REPUBLIC OF THE PHILIPPINES )

SS
CITY OF )

AFFIDAVIT OF SELLER/TRANSFEROR

I, __________________, of legal age, __________ citizen, single/married and with

residence and postal address at ______________________, after being duly sworn in accordance
with law hereby depose and state that:

1. The land sold to ____________________single/married with an area of _____________ square

meters more or less by virtue of a Deed of Sale acknowledged before Notary Public
_______________ under Doc No. ______, Page No. _______, Book No. ______ Series of 2003 is
my retention area or a portion of my retention area of not more than 5 hectares;

2. This affidavit is executed in Compliance with Department of Agrarian Reform administrative Order
No. 1, Series of 1989 as well as to show proof that the land subject of the aforementioned transaction
is my retention area or a portion of my retention area;

3. I am executing this Affidavit to attest to the truth of the foregoing declarations and for whatever legal
purpose it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand on this the __ day of _________, in
the City of ____________.

Affiant

SUBSCRIBED AND SWORN to before me on this the ____________, in the City of

_________; Affiant has personally exhibited to me his community tax certificate no. ____________
issued on _______________ in ____________.

Doc no.
Page no.
Book no.
Series of 200