Application Form (AGRI) CERT. TO AFFIDAVIT

REPUBLIC OF THE PHILIPPINES
PROVINCE OF PANGASINAN
MUNICIPALITY OF ____________
BARANGAY OF _______________
CERTIFICATION
TO WHOM IT MAY CONCERN:
This is to certify that a certain parcel of land identified as Lot No.

______________________________, Cad./PLS No. _____________ situated at Barangay ______________,
Municipality/ City of _______________, Province of Pangasinan is owned and possessed by
_______________.
This is to certify further that the Notice of Application for Free Patent filed by
__________________________ covering the same parcel of land was posted in a conspicuous place of the land
applied for in the bulletin board of Barangay/Municipal hall on the ____ day of ______________ and remained
posted until the _____ day of ___________________ .
That said parcel of land described above has no pending Civil Case or Claim and Conflicts as per our
records as of this date and no boundary encroachment on the adjoining lots. It further certified that no interested
party filed a protest over the Free Patent Application of the subject lot.
Issued for legal and reference purpose this ______ day of ______________ at Barangay
_______________, Municipality of ________________, Province of Pangasinan.
___________________________
Municipal Mayor/
Barangay Chairman
Republic of the Philippines
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
Community Environment and Natural Resources Office
Dagupan City, Region I
NOTICE OF APPLICATION FOR FREE PATENT
Notice is hereby given that ___________________

__ has filed with the CENR Office an application, under the provisions of Chapter VII of
Commonwealth Act No. 141, as amended, for a free patent to a tract of land situated in the Barrio of
________________ Municipality of _____________________, Province of Pangasinan, Philippines described
as follows:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
______________________________
Containing an area of ____________ hectares, _________ acres and ___________ centares. All adverse claim
to the tract of land above described must be filed in the Office of the DENR, CENRO, Dagupan City on or
before the ______ day of _____________________________, 202__. Any claims not so filed will be forever
barred.
FOR. FRANK VINCENT D. DANGLOSE

OIC, CENR Officer
REPUBLIC OF THE PHILIPPINES )

PROVINCE OF PANGASINAN ) S.S.
MUNICIPALITY OF __________________)
I, _________________________________ married to __________________being first duly sworn to

depose and say; That he is the same person who made application for the above described land that a copy of
the above notice was posted in a conspicuous place on the land applied for; on the bulletin board of the
barangay the land is located and at the door of the Municipal Building, on the _____ day of
__________________, 202___ and remained so posted until the _____ day of ________________, 202__.
________________________
Applicant
SUBSCRIBED AND SWORN to before me this ______ day of ___________________ 202 ___, the
affiant exhibited his/her Residence Certificate No. ___________________ issued at the Municipality of
_________________, Province of Pangasinan on ____________________, 202___.
___________________________
Land Inspector/D.P.L.I.
Paid Oath Fee _________________
Under O.R. No. ________________
Dated ________________________
Republic of the Philippines )
Province of Pangasinan :
Municipality of ___________________ )
JOINT AFFIDAVIT IN SUPPORT OF THE

FREE PATENT APPLICATION
We, ______________________________, married to ___________________________ and

______________________________, married to ___________________________ both of legal ages and
residents of the Municipality of _________________________ Province of Pangasinan after having been duly
sworn to in accordance with law depose and say:
1. That we personally know __________________________ who has filed Free Patent

Application No. ___________________ for a tract of land located in the Municipality of
____________________ Province of Pangasinan ;
2. That we are actual residents of the said municipallity of ________________________ and we
know the land applied for very well.
3. That the said applicant has continuously accupied and cultivated the land by himself and/or his
predecessor in interest since June 12, 1945 or prior thereto and it is free from claims and
conflicts.
4. That we are not related to the applicant either by consanguinity or by affinity and we are not
personally interested in the applied for nor in the granting of the patent thereto; and
5. That to the best of our knowledge, belief and information, the applicant is a natural born citizen
of the Philippines and not the owner of more that twelve hectares of the land in the Philippines.
IN WITNESS WHEREOF, we have hereunto set our hands and signed the affidavits this ______ day of
________________, 202_ in the Municipality of ________________________, Province of Pangasinan.
_______________________________ _________________________________
Res. Cert. No. ___________________ Res. Cert. No. _____________________
Issued on _______________________ Issued on_________________________
At ____________________________ At_______________________________
SUBSCRIBED AND SWORN TO before me as the date and place above-stated.
_______________________________
Land Inspector/D.P.L.I.
REPUBLIC OF THE PHILIPPINES )
PROVINCE OF PANGASINAN : S.S.
MUNICIPALITY OF ______________ )
AFFIDAVIT
I, ____________________________ of legal age, ____________________ Filipino citizen

and a resident of __________________________________________ after having been duly sworn
to in accordance with law hereby depose and say:
That I am the only holder of Free Patent Application No. ___________________ covering Lot
No. _____________ Cad./Pls. _____________ situated in the Municipality of _________________,
Province of Pangasinan.
That I am the only claimant of the aforecited lot during the survey;
That the land is agricultural and not tenanted and I am in actual occupation and cultivation of
the same;
That my total landholding do not exceed 12 hectares;
That the said lot __________ pending hearing in the Court under L.R.C/GLRO, Record No.
_________________ and as I recognize the same as public land, I will claim it as such during the
court hearing thereof. 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 corresponding title has in
fact been issued and for my statement I have made herein that may found untrue/false; and
IN WITNESS WHEREOF, I have hereunto set my hand this ________ day of

______________________, ___________ at ____________________, Pangasinan.
_____________________________
Applicant/Affiant
SUBSCRIBED AND SWORN to before me this ______ day of ____________________,

_______ at _________________________ affiant exhibiting his/her Res. Cert. No. _____________
issued at _____________________ on _____________________, __________.
______________________________
Land Inspector/DPLI

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REPUBLIC OF THE PHILIPPINES

TO WHOM IT MAY CONCERN:

This is to certify that a certain parcel of land identified as Lot No.

NOTICE OF APPLICATION FOR FREE PATENT

Notice is hereby given that ___________________

FOR. FRANK VINCENT D. DANGLOSE

REPUBLIC OF THE PHILIPPINES )

I, _______________ married to being first duly sworn to

JOINT AFFIDAVIT IN SUPPORT OF THE

We, ____, married to _ and

1. That we personally know __________________________ who has filed Free Patent

SUBSCRIBED AND SWORN TO before me as the date and place above-stated.

I, ________ of legal age, Filipino citizen

That my total landholding do not exceed 12 hectares;

IN WITNESS WHEREOF, I have hereunto set my hand this ________ day of

SUBSCRIBED AND SWORN to before me this day of ______________,

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