REVISED VERSION: 09-2019 ANI AT KITA 2x2 PICTURE RSBSA ENROLLMENT FORM REGISTRY SYSTEM FOR BASIC SECTORS IN AGRICULTURE (RSBSA) □ New ENROLLMENT: PHOTO TAKEN WITHIN 6 MONTHS □ Existing Reference/Control No.: PART I: PERSONAL INFORMATION SURNAME FIRST NAME MIDDLE NAME □ Male SEX: EXTENSION NAME □ Female ADDRESS HOUSE/LOT/BLDG. NO. STREET/SITIO/SUBDV. BARANGAY MUNICIPALITY/CITY PROVINCE REGION HIGHEST FORMAL EDUCATION: CONTACT NUMBER: PLACE OF BIRTH: DATE OF BIRTH: RELIGION: CIVIL STATUS: NAME OF SPOUSE IF MARRIED: □ Single □ Widowed □ Married □ Separated □ None □ Elementary □ High School □ Vocational □ College □ Post Graduate PERSON WITH DISABILITY (PWD): □ Yes □ No 4P’s Beneficiary? □ Yes □ Yes □ No □ No Member of an Indigenous Group? If yes, specify: □ Yes With Government ID? MOTHER’S MAIDEN NAME: HOUSEHOLD HEAD? □ Yes □ No Specify ID number if yes: □ No Member of any Farmers Association/Cooperative? If no, name of household head: □ Yes □ No If yes, specify: Relationship: PERSON TO NOTIFY IN CASE OF EMERGENCY: No. of living household members: No. of male: CONTACT NUMBER: No. of female: PART II: FARM PROFILE □ MAIN LIVELIHOOD □ FARMER For farmers: Kind of Work □ Rice □ Land Preparation □ Planting/Transplanting □ Cultivation □ Harvesting □ Others, please specify: □ Corn □ Other crops, please specify: □ Livestock, please specify: The Lending Conduit shall coordinate with the Bureau of Fisheries and Aquatic Resources (BFAR) in the issuance of a certification that the fisherfolk-borrower under PUNLA/ PLEA is registered under the Municipal Fisherfolk Registration (FishR). Type of Fishing Activity □ Fish Processing □ Fish Capture □ Aquaculture □ Fish Vending □ Gleaning □ Others, please specify: Poultry, please specify: Gross Annual Income Last Year: FISHERFOLK For fisherfolk: For farmworkers: Type of Farming Activity □ □ FARMWORKER/LABORER Farming: Non-farming: Registry System for Basic Sectors in Agriculture (RSBSA) ENROLLMENT CLIENT’S COPY Reference/Control No.: SURNAME MIDDLE NAME FIRST NAME EXTENSION NAME THIS FORM IS NOT FOR SALE No. of Farm Parcels: FARM PARCEL NO. □ Yes Agrarian Reform Beneficiary (ARB): CROP/COMMODITY (Rice/Corn/HVC/ Livestock/Poultry/ Agri-fishery) FARM LAND DESCRIPTION SIZE (ha) For Livestock & Poultry (specify type of animal) NO. OF HEAD (For Livestock and Poultry) □ No FARM TYPE ** ORGANIC PRACTITIONER (Y/N) Location (Barangay & Municipality): Total Farm Area: ___________________ha 1 *Ownership Document No: _______________ □ □ Registered Owner Tenant (Name of Land Owner: □ ) □ Lessee (Name of Land Owner: ) Others: Location (Barangay & Municipality): Total Farm Area: ___________________ha 2 *Ownership Document No: _______________ □ □ Registered Owner Tenant (Name of Land Owner: □ ) □ Lessee (Name of Land Owner: ) Others: Location (Barangay & Municipality): Total Farm Area: ___________________ha 3 *Ownership Document No: _______________ □ □ Registered Owner Tenant (Name of Land Owner: □ ) □ Lessee (Name of Land Owner: ) Others: OWNERSHIP DOCUMENT * 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. Certificate of Land Transfer Emancipation Patent Individual Certificate of Land Ownership Award (CLOA) Collective CLOA Co-ownership CLOA Agricultural sales patent Homestead patent Free Patent Certificate of Title or Regular Title Certificate of Ancestral Domain Title Certificate of Ancestral Land Title Tax Declaration FARM TYPE ** 1 - Irrigated 2 - Rainfed Upland 3 - Rainfed Lowland (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 BARANGAY CHAIRMAN SIGNATURE ABOVE PRINTED NAME / DATE CITY/MUNICIPAL AGRICULTURE OFFICE SIGNATURE ABOVE PRINTED NAME / DATE 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 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>. THIS FORM IS NOT FOR SALE VERIFIED TRUE AND CORRECT BY: SIGNATURE ABOVE PRINTED NAME / DATE BARANGAY CHAIRMAN SIGNATURE ABOVE PRINTED NAME / DATE CITY/MUNICIPAL AGRICULTURE OFFICE SIGNATURE ABOVE PRINTED NAME / DATE CAFC/MAFC CHAIRMAN