PREFECTURE (ADMINISTRATIVE CENTER) __________

TOWN OR MUNICIPALITY__________

SECTOR____

SUB-SECTOR___

HOUSEHOLD NUMBER____

NAME OF LOCALITY_____

NAME OF HEAD OF HOUSEHOLD_____

PREFECTURE (ADMINISTRATIVE CENTER)_______

TOWN OR MUNICIPALITY______

SECTOR_____

SUB-SECTOR_____

HOUSEHOLD NUMBER______

NAME OF LOCALITY _____
NAME OF HOUSEHOLD HEAD ______
PROVINCE ______
DISTRICT _____
SECTOR _____
CLUSTER NUMBER _____
STRUCTURE NUMBER _____
HOUSEHOLD NUMBER _____