_____________________ (Date)

The CENR OfficerCENRO-Laoag City

Sir:

I have the honor to certify that on _________________________ I was on and had examined the land applied for by ______________________________ married to _________________________under the Free Patent Application No.0128_____ situated in the Sitio of ____________________ Barangay ____________________, Municipality of ____________________ Province of Ilocos Norte and in conformity with Circular No. 30, report the following:

1. That the occupation and cultivation of the applicant as far as I have been able to ascertain date from ______________________________ and this occupation and cultivation have been continuous, open notorious and exclusive.

2. That the said land was first occupied and cultivated by _____________________________________________ in _______________ and the occupation and cultivation was continued by the applicant who acquired the right thereto through (purchase, inheritance, donation, relinquishment, quitclaim, long and peaceful possession, etc.) who is his/her ____________________ and immediate predecessor of the applicant, the names-of-all heirs and their address should be mentioned. If any of the heirs have relinquished whatever rights he or she may have, a sworn statement to that effect should be secured and attached to the report.

3. That the applicant is still living and survived by ______________________________________________________________________ (State name of heirs and of person to represent him/her in any transaction with the DENR) who is his/her ______________________________.

(State degree of relationship)

4. That the land is claimed by the applicant alone during the investigation whose post-office address is ______________________________________________.

5. That of the __________ hectares applied for, all hectares is under actual cultivation, __________ hectares are cleared but not cultivated and __________ hectares are still untouched.

6. That the improvement in the land consists of the following: _____________________________________________________________________.

7. That the land applied for is entirely inside the Alienable and Disposable Zone of the public domain, Block __________; Project No. __________ per LC Map No. __________.

8. That the said land has been surveyed and it corresponds to Lot No. __________, Cad/Pls No. __________ with no court registration proceedings by the Regional Trial Court of (NOT APPLICABLE)

9. That the applicant is not the owner of more than twelve (12) hectares.

Republic of the PhilippinesDepartment of Environment and Natural Resources

COMMUNITY ENVIRONMENT & NATURAL RESOURCES OFFICEBarit, Laoag City

Tel. Nos. (077) 772-0970 (077) 770-4802 (077) 772-3407 Fax No. (077) 772-0970

B.L. Form No. 28-11 (R)

DATE _________BY __________

10. That I have made a thorough ocular inspection of the land applied for and the sketch is reproduced herein below or attached hereto, noting thereon the dimension and area thereof and the improvement therein.

11. That the notice of this Free Patent Application for the lot has been posted at the barangay hall for a period of at least one month without any known records of claims and conflicts or whatsoever as certified by the barangay chairman.

12. That the attached tax declaration corresponds to the lot herein applied and is based on the approved module, public land and or cadastral survey. That the area and lot number shall be revised and conformed after the registration and issuance of title.

13. REMARKS: That the applicant is a natural born Filipino citizen and who is not a recipient/beneficiary of a CARPable land. That the land is not mortgaged in any bank/financing institution and further subject lot is free from claims and conflicts. Likewise, said lot is outside any established civil/military reservation and not within an identified KKK area.

In view of the foregoing, it is recommended that the Free Patent be NOW granted to the applicant.

Reviewed by: Very truly yours,

OLIVAT ABITONG __________________________ Land Mgt. Inspector Land Investigator/Inspector/

Dep. Public Land Inspector Recommending approval:

ENGR. SHEILA R. CAMAGONLand Mgt. Officer III/ Chief, LMS

Republic of the Philippines )Province of Ilocos Norte : SS.City of Laoag )

SUBSCRIBED AND SWORN to before me this _____ day of _______________ 20___, the SPLI/LMI/DPLI ______________________ with CTC No. _______________, issued on ____________________ at ____________________ who is personally known to me to be the same person who submitted the foregoing facts and investigation report based on documents presented during inspection.

N

SKETCH FLORENCIO P. SOLIVEN, JR. CENR Officer

SRC\macky\form\blform#28.doc