REPUBLIC OF THE PHILIPPINES )

PROVINCE OF Agusan del Norte )

CITY/MUN. OF ________________)

AFFIDAVIT

I, __________________________________ of legal age, single/ married/ widow/er, Filipino

citizen and a resident of ___________________________________________________________ after
having been duly sworn to in accordance with law depose and say:

That I am the holder of _________________________________ Application No.

_____________ covering Lot No.
_______________________________________________________________________ Cad/Pls
________________________________situated in the Municipality of ______________________
Province of Agusan del Norte, Philippines.

That I am the only claimant of the aforesaid lot during the survey thereof;

That the said lot is not yet filed or has no pending hearing in court in the L.R.C., GLRC Cad
Report No. ____________________ and as I recognized the same as public land. In the meantime, I will
proceed with my ______________________________________ Application No.
__________________________.

That the said lot is not yet responsible for any liability, whether civil and/or criminal that may
arise of the land had already been adjudicated as private property and as the corresponding certificate of
title had in fact been issued and for any statement that I have made therein that may be found untrue or
false; and

That I execute this Affidavit, freely and voluntarily and fully understand the interest thereof.

IN WITNESS WHEREOF, I have hereunto signed my name at

____________________________
__________________________________, Philippines this ________________ day of
_______________.

________________________________
Applicant

SUBSCRIBED AND SWORN to before me this _______________ day of

_______________________ at the City/ Mun. of _____________________________________ Province
of ___________________________________________, Philippines. Affiant exhibited to me his/her
Residence Certificate No. _______________________________issued on
_________________________.
________________________________
Officer Administer Oath

________________________________
Official Title