ANI AT KITA RSBSA ENROLLMENT FORM - Department of …

1 2x2 PICTUREPHOTO TAKENWITHIN 6 MONTHS Reference/Control No.: PART I: PERSONAL INFORMATIONSURNAMEMIDDLE NAMEFIRST NAMEEXTENSION NAMEMIDDLE NAMEEXTENSION NAMESURNAMEFIRST NAMEADDRESSHOUSE/LOT/BLDG. CONTACT NUMBER:PERSON WITH DISABILITY (PWD): Y es NoMOTHER SMAIDEN NAME: PLACE OF BIRTH: DATE OF BIRTH: CIVIL STATUS:RELIGION:NAME OF SPOUSEIF MARRIED: Single Married Widowed Separated HIGHEST FORMAL EDUCATION: None Elementary High School Post Graduate V ocational College HOUSEHOLD HEAD? Y es No If no, name of household head: Relationship:No.

2 Of living household members:No. of male:No. of female:Specify ID number if yes: Member of an Indigenous Group? Y es No 4P s Beneficiary? Y es No If yes, specify:If yes, specify:With Government ID? Y es NoMember of any Farmers Association/Cooperative? Y es No PART II: FARM PROFILEMAIN LIVELIHOOD FARMER FARMWORKER/LABORER FISHERFOLK For farmers: Type of Far ming Activity Rice Corn Other crops,please specify: Livestock,please specify: P oultry,please specify: For farmworkers:For fisherfolk: Kind of Work Land Preparation Planting/Transplanting Cultivation Harvesting Others, please specify: T ype of Fishing Activity Fish Capture AquacultureGleaning Fish ProcessingFish Vending Others, please specify: Gross Annual Income Last Year: Far ming: Non-farming.

3 The Lending Conduit shall coordinate with the Bureau ofFisheries and Aquatic Resources (BFAR) in the issuance ofa certification that the fisherfolk-borrower under PUNLA/PLEA is registered under the Municipal FisherfolkRegistration (FishR). RSBSA ENROLLMENT form ANI AT KITAR eference/Control No.:REGISTRY SYSTEM FOR BASIC SECTORS IN AGRICULTURE ( RSBSA ) ENROLLMENT : New ExistingSEX: Male FemaleRegistry System for Basic Sectors in Agriculture ( RSBSA ) ENROLLMENT CLIENT S COPYTHIS form IS NOT FOR SALEREVISED VERSION: 09-2019 CONTACT NUMBER:PERSON TO NOTIFY INCASE OF EMERGENCY:FARMPARCEL LAND DESCRIPTIONSIZE (ha)NO.

4 OFHEAD(For Livestockand Poultry)FARM TYPE**ORGANICPRACTITIONER(Y/N)CROP/COMMO DITY(Rice/Corn/HVC/Livestock/Poultry/Agr i-fishery)For Livestock & Poultry(specify type of animal)SIGNATURE ABOVE PRINTED NAME / DATECITY/MUNICIPAL AGRICULTURE OFFICESIGNATURE ABOVE PRINTED NAME / DATECAFC/MAFC CHAIRMANSIGNATURE ABOVE PRINTED NAME / DATEBARANGAY CHAIRMANDATE VERIFIED TRUE AND CORRECT BY:THUMBMARKSIGNATURE OF APPLICANTPRINTED NAME OF APPLICANTVERIFIED TRUE AND CORRECT BY:THIS form IS NOT FOR SALESIGNATURE ABOVE PRINTED NAME / DATECITY/MUNICIPAL AGRICULTURE OFFICESIGNATURE ABOVE PRINTED NAME / DATECAFC/MAFC CHAIRMANSIGNATURE ABOVE PRINTED NAME / DATEBARANGAY CHAIRMAN 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 Sector s in Agriculture ( RSBSA ) and other legitimate inter ests of the Department pursuant to its mandates.

5 The collection of personal information is for documentation, planning, reporting and processing purposes in availing agricultural related interventions. Processed data 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 Data 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>.

6 DATA PRIVACY POLICYOWNERSHIP DOCUMENT *FARM TYPE **1. Certificate of Land Transfer2. Emancipation Patent3. Individual Certificate of Land Ownership Award (CLOA)4. Collective CLOA5. Co-ownership CLOA6. Agricultural sales patent7. homestead patent8. Free Patent9. Certificate of Title or Regular Title10. Certificate of Ancestral Domain Title11. Certificate of Ancestral Land Title12. Tax Declaration1 - Irrigated2 - Rainfed Upland3 - Rainfed Lowland(NOTE: not applicable to agri-fishery)Location (Barangay & Municipality):Total Farm Area: _____ha*Ownership Document No: _____Registered Owner Others: Tenant(Name of Land Owner: ) Lessee(Name of Land Owner: ) No.

7 Of Far m Par cels:Agrarian Reform Beneficiary (ARB): Y es No2 Location (Barangay & Municipality):Total Farm Area: _____ha*Ownership Document No: _____Registered Owner Others: Tenant(Name of Land Owner: ) Lessee(Name of Land Owner: ) 3 Location (Barangay & Municipality):Total Farm Area: _____ha*Ownership Document No: _____Registered Owner Others: Tenant(Name of Land Owner: ) Lessee(Name of Land Owner: )