App-FLA-ind-sps

Republic of the Philippines

Department of Agriculture
BUREAU OF FISHERIES AND AQUATIC RESOURCES
2/F & 3/F PCA Building, Elliptical Road, Quezon City

APPLICATION FOR FISHPOND LEASE AGREEMENT

Application No. _________________________ Place______________________________________

New Lease, Conversion, Renewal, Transfer Date ______________________________________
Or Change of Area (State which)

__________________________________

The Director
Bureau of Fisheries and Aquatic Resources
Quezon City

I/We __________________________________________, a citizen of the Philippines, _________ years old, single/married, my

occupation is _____________________ and with residence/postal address at _________________________________________, do
hereby apply under the provisions of Republic Act No. 8550, to lease and occupy a parcel of public forest land for fishpond purposes
containing ________________ hectares, more or less, as shown in the attached sketch/survey plan and particularly bounded and
described as follows:

Province : _________________________ North : _________________________________

Municipality : _________________________ East : _________________________________
Barangay : _________________________ South : _________________________________
Sitio : _________________________ West : _________________________________

My/Our initial capital for the development/maintenance of the area based at Php 5,000.00 per hectare is Php ________________ as
evidenced by the attached certification of bank deposit. Also enclosed is an affidavit stating that the said initial capital will be exclusively
used for the development of the area, a verified statement of our assets and properties from which the initial capital needed will be
derived.

I/We understand that this application does not authorize me/us to enter the area or introduce improvements therein, unless a Fishpond
Lease Agreement is issued in my/our favor. I/We also bind ourselves to comply with the provisions of existing fishery laws, rules and
regulations and the instructions issued by that Office and those that may subsequently be issued regarding the use and operation of the
area herein described and shall be solely responsible for the proper compliance with the same by all persons who will operate under our
authority. I/We understand that this application is non-transferrable and that the application fee paid therefor is non-refundable.

Herewith enclosed is an application fee of Php 2,000.00 pesos in cash, check or Postal Money Order No. _______________ dated
_________________________.

__________________________________________________ ___________________________________________

(Postal Address) (Signature of Applicant)

TIN : _______________________________________

Subscribed and sworn to before me this _______ day of ______________________ at __________________________________,

Philippines. The affiant exhibited to me his/ her Community Tax Certificate No. or Government-Issued Identification No.
__________________________ issued at _____________________________ on ________________________.

Doc. No. ____________________ ;

Page No. ____________________;
Book No. ____________________; __________________________________________
Series of 20_______. Notary Public