LTC Form No.

Republic of the Philippines) LTC Application No. _____-2021

Municipality of La Trinidad, Benguet)
Province of Benguet) S.S.

APPLICATION FOR ISSUANCE OF LAND TRANSFER CLEARANCE

We, Mesian Basalong and Noralyn B. Handayan, both/all of legal age, Filipinos, single,
married and residents of Upper Wangal, La Trinidad, Benguet, after being sworn in accordance
with law, hereby state:

1. We are the parties in a that Deed of Donation involving a parcel of land covered by TCT
No. P-25544 and Tax Declaration/ARP No. 2010-03-16-02482, located at Wangal, La
Trinidad, Benguet, with Lot No. 216, SGS-CAR-000120, with an area of Two Hundred
Seventy Three (273) square meters, more or less;

2. This application for the issuance of Land Transfer Clearance (LTC) is not contrary to law
because both of us are qualified to dispose and acquire the land described above. In
addition, the said land is neither covered under the agrarian reform program nor within
the CARPER LAD Balance, and that the deed/contract will not violate the retention limit
provided under the law;

3. In support thereto and in compliance with DAR A.O. No. 04, Series of 2021, the
pertinent applicable documents are hereto attached and made integral parts hereof as
(please check appropriate box):

3.1. FOR THE TRANSFEROR:

/ Official Receipt : Annex ___

Electronic Copy of the Title or Tax Dec : Annex ___
Deed or document to be registered : Annex ___
Affidavit of Aggregate Landholding INCLUDE SPOUSE : Annex ___
Affidavit of Retention, Non-Tenancy/tenancy with : Annex ___
compliance of tenant’s right of Pre-emption and/or
Redemption and no pending case before the regular
courts or any tribunal involving the land subject of the
transaction, if there is a case before the regular courts
or any tribunal the same had been decided with finality
Municipal Assessor’s Certificate of Aggregate : Annex ___
City Assessor’s Certificate of Aggregate Landholding : Annex ___
Provincial Assessor’s Certificate of Aggregate Landholding : Annex ___

3.2. FOR THE TRANSFEREE:

Affidavit of Aggregate Landholding INCLUDE SPOUSE : Annex ___

Municipal Assessor’s Certificate of Aggregate Landholding : Annex ___
City Assessor’s Certificate of Aggregate Landholding : Annex ___
Provincial Assessor’s Certificate of Aggregate Landholding : Annex ___
Municipal Agrarian Reform Program Officer : Annex ___
(LTC Form No. 2)

4. Having submitted/attached hereof the applicable mandatory documents as required under

DAR A.O. No. 04, Series of 2021, I/we hereby file this instant application/request to
facilitate the issuance of the corresponding Certificate on LTC.
IN WITNESS WHEREOF, we have hereunto set our hands this _____ day of ____________ at
_________________________, Philippines.

Mesian Basalong Noralyn Handayan

Donor Donee
Valid ID No ________________ Valid ID No. _______________
CTC No. __________; ________ CTC No. ___________; _________
Issued at ________________ Issued at ____________

SUBSCRIBE AND SWORN to before me this __________ at La Trinidad, Benguet,

Philippines, affiants upon exhibiting to me their duly issued government IDs with details stated
above.

Doc. No.: _____;

Page No.: _____;
Book No.: _____;
Series of 2021

Copy Distribution:
Original – DARPO/LTC Folder
Duplicate – Applicant