Republic of the Philippines

Department of Environment and Natural Resources

Region IV-B
COMMUNITY ENVIRONMENT AND NATURAL RESOURCES OFFICE
Brooke’ss Point, Palawan

APPLICATION FOR RESIDENTIAL FREE PATENT

Application No: Entry No:

Name of Applicant:

Address:

Citizenship Civil Status

Age: if minor, name of legal guardian

Date of Birth Place of Birth

Location of residential land applied for

Lot No.: Pls/Cad No’:

Iden. To Lot No.: Pls/Cad No:

Land Area: Sq.

Sq.m.

Applicant’s predecessor-in-interest
interest (if any)

Dater of entry by applicant or predecessor

predecessor-in
in interest upon the residential land applied for: (on of

about)

I declare, under the penalties of perjury, that my total land holdings

hol are not more than 12 hectares
and that this application has been made in good faith to the best of my knowledge all information
contained herein are true and correct.

Applicant Name and Signature

Applicant’s

SUBSCRIBED AND SWORN

WORN TO before me this _______
_______day
day of ____________________,20_______
________________

at________________________________________________________.
_______________________________________________________.

Officer Authorized Administer

A Oath

This form is not for sale.

This form must be accomplished in (5)