NCIP ADO FORM AD-1 ATTACH

To be filed in 2 copies PASSPORT SIZE

PICTURE

Republic of the Philippines

Office of the President
NATIONAL COMMISSION ON INDIGENOUS PEOPLES
Regional Office No. 12
________________________

Petition No.
Date:

PETITION FOR IDENTIFICATION, DELINEATION AND RECOGNITION

OF ANCESTRAL DOMAIN CLAIM AND FOR THE ISSUANCE OF
CERTIFICATION OF ANCESTRAL DOMAIN TITLE (CADT)

I HEREBY PETITION THIS COMMISSION FOR THE IDENTIFICATION

DELINEATION AND RECOGNITION OF ANCESTRAL DOMAIN CLAIM AND FOR THE
ISSUANCE OF CERTIFICATE OF ANCESTRAL DOMAIN TITLE, AND HEREBY DECLARE:

1. CADT Applicant:

2. Tribe/Ethnolinguistic Group:

3. Representative:
Surname Given/First Name Middle Name

4. Address:

5. Date of Birth: ____________ 6. Age: _____ 7. Civil Status: ________ 8. Sex: ______

9.a. Nature of Authority:

9.B. Date Given: _____________ 9.c. Body Giving Authority:

Council of Leaders Council of Timuays Others

9.d. Elders/Leaders/Timuays/Person who give authority:

10. Number of Stakeholders: Communities _______ Clans _______ Families: ________

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If ancestral domain has been technically surveyed, please complete items 11.a, 11.b,
11.c, 11.d and 11.e.
11. Date of Survey 11.a. Survey Authority Number:

11.b. Issuing Official 11.c. Designation

11.d. Approving Official 11.e. Position

12. Location of Ancestral Domain: _________________________________________

_______________________________________________________________________

13. Area: ____________________________________________ (_________) Hectares

I hereby certify that the entries/statements made hereon are true and correct to the best of
my knowledge.
In witness whereof, I have hereunto set my hand this ____ day of _____________, 20____,
at _______________________________________ Philippines.

___________________________
Thumb Mark/Signature of CADT
Authorized Representative

CONFORME:

___________________________
Tribal Leader/Elder/Chieftain/Datu

Republic of the Philippines )

___________________________)SS
___________________________)

SUBSCRIBED AND SWORN to before me this ___ day of ________________,

20___, representative showing to me his/her Community Tax Certificate No.
___________________ issued on ________________ at ________________________,
Philippines.

___________________________
Officer Administering Oath

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