Republic of the Philippines

Department of Environment and Natural Resources

COMMUNITY ENVIRONMENT AND NATURAL RESOURCES OFFICE
Culasi, Antique
NOTE: This application must be submitted in duplicate, otherwise, it will
be rejected

AGRICULTURAL, FORESHORE, RECLAIMED LAND

FOR MISCELLANEOUS LEASE APPLICATION
Bureau of Lands No. _______________________
___________________________

Entry No.

1. The undersigned herby makes application under provision of

Chapter VI, IX of
Commonwealth Act. No. 141, as amended, to lease for period of
______________
years
the
tract
of
land
described
as
follows:
_______________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
situated
in
the
barrio
of
_______________________
Municipality
of_____________________________
Province of ____________________, Philippines, containing an area of
____________ has., ares, and
_________ centares, the shape and dimensions of said tract being as
indicated in the sketch drawn on the back of this application.
2. My name is ___________________________________, I am married, single
and the name of
my wife/husband is ___________________________________ who is citizen of
__________________.
I am employed in the government service. I suppose funds and personal
property as follows, and I expect to put into beneficial use of the land
applied for within the period fix by law, _______________
(If applicant is a corporation or association attach is a certified copy of
articles of incorporation or co-partnership and evidence of this having
been registered in the Securities and Exchange Commission or authorized
to transact business in the Philippines Island)
3. I have been upon and examined the land applied for, and it
containing no improvements or indication of occupation and settlement,
except as follows:
_____________________________________________________________________________________
_____________________________________________________________________________________
4. This application is made and in good faith for exclusive benefit of
the applicant and not either directly of indirectly , for the benefit of any
other person, corporation, association, or partnership and for their actual
purpose of using the land for the object specified in this application and
for no other purpose. I will not sell, assign, transfer, sublet for any
manner encumber he land of the right or rights that I may acquire,
without the approval of the Secretary of Agricultural and Natural
resources first had and obtained as provided in Section 40 Commonwealth
Act. No. 141, as amended.
5.
I agree to defray all expenses that might be incurred in the
survey of the land applied for, in the advertisement of this application and
other legal and necessary expense and to deposit on account thereof, such

amounts as the Director of Lands may require and to conform to

delimitation, classification, survey or resurvey of the land wherein applied
for.
6. That I agree that a strip forty meters wide starting from the bank
of each side of any river or stream that may be on the land I applied for
shall be demarcated and preserved as permanent timberland to be
planted exclusively to trees of known economic value, and that I shall not
make any clearing thereon to utilize the same for ordinary farming,
purpose even after patent shall have been issued me or a contract of
lease shall have been executed in my favor, (NOTE) Not applicable if land
applied for is (for residential, commercial purposes).

7. I am _______________________________ a member, a stockholder, officer,

representative,
attorney agent, employee or bond holder of the following corporation,
association, partnership which are engaged in agriculture and are holder
of agricultural public lands in the Philippines.
8. I understand that his application conveys no right to me to enter
upon, occupy, cultivate or make clearing on the land until the same has
been finally approved and is strongly submit false statements or execute
guilty, or perjury and punished by a fine of not more than two thousand
pesos and by imprisonment for not more than five years, and in addition
thereto this application shall be cancelled and all amounts paid on account
thereof forfeited to the government and shall not entitled to apply for any
public land in the Philippines.
_____________________________
(Signature of the Applicant)

AFFIDAVIT

REPUBLIC OF THE PHILIPPINES

PROVINCE OF ANTIQUE
MUNICIPALITY OF ___________ )

)
) S. S

9. I _______________________________ the person making this application

first being duly sworn, upon my oath and say: I have read or have had
read to me and thoroughly understand the foregoing application; that I
signed said application and this affidavit I the presence of the officer
administer the oath that each and every statement, in said application is
true and correct SO HELP ME GOD.
_________________________
(Applicant)
10. Before me, at the place aforesaid, on this ________ day of
_______________ 20________,

personally appeared known to me to be the same person whose name

appear in the foregoing application and authorized and sworn to this
affidavit .
11.
The
affiant
exhibited
of
his
residence
certificate
no.__________________________ which
showed
him
at
the
date
said
residence
certificate
to
be
__________________________________ on
_____________________________.
To all of which I CERTIFY.
Notarial Refgister No. _____ _Pagew No. ______ Series of __________
Book No. ________

_________________________________
(Officer authorized to administer oath)

_____________________________
(Official Title)
Until December 31, 20_____