Republic of the Philippines

DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES

Community Environment and Natural Resources Office
Region I, Dagupan City

APPLICATION FOR AGRICULTURAL FREE PATENT

(under Chapter VII of CA 141, as amended, and R.A. No. 11573)

Lot Information

Lot No. ________________ Location

Survey No. _____________ Barangay: __________________________
Area (sq.m.): ___________ City/Municipality: ___________________
Province: Pangasinan

Applicant’s Information

Name: ________________________________________________________________
(Last name) (First Name) (Middle Name)
Birthday: ______________
Sex: ☐ Male ☐ Female
Age: ___________
Mailing Address: ________________________________________________________
Civil Status: ☐ Single ☐ Married ☐ Divorced ☐ Separated ☐ Widowed
Name of Spouse (if married): ___________________
Citizenship: __________________________ Natural-born Citizen: Yes ☐ No ☐
Mobile No.: ___________________________
Email address: ________________________

1. I am not an owner of more than 12 hectares of land.

2. I have not filed any petition for judicial titling on the same subject lot.
3. I entered upon and began cultivation of the same on ____________________(mm/dd/yyyy),
and since then, I have continuously cultivated the land; and have made thereon the following
improvements:
__________________________________________________________________________________
______________________________________________________________________________
4. (Optional, if the applicant is a transferee)

The Land described and applied for is not claimed or occupied by any other person but is public land
which was first occupied and cultivated by _________________________________________
on __________________ (mm/dd/yyyy).
5. (Optional, if the applicant is an heir)

The previous cultivator, _______________________________ who was my ancestor, died on

________________ (mm/dd/yyyy). Since his/her death, I have cultivated the said land and existing
improvements thereon which consists of the following:
__________________________________________________________________________________
______________________________________________________________________________
Evidence of Relationship, death, burial, and heirship is hereto attached and consist of
__________________________________________________________________________________
_________________________________________.
The following are the names and addresses of the heirs of my ancestor
Name address
1. __________________________ ____________________________________
2. __________________________ ____________________________________
3. __________________________ ____________________________________
6. I am _____________________________________, the only heir/representative of the heirs of
_____________________________________ entitled to succeed him/her according to the laws of the
Philippines.
 7. 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
__________________________________________________________________________________
__________________________________________________________________________________

8. To the best of my knowledge, information and belief, the land applied for is an alienable and
disposable public agricultural and suitable for agricultural purposes.

9. I agree to demarcate applicable easements consistent with the existing policies and regulation.

10. The following two (2) disinterested persons named witnesses will testify that the allegations in
this application are true:

Name address
1. __________________________ ____________________________________
2. __________________________ ____________________________________

11. I understand that any applicant who willfully and knowingly submit false statements or
executes false affidavits in connection with this application shall be deemed guilty of perjury and that
any person who, not being qualified to apply for public lands, files an application or induces or permits
another to file it on his/her behalf shall be punishable in accordance with existing laws. His/her
application shall be rejected or cancelled and all amount paid on account thereof shall be forfeited in
favor of the Government, and he/she shall not be entitled to apply for any public land in the
Philippines.

____________________________________
Applicant’s Name and Signature

AFFIDAVIT
Republic of the Philippines
_____________________:S.S.
_____________________)

The person making the foregoing application under oath depose and say:

That I have read, or someone has read to me, and I thoroughly understand the foregoing application
and that I signed the same and this affidavit in the presence of the officer who administered the oath;
and that each and every statement in the applicant is true and correct.

____________________________________
Applicant’s Name and Signature
*This portion shall be filled up the DENR

APPLICATION NO. _________________.

Before me, at the place aforesaid on this ________ day of ________, _______________________
personally appeared ____________________ 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. He/She exhibited to me his/her Government Issued ID No. _________________
issued at _________________________________________________ on
_________________ (dd/mm/yyyy).

____________________________________
Office Authorized to Administer Oath
________________________
Official Title
This form is not for sale.
 Checklist of Requirements for Agricultural Free Patent Application

● Duly Accomplished Application Form with 1 Documentary stamp

● Notarized Special Power of Attorney (in case the application is filed by a representative)
● In case the applicant is a former natural-born Filipino citizen who subsequently acquired
foreign citizenship, the following additional documents shall be submitted:

 Birth Certificate issued by the Philippine Statistics Authority; and

 Identification Certification issued by the Bureau of Immigration

● Official Receipt of Payment of Application Fee

● Tax Declaration (in the name of the applicant). If the Tax Declaration is in the name of the
applicant’s predecessor-in-interest, any of these documents shall be submitted:

● Deed of Sale
● Extra Judicial Settlement of Estate
● Waiver of Rights
● Deed of Donation or other form of muniments of ownership

● Clearance from the Land Registration Authority (LRA) (to be submitted within 90 days after
filing of application)

Note: The LRA Clearance will be waived when the lot subject of application is covered by a cadastral subdivision plan (CSD).
 Republic of the Philippines
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
Community Environment and Natural Resources Office
Region I, Dagupan City

NOTICE OF APPLICATION FOR FREE PATENT

Notice is hereby given that Mr./Ms. ______________________________ has filed with this
Office an Agricultural Free Patent Application under the provisions of Chapter VII of Commonwealth
Act 141, as amended, and Republic Act No. 11573 to a tract of land situated in
____________________, ___________________, Pangasinan, Philippines, described as follows:
Barangay Municipality Province

Lot No. ____________________

Survey No.: _________________
Area (sq. m.): ________________

All adverse claims to the tract of land as described above must be filed in this Office within the
posting period, otherwise, said application shall be given due to course.

