B.L. Form No.

28-11 (R)

Republic of the Philippines

Department of Environment and Natural Resources
COMMUNITY ENVIRONMENT & NATURAL RESOURCES OFFICE
Barit, Laoag City
Tel. Nos. (077) 772-0970  (077) 770-4802  (077) 772-3407  Fax No. (077) 772-0970

_____________________
(Date)
The CENR Officer DATE _________
CENRO-Laoag City BY __________

Sir:

I have the honor to certify that on _________________________ I was on and

had examined the land applied for by ______________________________ married to
_____________________________ under the Free Patent Application No. __________
situated in the Sitio of ____________________ Barangay ____________________,
Municipality of ____________________ Province of Ilocos Norte and in conformity with
Circular No. 30, report the following:

1. That the occupation and cultivation of the applicant as far as I have been
able to ascertain date from ______________________________ and this occupation
and cultivation have been continuous, open notorious and exclusive.

2. That the said land was first occupied and cultivated by

_____________________________________________ in _______________ and the
occupation and cultivation was continued by the applicant who acquired the right thereto
through (purchase, inheritance, donation, relinquishment, quitclaim, long and peaceful
possession, etc.) who is his/her ____________________ and immediate predecessor
of the applicant, the names-of-all heirs and their address should be mentioned. If any of
the heirs have relinquished whatever rights he or she may have, a sworn statement to
that effect should be secured and attached to the report.

3. That the applicant is still living and survived by

______________________________________________________________________
(State name of heirs and of person to represent him/her in any transaction with the DENR)
who is his/her ______________________________.
(State degree of relationship)

4. That the land is claimed by the applicant alone during the investigation
whose post-office address is ______________________________________________.

5. That of the __________ hectares applied for, all hectares is under actual
cultivation, __________ hectares are cleared but not cultivated and __________
hectares are still untouched.

6. That the improvement in the land consists of the following:

_____________________________________________________________________.

7. That the land applied for is entirely inside the Alienable and Disposable
Zone of the public domain, Block __________; Project No. __________ per LC Map
No. __________.

8. That the said land has been surveyed and it corresponds to Lot No.
__________, Cad/Pls No. __________ with no court registration proceedings by the
Regional Trial Court of ________________________________________.

9. That the applicant is not the owner of more than twelve (12) hectares.
 10. That I have made a thorough ocular inspection of the land applied for and
the sketch is reproduced herein below or attached hereto, noting thereon the dimension
and area thereof and the improvement therein.

11. That the notice of this Free Patent Application for the lot has been posted
at the barangay hall for a period of at least one month without any known records of
claims and conflicts or whatsoever as certified by the barangay chairman.

12. REMARKS: That the applicant is a natural born Filipino citizen and who
is not a recipient/beneficiary of a CARPable land. That the land is not mortgaged in any
bank/financing institution and further subject lot is free from claims and conflicts.
Likewise, said lot is outside any established civil/military reservation and not within an
identified KKK area.

In view of the foregoing, it is recommended that the Free Patent be NOW granted
to the applicant.

Recommending Approval: Very truly yours,

SHEILA R. CAMAGON OLIVA T ABITONG __________________________

Land Mgt. Officer III Land Mgt. Inspector Land Investigator/Inspector/
Dep. Public Land Inspector

Republic of the Philippines )

Province of Ilocos Norte : SS.
City of Laoag )

SUBSCRIBED AND SWORN to before me this _____ day of _______________

20___, the SPLI/LMI/DPLI ______________________ with CTC No.
_______________, issued on ____________________ at ____________________
who is personally known to me to be the same person who submitted the foregoing
facts and investigation report based on documents presented during inspection.

LEONARDO P.ACOSTA
CENR Officer

SKECTCH

SRC\macky\form\blform#28.doc