B.L. Form No.

28-11 (R)

REPUBLIC OF THE PHILIPPINES )

PROVINCE OF ILOCOS NORTE : SS.
MUNICIPALITY OF ________________ )

AFFIDAVIT

I, ______________________________, of legal age, Filipino citizen and a

resident of ___________________________________________________ after having
been duly sworn to in accordance with law, depose and say:

That I am the holder of Free Patent Application No. _______________ covering

Lot No. _______________, Cad/Pls. No. __________ situated in the Barangay of
__________________, Municipality of __________________, Province of Ilocos Norte;

That I am only the claimant of the afore-cited lot during the survey;

That the land is agricultural and not tenanted and I am in actual occupation and
cultivation of the same;

That the said lot is NOT pending hearing in the court under L.R.C./G.L.R.C. Cad-
Record No. N/A and I recognize the same as public land. In the meantime, I will
proceed with my Free Patent Application No. __________;

That I hold myself solely responsible for any liability, whether civil and/or criminal
that may arise if the land has already been adjudicated as private property and/or the
corresponding title had in fact been issued, and for my statement I have made herein
that may be found untrue or false;

That I am a natural born citizen of the Philippines and not the owner of more than
twelve (12) hectares of land in the Philippines; and

That I execute this Affidavit freely and voluntary and fully understand the
contents hereof.

IN WITNESS WHEREOF, I have hereunto signed my name at

__________________, Province of Ilocos Norte this _____ day of __________, 20___.

__________________________
Applicant/Affiant

SUBSCRIBED AND SWORN to before me this _____ day of

____________________ 20___ at ______________________________ affiant
exhibiting his/her Community Tax Certificate No. __________ issued at
______________________________ on ______________________________.

__________________________
Special Land Investigator/
Land Management Inspector/
Deputized Land Mgt. Inspector

SRC\macky\form\affidavit.doc