B.L. Form No.

28-8 (R)

Republic of the Philippines

Department of Environment and Natural Resources
COMMUNITY ENVIRONMENT & NATURAL RESOURCES OFFICE
Barit, Laoag City
Tel. Nos. (077) 772-0970  (077) 770-4802  (077) 772-3407  Fax No. (077) 772-0970
RECEIVED
VERIFICATION Date _______________
LOT NO. ___________ CAD __________ By ________________
SURVEY CLAIMANT _________________
NOT COVERED BY ANY PUBLIC
LAND APPLICATIONS. APPLICATION FOR FREE PATENT
DATE ________
EDNA L. LEANO F.P.A. 0128________
OIC, Records Officer

1. I hereby make application for a Free Patent to the following described tract of
agriculture public land under the provisions of Chapter VII of Commonwealth Act 141, as
amended, to wit: (Give as accurate a description as possible showing the boundaries of land
having reference to national objects, accidents on the ground and permanent monuments, if
any. If the lot corresponding to the tract, and give information on what plans the lot may be
identified:
____________________________________________________________________________
Situated in the Sitio of _________, Barangay ____________________, Municipality of
____________________ Province of Ilocos Norte, Island of Luzon, Philippines containing an
area of __________ hectares, __________ areas, and __________ centares.

2. I submit the following statements of facts to show that I am entitled to make this
application.

3. My name is _________________________ and my post office address is

______________________________ my age is _____ years; I was born in
______________________________, I am a citizen of the Philippines. My civil status is (if
married, state (a) Name, (b) Place of birth (c) Citizenship and Residence address of spouse)
____________________________________________________________________________
and I am not the owner of more than twelve (12) hectares of land.

The following are my near relatives (State their names and relations to the applicant
such as husband or wife, parents, children, brother, etc. If children, give their ages:
___________________________________________________________________________________
___________________________________________________________________________________

4. That the land described and applied for is not claimed or occupied by any other
persons, but is public land. I entered upon and began cultivation of the same in
____________________ day of _______________, 20___ and since that date, I have
continuously cultivated the land and have made thereon the following improvement viz:
____________________________________________________________________________
_.
NOTE: If applicant claims ancestors, paragraphs 5, 6, 7 and 8 must be filled out.

5. That land described and applied for is not claimed or occupied by any other
person but is public land. It was first entered upon, cultivated and occupied on or about the
_______day of ____________ by________________________________________________
who are my ____________________________. My ancestor died on ____________________
at the Municipality of _______________ Province of _______________.

Evidence of relationship, death, burial and heirship is hereto attached and consist of
______________________________.
STATISTICS
INDEXED The following are the names and address of the heirs of my ancestors:
________ _________
INITIAL __________ DATE INITIAL
DATE ___________
NAME POST OFFICE ADDRESS
______________________________ ________________________________
______________________________ ________________________________
______________________________ ________________________________
______________________________ ________________________________
 6. I, _________________________, and the only heir/representative of the heirs
of _________________________, who are _________________________ entitled to succeed
him according to the laws of the Philippines.

7. Since the death of my said ancestor, I have cultivated said land, the
improvements now on the land consist of the following viz: _______________________
_____________________________________________________________________.

8. The land has been continuously and cultivated by me, or my said ancestors,
since the date of entry thereon as above-stated, except during the following named periods
when the land was not occupied for the reasons stated, viz:
_____________________________________.

9. The land applied for is now occupied and cultivated by me and to the best of my
knowledge, information and belief it is otherwise unreserved and unappropriated and is non-
mineral agricultural public land, contains no valuable deposits of guano, coal or salt and is
more valuable for agricultural than for forestry or other purposes.

10. The land applied for is not mortgaged in any banking or financial institutions.

11. That I am not a recipient/beneficiary of CARPable land.

12. The following names witnesses will testify that the allocations in the application
are true:

NAME POST OFFICE ADDRESS

______________________________ ________________________________
______________________________ ________________________________
______________________________ ________________________________
______________________________ ________________________________

__________________________
Applicant

AFFIDAVIT

REPUBLIC OF THE PHILIPPINES )

PROVINCE OF ILOCOS NORTE : SS.
MUNICIPALITY OF _______________ )

I, ________________________, the person making the foregoing application first

being duly sworn, under my oath, depose and say; that I have real someone has translated to
me; and thoroughly understand the foregoing application that I signed the same and this
affidavit in the presence of the Officer who administered the oath, that each and every
statement in said application is true and correct. SO HELP ME GOD.

______________________________
Applicant

BEFORE ME, at the place aforesaid, on this _____ day of ____________________,

20___ personally appeared the applicant who is personally known to be the same person whose
name appears in the foregoing application, and in my presence signed the said application and
subscribed and sworn to this affidavit.

____________________________________
Special Land Investigator/Land Mgt. Inspector/
Deputized Public Land Inspector
SRC\macky\form\app-fp.doc