ANNEX C ADR Form Number 003

INFORMATION OWNER AND ADJOINING OWNERS OF THE LOT

1. NAME: ______________________________________ OWNED LOT: ___________________

PLACE OF BIRTH: ____________________________ DATE OF BIRTH: ________________
SEX: ________________ CIVIL STATUS: ___________________ AGE: _______
HOME ADDRESS: ________________________________________________________________
NAME OF SPOUSE: _______________________________________________________________

2. NAME: ______________________________________ OWNED LOT: ___________________

PLACE OF BIRTH: ____________________________ DATE OF BIRTH: ________________
SEX: ________________ CIVIL STATUS: ___________________ AGE: _______
HOME ADDRESS: ________________________________________________________________
NAME OF SPOUSE: _______________________________________________________________

3. NAME: ______________________________________ OWNED LOT: ___________________

PLACE OF BIRTH: ____________________________ DATE OF BIRTH: ________________
SEX: ________________ CIVIL STATUS: ___________________ AGE: _______
HOME ADDRESS: ________________________________________________________________
NAME OF SPOUSE: _______________________________________________________________

4. NAME: ______________________________________ OWNED LOT: ___________________

PLACE OF BIRTH: ____________________________ DATE OF BIRTH: ________________
SEX: ________________ CIVIL STATUS: ___________________ AGE: _______
HOME ADDRESS: ________________________________________________________________
NAME OF SPOUSE: _______________________________________________________________

5. NAME: ______________________________________ OWNED LOT: ___________________

PLACE OF BIRTH: ____________________________ DATE OF BIRTH: ________________
SEX: ________________ CIVIL STATUS: ___________________ AGE: _______
HOME ADDRESS: ________________________________________________________________
NAME OF SPOUSE: _______________________________________________________________

6. NAME: ______________________________________ OWNED LOT: ___________________

PLACE OF BIRTH: ____________________________ DATE OF BIRTH: ________________
SEX: ________________ CIVIL STATUS: ___________________ AGE: _______
HOME ADDRESS: ________________________________________________________________
NAME OF SPOUSE: _______________________________________________________________

7. NAME: ______________________________________ OWNED LOT: ___________________

PLACE OF BIRTH: ____________________________ DATE OF BIRTH: ________________
SEX: ________________ CIVIL STATUS: ___________________ AGE: _______
HOME ADDRESS: ________________________________________________________________
NAME OF SPOUSE: _______________________________________________________________

8. NAME: ______________________________________ OWNED LOT: ___________________

PLACE OF BIRTH: ____________________________ DATE OF BIRTH: ________________
SEX: ________________ CIVIL STATUS: ___________________ AGE: _______
HOME ADDRESS: ________________________________________________________________
NAME OF SPOUSE: _______________________________________________________________