Republic of the Philippines

DEPARTMENT OF AGRARIAN REFORM

ADJUDICATION BOARD
PROVINCIAL AGRARIAN REFORM ADJUDICATOR
BRANCH –II
nd
2 Floor, Geocaden Building. # 41, Mabini St., Bacolod City, Negros Occidental

CANC. Case No._______

IN RE: PETETION FOR CANCELLATION, OF LOT NO. _______ WITH

ROD/CLOA NO. _____ AN AREA OF __________ HECTARES

__________________ _________________ _______________

Petitioners

DAR, Represented by ______________ (PARO)

CLOA Holders:
1. ________________________
2. ________________________
3. ________________________
4. ________________________
5. ________________________
6. ________________________
7. ________________________
8. ________________________
9. ________________________
10. ________________________

REGISTER OF DEEDS, REPRESENTED BY

______________________
Respondent

x-------------------------------------------------------------------------------------------------x

PETITION

COMES NOW, Petitioner, unto this honorable Office, most respectfully allege:

1. That the petitioner (NAME OF PETITIONERS) is of legal age, Filipino,

and resident of (ADDRESS);

2. That the public Respondent, DEPARTMENT OF AGRARIAN

REFORM, is a government Agency tasked with the duty to implement
 the Comprehensive Agrarian Reform Program Extension and Reform
(CARPER), pursuant to RA. No. 6657 as amended by RA No. 9700, as
herein represented by (NAME OF PARO) in her capacity as the
Provincial Agrarian Reform Officer, Negros Occidental, with office
address at (ADDRESS OF DARPO)

3. That the Public Respondent, Kabankalan City (sample only), Negros

Occidental REGISTER OF DEEDS, is also a government agency created
pursuant to Republic Act No. 496, as amended, tasked with the duty to
record title to property with office address at Hall of Justice Compound,
Luzuriaga St., Bacolod City, Negros Occidental(sample address);

4. That the landholding formerly owned by (NAME OF LAND OWNER)

particularly described as LOT NO. ________ WITH ROD NO.
__________ AN AREA OF _________ HECTARES, and is situated at
(ADDRESS);

5. That the occupancy of petitioner since 1993 continuously up to the

present, in the portion of LOT NO. ________ WITH ROD NO. _______
AN AREA OF ________ HECTARES, and is situated at (address); is
evidenced by the certification of Punong Barangay (NAME OF PUNONG
BARANGAY) of (ADDRESS), and other require documents.

6. That also herein petitioner has a willingness, aptitude, and ability to

cultivate and make the land as possible as mandated by the program, as
evidenced by her actual occupancy in the portion LOT NO. ______
WITH ROD NO. _______ AN AREA OF ________ HECTARES, and is
situated at (ADDRESS); and the actual occupant of the petitioner is
almost (NUMBER OF HECTARE) hectare more or less at the present;

7. That the petitioners filed petition for exclusion in the name of (NAME
OF PERSON TO EXCLUDED) of LOT NO. ______ WITH ROD NO.
_______ AN AREA OF ________ HECTARES, because he Transact of
illegal activities (Prenda, mortgage, sale of rights and others)
8. That the petitioner, as an actual Occupant-farmer beneficiary, would like
to avail herself of the rights and privileges of a pauper litigant as
mandated under our Agrarian laws.

WHERFORE, premises considered, it is most respectfully prayed of the

Honorable Board that, after hearing of the case on it merit, judgments shall
issue for the Cancellation of mother CLOA and issue for the individual
CLOA and included the name of the petitioner (NAME OF PETITIONERS),
as CARP beneficiary.

Other reliefs and remedies are likewise prayed for.

PETITIONERS;

_________________ ________________ ________________

Affiant Affiant Affiant
Republic of the Philippines )
Province of Negros Occidental ) S.S
x-----------------------------------------x

VERIFICATION AND DISCLOSURE STATEMENT

I, (NAME OF PETITIONER), of legal age, Filipino and a resident of

(ADDRESS OF PETITIONER), Philippines. After having been duly sworn to in
accordance with law do hereby depose and say:

1. That I petitioner in the case of bar and have caused the preparation of the
petition;

2. That I have read the pleading and confirm that the allegation therein are true
and correct as of our personal knowledge or based on authentic record ; and

3. That I further certify that I have not commenced and/or are not aware on any
action or proceeding involving the same land , or a portion thereof , or issue
in any court, tribunal , or quasi-judicial agency; and to the best of our
knowledge , no such action or proceeding is pending in any court , tribunal, or
quasi-judicial agency , and if I should thereafter learn that the same or similar
action or claim has been filed or is pending, shall report that fact within five (5)
days therefrom to the DAR Office where this aforesaid Petition for Cancellation
has been filed.

_________________ ________________ ________________

Affiant Affiant Affiant
ID No.___________ ID No.__________ ID No.__________
Issued by_________ Issued by________ Issued by_________
Issued on_________ Issued on________ Issued on_________

SUBSCRIBED AND SWORN to before me this _____ day of (MONTH),

(YEAR) at (name of city/mun.), Negros Occidental. Affiant me this competent to
exhibited evidence or identity as above-stated. And I hereby certify that I have
personally examined the affiant and I am satisfied that he voluntarily executed and
understood his verification and Disclosure Statement.

Doc. No._______
Page no._______ NOTARY PUBLIC
Book no._______
Series of 2021