ANNEX C OF HSRC Memo Circular No.

03, Series of 1986

MPDC-003-0

A F F I D A V I T

WE / I, _____________________________________, of legal age, married, Filipino citizen with postal

address and residence at ___________________________________ after being sworn to in accordance with
law, hereby depose and state the following:

1. That I / we am/are the owner of certain parcel/s of land located at

__________________________________with an area of ________sq.m.. Covered by Tax Declaration
No._______________.

2. That the above - mentioned property/ies is/are subject of application for Certificate of Zoning
Compliance for ________________________________________ (state project type).

3. That the above - mentioned property/ies was/were acquired by way of ______________________

(state whether by sale on inheritance, etc.)

4. That the above - mentioned property/ies is/are not yet issued Certificate(s) of Title considering the
following reasons:______________________________________.

5. That the best of my knowledge, the above - mentioned property/ies is/are situated within the alienable
and disposal lands and outside land reserved for the public domain.

6. That the best of my knowledge, the above - mentioned property/ies is/are free from lien or
encumbrances other than ______________________ (indicate liens and encumbrances, if any).

7. For agricultural lands only, that the above - mentioned property/ies is/are utilized for agricultural
purpose, particularly for cultivation of ____________________________________ (indicate crop) is/are
[ ] tenanted [ ] not tenanted

8. That I am authorizing ________________________________________ to construct/erect his/her

_________________________________________

9. That I am executing this affidavit to attest to the veracity of the above - mentioned facts thereby
satisfying the requirements of the Housing and Land Use Regulatory Board relative to the application of
Certificate of Zoning Compliance for the above - mentioned project.

Affiant further says nothing.

___________________________, 20__, Pagudpud, Ilocos Norte, Philippines.

_____________________
AFFIANT
ID :
ID No :

Republic of the Philippines )

Province of Ilocos Norte ) S.S.

SUBSCRIBE AND SWORN to before me this _______ day of _____________, 20__, and affiant
exhibiting to me his/her abovementioned identification card as competent proof of his/her identity.

Doc. No. _______________

Page No. _______________
Book No. _______________
Series of 202_