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_____________________

(Date)The CENR OfficerCENRO-Laoag City

Sir:

I have the honor to certify that on _________________________ I was on andhad 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 beenable to ascertain date from ______________________________ and this occupationand cultivation have been continuous, open notorious and exclusive.

2. That the said land was first occupied and cultivated by_____________________________________________ in _______________ and theoccupation and cultivation was continued by the applicant who acquired the right theretothrough (purchase, inheritance, donation, relinquishment, quitclaim, long and peacefulpossession, etc.) who is his/her ____________________ and immediate predecessor

of the applicant, the names-of-all heirs and their address should be mentioned. If any ofthe heirs have relinquished whatever rights he or she may have, a sworn statement tothat 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 actualcultivation, __________ 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 DisposableZone 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 theRegional Trial Court of ________________________________________.

9. That the applicant is not the owner of more than twelve (12) hectares.

Republic of the PhilippinesDepartment of Environment and Natural Resources

COMMUNITY ENVIRONMENT & NATURAL RESOURCES OFFICEBarit, Laoag City

Tel. Nos. (077) 772-0970 (077) 770-4802 (077) 772-3407 Fax No. (077) 772-0970

B.L. Form No. 28-11 (R)

DATE _________

BY __________

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10. That I have made a thorough ocular inspection of the land applied for andthe sketch is reproduced herein below or attached hereto, noting thereon the dimensionand area thereof and the improvement therein.

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

12. REMARKS: That the applicant is a natural born Filipino citizen and whois not a recipient/beneficiary of a CARPable land. That the land is not mortgaged in anybank/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 anidentified KKK area.

In view of the foregoing, it is recommended that the Free Patent be NOW grantedto 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 foregoingfacts and investigation report based on documents presented during inspection.

LEONARDO P.ACOSTA CENR Officer

SKECTCH

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SRC\macky\form\blform#28.doc