Republic of the Philippines

Department of Environment and Natural Resources

MIMAROPA Region
PROVINCIAL ENVIRONMENT AND NATURAL RESOURCES OFFICE
Odiongan, Romblon

APPLICATION FOR FREE PATENT

Application No.__________________

1. I hereby make application for a free patent to the following described tract of agricultural public
land under the provision of Chapter VII of Commonwealth Act No. 141, as amended, Republic
Act No. 782 (if the land is a subdivision of Cadastral Lot, mention of number and survey number);
_______________________________________________________________________________
situated at in the sitio of ____________________ Barrio of ___________________ Municipality
of ______________________ Province of Romblon, Island of __________________, Philippines
and containing an area of ________________hectares _________ ares and __________ centares
(an approved plan of which is hereto attached).

2. My name is _______________________________________________, my post office address is

_________________________________________________________, my age is ____ years old,
my birth place is ______________________________, I am a natural-born citizen of the
Philippines and my civil status is __________________________________________, (If married
state name, birth place, citizenship and residence address of spouse): _______________________
______________________________________________________________________________.

3. I am not the owner of twelve (12) hectares of land.

4. That land described and applied is not claimed or occupied by any person but is a public land
which was first cultivated by: ___________________________________________________ and
____________________________ 19___ I entered upon and began cultivation of he same on the
_____ day of _________________ 19___ since that date I have continuously cultivated the land
and introduced the following improvements thereon _____________________________________
______________________________________________________________________________.

5. I agree that a strip of forty meters wide starting from the bank of each side of any river or stream
that may be found on the land shall be demarcated preserved as permanent timberland to be
planted exclusively to trees to known economic value, and that I shall not make any clearing
thereon or utilize the same for ordinary farming purposes even after patent shall have been issued
to me.

NOTE: If applicant claims thru inheritance, paragraphs 6, 7, 8 & 9 must filled up.

6. The land applied for was entered upon, cultivated and occupied on or before the ___ day of
____________________,19____ by___________________________________________ who
was my________________________________________. My said ancestor died on the ___ day
of ____________________________ 19___ and was buried at ___________________ province
of _______________________ on the _____ day of _______________________19___. Evidence
of relationship, death, burial and heir ship is hereto attached and consist of
_______________________________________________________________________________
______________________________________________________________________________.

The following are the names and address of the heirs of my said ancestor:

NAME POST OFFICE ADDRESS

_____________________________________ __________________________________
_____________________________________ __________________________________
_____________________________________ __________________________________
_____________________________________ __________________________________
 ___________________________________________________________________ the (only
heirs/representative of the heirs of) ___________________________________________ entitled to
succeed him accordingly to the laws of the Philippines.

7. Since the death of my said ancestors, I have cultivated the said land and existing improvements
thereon consist of the following: ____________________________________________________
______________________________________________________________________________.

8. The land has been continuously occupied and cultivated by me or my said ancestor since the date
of entry thereon as above stated except during the following period, when the land was not
occupied for the reason stated. ______________________________________________________
______________________________________________________________________________.

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

10. The following named witnesses will testify that the allegations in the application are true:

NAME POST OFFICE ADDRESS

______________________________ _________________________________
______________________________ _________________________________
______________________________ _________________________________
______________________________ _________________________________

11. The land applied for is ________________________________mortgaged to _________________

12. I understand that any applicant who willfully and knowingly submits false statement or executes
false affidavits in connection with his application shall be deemed guilty of perjury and punishable
accordingly, and that any person who, not being qualified to apply for public lands files an
application or induces or permit another to file it in his behalf shall be punished by a fine of not
more than five thousand pesos and by imprisonment for not more than five (5) years, or both and
in addition thereto his application shall be rejected or cancelled and all amounts paid in account
thereon forfeited in favor of the Government and he shall be not entitled to apply for any public
land in the Philippines.

______________________________
Applicant
Republic of the Philippines )
Province of Romblon ) S.S.
Municipality of ___________)

I, ___________________________________________________ the person making the foregoing

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

______________________________
Affiant

BEFORE ME, at the place aforesaid on this ___ day of ________________, 20___ personally
appeared _______________________ to me known to be the person whose name appears in the
foregoing application and in my presence signed the said application and subscribed and sworn to this
affidavit.

_______________________________

DPLI/Public Land Inspector/Spl. Investigator