PRLD.SRS.002-B.

00
Republic of the Philippines
Office of the President
HOUSING AND LAND USE REGULATORY BOARD
Lupong Nangangasiwa sa Pabahay at Gamit ng Lupa
Northern Tagalog Regional Field Office - San Fernando, Pampanga

REGISTRATION STATEMENT
(For Single Proprietorship)

I, _________________________ , Filipino, of legal age, single / married, with

postal address and residence at ________________________________________ ,
after being sworn in accordance with the law, do hereby state that:

1. I am engaged in the business of _________________________________

with capitalization of _________________________________________;

2. I am the owner of certain parcel(s) of land located at

___________________________ covered by TCT No. (s) ______________
comprising an aggregate area of ____________ sq.m.

3. That I am developing said parcel(s) of land into a ______________________

______ hereinafter called _________________________ (Type of Project)

4. As the owner, and ________________________________, as the developer

(Name of Developer)

5. The project, I undertake to develop said project in accordance with the plans
approved by the ___________________________________________.
(Approving Institution)

6. Attached hereto is the Declaration of UDHA Compliance, pursuant to the

implementing rules and regulations and circulars issued under Section 18 of
Republic Act No. 7279 as amended by R.A. No. 10884.

(Fill-out the attached Declaration of UDHA Compliance form

for main subdivision project or compliance project)

7. My authorized broker(s) shall be ___________________________________

_____________________________________________________________;

8. In my capacity as owner of the project, I bind myself to comply with all the
rules and regulations pertaining to this project and shall be held responsible
for all the facilities, improvement, infrastructures and similar form of
development hereon.
________________________ ___________________________________
Date Place

___________________________________
Affiant

SUBSCRIBED AND SWORN to before me this _______ day of _______________,

18
20____, affiant exhibiting to me ____________________ issued in ____________
on __________.

NOTARY PUBLIC

Doc. No. : _______

Page No. : _______
Book No. : _______
Series of : _______