Republic of the Philippines

) S. S.
)
x------------------------------x

AFFIDAVIT

I, xxxxxxxxxxxxxxxxxxxxx, xxxxxxxxxxxxxxxxx, after having been duly sworn to in

accordance with law hereby depose and state:

1. That I acquire a parcel of land covered with Transfer Certificate of Title No. xxxxxxxx
located at xxxxxxxxxxxxxxxxxxxx under Doc. No. xxxxxxx, Page No. xxxxxxx, Book No.
xxxxxxxx series of xxxxxxxxxx, Notary Public by xxxxxxxxxxxxxxx dated
xxxxxxxxxxxxxx;

2. That I am processing the transfer of tax declaration with the City Assessor’s Office,
Calamba City, Laguna.

3. That I did not secure DAR Clearance from the concerned Agency;

4. That I did not submit said clearance to the Assessor’s Office;

5. That I hereby hold myself liable and accountable if any National and/ or Local Government
Unit checks/ claim upon the same DAR Clearance;

6. That I executed this affidavit to attest to the truth of foregoing and for whatever legal
purpose it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this __________________ at

_________________.

____________________
xxxxxxxxxxxxx
Affiant
Id.No.

SUBSCRIBED AND SWORN to before me this ______________ at ________________.

WITNESS MY HAND AND NOTARIAL SEAL. . . . . .

Doc No. ________;

Page No. _______;
Book No. _______;
Series of ________;