REPUBLIC OF THE PHILIPPINES

PROVINCE OF PANGASINAN
MUNICIPALITY OF ____________
BARANGAY OF _______________

CERTIFICATION

TO WHOM IT MAY CONCERN:

This is to certify that a certain parcel of land identified as Lot No.

______________________________, Cad./PLS No. _____________ situated at Barangay ______________,
Municipality/ City of _______________, Province of Pangasinan is owned and possessed by
_______________.

This is to certify further that the Notice of Application for Free Patent filed by
__________________________ covering the same parcel of land was posted in a conspicuous place of the land
applied for in the bulletin board of Barangay/Municipal hall on the ____ day of ______________ and remained
posted until the _____ day of ___________________ .

That said parcel of land described above has no pending Civil Case or Claim and Conflicts as per our
records as of this date and no boundary encroachment on the adjoining lots. It further certified that no interested
party filed a protest over the Free Patent Application of the subject lot.

Issued for legal and reference purpose this ______ day of ______________ at Barangay
_______________, Municipality of ________________, Province of Pangasinan.

___________________________
____________________________
Barangay Chairman
 Republic of the Philippines
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
Community Environment and Natural Resources Office
Dagupan City, Region I

NOTICE OF APPLICATION FOR FREE PATENT

Notice is hereby given that ____________________, married to ____________________________,

has filed with the CENR Office an application, under the provisions of Chapter VII of Commonwealth Act No.
141, as amended, for a free patent to a tract of land situated in the Barrio of Agdao, City of San Carlos, Province
of Pangasinan, Philippines described as follows:
Lot No. 24005 Cad. 457-D___________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
______________________________________________________________________________
Containing an area of ___ hectares, ____acres and __ centares. All adverse claim to the tract of land above
described must be filed in the Office of the DENR, CENRO, Dagupan City on or before ____________, 2021.
Any claims not so filed will be forever barred.

FOR. FRANK VINCENT D. DANGLOSE

OIC, CENR Officer

REPUBLIC OF THE PHILIPPINES )

PROVINCE OF PANGASINAN ) S.S.
CITY OF SAN CARLOS )

I, Alberta J. Iglesias married to ______________ being first duly sworn to depose and say; That she is
the same person who made application for the above described land that a copy of the above notice was posted
in a conspicuous place on the land applied for; on the bulletin board of the barangay the land is located and at
the door of the Municipal Building, on the ________________ and remained so posted until the
______________________________.

_______________________
Applicant

SUBSCRIBED AND SWORN to before me this 21 st day of October, 2020, the affiant exhibited his
Philippine Passport No. P2551442B issued at DFA NCR West, expires on 14 June 2029.

________________________________
Land Inspector
Paid Oath Fee _________________
Under O.R. No. ________________
Dated ________________________
Republic of the Philippines )
Province of Pangasinan :
Municipality of ___________________ )

JOINT AFFIDAVIT IN SUPPORT OF THE

FREE PATENT APPLICATION

We, ______________________________, married to ___________________________ and

______________________________, married to ___________________________ both of legal ages and
residents of the Municipality of _________________________ Province of Pangasinan after having been duly
sworn to in accordance with law depose and say:

1. That we personally know __________________________ who has filed Free Patent

Application No. ___________________ for a tract of land located in the Municipality of
____________________ Province of Pangasinan ;
2. That we are actual residents of the said municipallity of ________________________ and we
know the land applied for very well.
3. That the said applicant has continuously accupied and cultivated the land by himself and/or his
predecessor in interest since June 12, 1945 or prior thereto and it is free from claims and
conflicts.
4. That we are not related to the applicant either by consanguinity or by affinity and we are not
personally interested in the applied for nor in the granting of the patent thereto; and
5. That to the best of our knowledge, belief and information, the applicant is a natural born citizen
of the Philippines and not the owner of more that twelve hectares of the land in the Philippines.

IN WITNESS WHEREOF, we have hereunto set our hands and signed the affidavits this ______ day of
________________, 202_ in the Municipality of ________________________, Province of Pangasinan.

_______________________________ _________________________________
Res. Cert. No. ___________________ Res. Cert. No. _____________________
Issued on _______________________ Issued on_________________________
At ____________________________ At_______________________________

SUBSCRIBED AND SWORN TO before me as the date and place above-stated.

_______________________________
Land Inspector/D.P.L.I.
REPUBLIC OF THE PHILIPPINES )
PROVINCE OF PANGASINAN : S.S.
MUNICIPALITY OF STA. BARBARA )

AFFIDAVIT

I, _______________________, of legal age, married to Nerrie Verzosa, Filipino citizen and a

resident of __________________after having been duly sworn to in accordance with law hereby
depose and say:

That I am the only holder of Free Patent Application No. _____________ covering Lot No.
___________ Cad./Pls. ______ situated in the __________________.

That I am the only claimant of the afore-cited lot during the survey;

That the land is agricultural and not tenanted and I am in actual occupation and cultivation of
the same;

That my total landholding do not exceed 12 hectares;

That the said lot has no pending hearing in the Court under L.R.C/GLRO, Record No. n/a and
as I recognize the same as public land, I will claim it as such during the court hearing thereof. In the
meantime I will proceed with my Free Patent Application No. ________________.

That I hold myself solely responsible for any liability, whether civil and/or criminal that may
arise if the land has already been adjudicated as private property and or corresponding title has in
fact been issued and for my statement I have made herein that may found untrue/false; and

IN WITNESS WHEREOF, I have hereunto set my hand this ________ day of

______________________, ___________ at ____________________, Pangasinan.

_____________________
Applicant/Affiant

SUBSCRIBED AND SWORN to before me this ______________________, the affiant

exhibited his Philippine Passport No. ________________ issued at _____________, .

_________________________
Land Inspector/DPLI