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EVALUACIÓN N°: _________________________
Tipo de Peligro: __________________________ Hora de Ocurrencia estimada:_____________ Fecha del Empadronamiento: ___/___/__
Departamento: ___________________________ Localidad: ______________________________
Número de hoja: de
PARENTESCO
Nro.
Integrante
JEFE (A) DE FAMILIA O PERSONA QUE RESPONDE
(Empadronar al
total de los miembros de la familia)
Nro. de Documento Edad
Jefe(a)
/Esposo(a) / Hijo(a)
AFECTADO
PERDIDO
AFECTADO
PERDIDO
AFECTADO
PERDIDO
AFECTADO
PERDIDO
AFECTADO
PERDIDO
AFECTADO
PERDIDO
AFECTADO
PERDIDO
AFECTADO
PERDIDO
AFECTADO
PERDIDO
AFECTADO
PERDIDO
AFECTADO
PERDIDO
MUNICIPALIDAD PROVINCIAL DE MORROPÓN - CHULUCANAS
Firma y Sello Presidente Asociación / Autoridad
D N I N°___________________
D N I N°___________________ D N I N°___________________
Nombre, Apellidos y Firma del (la) Evaluador(a) EDAN PERÚ Firma y Sello Jefe(a) Oficina de Defensa Civil
Centro Poblado: ___________________________________________
Caserío/: __________________________________________ Anexo: ___________________________________________ Otros: _____________________________
CÓDIGO SINPAD N° __________________
Fecha de Ocurrencia: ________/________/________
Provincia: _____________________________________ Distrito: _________________________________ Hora del Empadronamiento:__________
Barrio/Sector/Urbanización: _________________________________
Calle/Manzana: ____________________________________ Edificio/Piso/Dpto: _________________________________
AVES
(Unidades)
Nro
Vivienda
Composición familiar
(Empadronar a todos los miembros de la familia)
APICULTURA
(Número de
Colmenas)
CAPRINO
(Número de
Cabezas)
VACUNO
(Número de
Cabezas)
OVINO
(Número de
Cabezas)
EQUINO
(Número de
Cabezas)
PORCINO
(Número de
Cabezas)
CULTIVOS
PAN LLEVAR
(Hás)
CULTIVOS
PERMANENTE
(Hás)
CULTIVOS
TRANSITORIOS
(Hás)
CULTIVOS NO
PERMANENTE
(Hás)
I. INFORMACIÓN
VIVIENDA
II. INFORMACIÓN POR FAMILIA III. MEDIOS DE VIDA - GANADERIA
III. MEDIOS DE VIDA - AGRICULTURA
FORMULARIO DE CAMPO 2B: EMPADRONAMIENTO MEDIOS DE VIDA
(Declaración Jurada - Ley 27444 - Ley de Procedimiento Administrativo General)

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2B_EMP. CHULU.pdf

  • 1. EVALUACIÓN N°: _________________________ Tipo de Peligro: __________________________ Hora de Ocurrencia estimada:_____________ Fecha del Empadronamiento: ___/___/__ Departamento: ___________________________ Localidad: ______________________________ Número de hoja: de PARENTESCO Nro. Integrante JEFE (A) DE FAMILIA O PERSONA QUE RESPONDE (Empadronar al total de los miembros de la familia) Nro. de Documento Edad Jefe(a) /Esposo(a) / Hijo(a) AFECTADO PERDIDO AFECTADO PERDIDO AFECTADO PERDIDO AFECTADO PERDIDO AFECTADO PERDIDO AFECTADO PERDIDO AFECTADO PERDIDO AFECTADO PERDIDO AFECTADO PERDIDO AFECTADO PERDIDO AFECTADO PERDIDO MUNICIPALIDAD PROVINCIAL DE MORROPÓN - CHULUCANAS Firma y Sello Presidente Asociación / Autoridad D N I N°___________________ D N I N°___________________ D N I N°___________________ Nombre, Apellidos y Firma del (la) Evaluador(a) EDAN PERÚ Firma y Sello Jefe(a) Oficina de Defensa Civil Centro Poblado: ___________________________________________ Caserío/: __________________________________________ Anexo: ___________________________________________ Otros: _____________________________ CÓDIGO SINPAD N° __________________ Fecha de Ocurrencia: ________/________/________ Provincia: _____________________________________ Distrito: _________________________________ Hora del Empadronamiento:__________ Barrio/Sector/Urbanización: _________________________________ Calle/Manzana: ____________________________________ Edificio/Piso/Dpto: _________________________________ AVES (Unidades) Nro Vivienda Composición familiar (Empadronar a todos los miembros de la familia) APICULTURA (Número de Colmenas) CAPRINO (Número de Cabezas) VACUNO (Número de Cabezas) OVINO (Número de Cabezas) EQUINO (Número de Cabezas) PORCINO (Número de Cabezas) CULTIVOS PAN LLEVAR (Hás) CULTIVOS PERMANENTE (Hás) CULTIVOS TRANSITORIOS (Hás) CULTIVOS NO PERMANENTE (Hás) I. INFORMACIÓN VIVIENDA II. INFORMACIÓN POR FAMILIA III. MEDIOS DE VIDA - GANADERIA III. MEDIOS DE VIDA - AGRICULTURA FORMULARIO DE CAMPO 2B: EMPADRONAMIENTO MEDIOS DE VIDA (Declaración Jurada - Ley 27444 - Ley de Procedimiento Administrativo General)