District: ____ Code: _ _ _
County/Municipality: ____ Code: _
Sub county/Division/Town council: ____ Code: _ _
Parish/Ward: ____ Code: _ _
LC1: ____ Code: _ _
EA: ____ Code: _ _
Enumerator's name: ____ Enumerator code: _ _ _
Enumerator's signature: ____
Date (dd/mm/yyyy): _ _/_ _/_ _ _ _
Parish supervisor's name: ____ Parish supervisor's code: _ _ _
Parish supervisor's signature: ____
Date (dd/mm/yyyy): _ _/_ _/_ _ _ _
Number of books used: Book _ of _ (exclude spoilt and unused books)