Confidential - Information contained in this document is confidential and shall not be used for prosecution, tax control, or economic penalties. Any failure to answer or any inaccurate answer shall be punished in accordance with Law No. 83/017 of 21st July 1963 relating to the obligation to furnish statistics and the secrecy attached thereto.

A. Province: _
B. Division: _ _
C. Sub-division or district: _ _ _
D. Town or village: _ _ _
E. Quarter of town or locality: _ _
F. Enumeration area No.: _ _ _
G. Structure No.: _ _ _
H. Household No.: _ _

Total number of questionnaires used in this household _
Questionnaire No. _