VILLAGE
PANACAN DAVAO CITY
Contact #:09284544083
Indicate the size and describe the Material of the House (Sample: 2 storey, cement, 45 sqm):
1 STOREY WOOD 30 SQM
Source of Power : DAVAO LIGHT Source of Water : DAVAO CITY WATER DESTRICT
Remarks :
1. ON OCTOBER 28, 2021, RAFAEL ONTAO RUFO EXECUTED A “KASABUTAN BAHIN SA PAGBALIGYA UG YUTA” IN FAVOR OF LOVELLA MAE
BERNABE SAKAKI. CARLOS DE GRACIA NAPOLES IS THE REPRESENTATIVE OF LOVELLA MAE BERNABE SAKAKI

Case No. (For with Decision and Finality on Partial Partition or Inclusion) :
As Respondent of the interview, I hereby CERTIFY the correctness of data provided above.
RESPONDENT’S
Respondent’s (ARB/AO) Signature over Full Name : CARLOS DE GRACIA NAPOLES [ ü ] Photo Taken
Date Interviewed: AUGUST 15, 2023 Interviewed by (Full name): NADIN MORGADO
Position : LEGAL OFFICER FVT Number : 7 Team Leader (Full Name): NADIN MORGADO
of Interviewer
Date Submitted/Sent to Kobo (3a) : Date Submitted/Sent to Kobo (3b) :
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