FRANK VINCENT D. DANGLOSE

CENR Officer

Date: __________________
Date of Posting:
From ____________________ to ____________________.

Republic of the Philippines

DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
Community Environment and Natural Resources Office
Region I, Dagupan City

NOTICE TO THE APPLICANT

Date: _______________

This is to inform you that your application for agricultural free patent is hereby returned
for the following reason/s:

 There is an existing application over the same subject lot.

 The subject lot is not alienable and disposable (A&D) based on our record and cannot be
issued with a patent.
 Not qualified to apply for an agricultural free patent due to
______________________________.
 Incomplete submission of documentary requirements.

For incomplete requirements, you are advised to submit the following documents as
marked below to this Office. Please note that your application will not be processed until all
requirements are complied.

 Tax Declaration (in the name of applicant). If the Tax Declaration is in the name of
applicant’s predecessor-in-interest, any of these documents shall be submitted:

 Deed of Sale
 Extra Judicial Settlement of Estate
 Waiver of Rights
 Deed of Donation or other form of muniments of ownership
 ______________________________
RPS Staff

Republic of the Philippines

DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
Community Environment and Natural Resources Office
Region I, Dagupan City

MEMORANDUM

FOR : The CENR Officer/Implementing PENR Officer

FROM : The Land Investigator/DPLI

SUBJECT : INVESTIGATION REPORT ON THE APPLICATION OF

_______________________________________________________________

DATE :
___________________________________________________________________________

In connection with the abovementioned application, respectfully submitted is the investigation

report with the following details:

1. That on _________________ (mm/dd/yyyy), I examined the land applied for by

__________________ (name of applicant), single/married to __________________________
under Agricultural Free Patent Application No. __________________ situated in barangay
________________, city/municipality of ________________, province of
_________________.

2. That the area applied for corresponds to Lot No. ________, Plan/CM No. _______ containing
an area of ______ square meters.

3. That I was able to ascertain that the applicant has occupied and cultivated the land applied for
since _________ (year) up to the present.

4. That the said land was first occupied and cultivated by ______________________________ in
_________ (year) and the occupation and cultivation were continued by the applicant who
acquired his/her rights thereto through ____________________ (sale, donation, waiver, inheritance)
from _______________________________.
 (if rights are claimed through inheritance and there are two or more heirs of the immediate predecessors of the applicant, the
names of all heirs and their addresses should be mentioned. If any of the heirs have relinquished whatever rights he or she may
have, sworn affidavit to that effect should be secured and attached to the report).

5. That the land is claimed by ________________________________________ whose post

office address is _____________________________________________________________.

6. That the land applied for is dominantly used for agricultural purposes.

7. That improvements on the land consist of the following:

_______________________________________________________
_______________________________________________________

8. That the land applied for is alienable and disposable agricultural land pursuant to LC Map No.
________ as certified by the CENR Officer.

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

10. That the Notice of Application has been posted for fifteen (15) consecutive days in the
municipal building and barangay hall. A geo-tagged photograph of the posted Notice of
Application is hereto attached.

11. Remarks: ___________________________________________________________________

___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

Attached is the V-37 noting the dimensions of the area and the improvements thereon.

IN VIEW OF THE FOREGOING, it is respectfully recommended that the application be given

due course/rejected.

I declare under pain of administrative sanctions that the statements indicated in this report are
true and based on facts gathered in the course of the investigation, and on the documents presented by
the applicant.

FOR YOUR INFORMATION.

_____________________________
Land Investigator/DPLI
 Republic of the Philippines
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
Provincial Environment and Natural Resources Office
Region I, Dagupan City

Free Patent Application No. _________________ X Lot No.: ______________________

: Survey No.: ___________________
: Barangay: ____________________
: City/Municipality: _______________
: Province: _____________________
: Area (sq. m.): ___________________
Applicant :
X-------------------------------------------X

O R D E R: APPROVAL OF APPLICATION AND ISSUANCE OF PATENT

From the records of this case, it appears:

1. That the applicant is a natural-born citizen of the Philippines, and is qualified to acquire
public lands through free patent;
2. That the land applied for has been classified as alienable and disposable agricultural
lands and is subject to disposition under the Public Land Act as amended by Republic
Act No. 11573;

3. That upon investigation conducted by Land Investigator/Inspector

_____________________________________ whose report was duly indorsed by
CENRO/PENRO/RED ____________________________________, it was found that
the land applied for has been occupied and cultivated by the applicant himself/herself
and/or through his/her predecessors in interest, since ___________ or prior thereto;

4. That the property has been declared for taxation purposes;

5. That the Notice of Application for Free Patent has been posted at the City/Municipal
Building and Barangay Hall where the land is located; and

6. That there is no adverse claim involving the land applied for still pending determination
in this Office.
 WHEREFORE, finding that the applicant has already complied with all the
requirements of the law, the above numbered application is hereby ordered approved and the
corresponding patent to the land be issued to the applicant.

__________________________

PENRO/RED/Secretary

Date: ____________________