Republic of the Philippines )

Province of Leyte ) S.S.

Municipality of _______ )

SWORN STATEMENT

I, ___________, of legal age, Filipino, married and a resident of ___________________,

after having been duly sworn to in accordance with law hereby depose and state:

1. That I am aware that _______ was placed under the coverage of the Comprehensive
Agrarian Reform Program under Republic Act No. 6657 and Original Certificate of
Title No. _____________ was subsequently issued in favor of _________________;

2. That my father _________________ was the tenant, actual cultivator and tiller of a
portion of the above-identified lot. Thus, as one of his heirs I could validly succeed
such tenancy right;

3. That I was not informed when the Department of Agrarian Reform conducted the
identification and screening process for potential beneficiaries, thus I was erroneously
excluded as a farmer-beneficiary of said lot;

4. That I am currently in possession, occupying, cultivating and making productive a

portion of the above-described lot;

5. That I am willing, able and equipped with the aptitude to cultivate and make the land
productive;

6. That I am executing this sworn statement to attest to the truth of the foregoing
averments and to support my Petition for Inclusion/Exclusion as farmer-beneficiary of
________ under Original Certificate of Title No. ____________ and for whatever
legal purpose this may serve.

IN WITNESS WHEREOF, I have hereunto affixed my signature, this ____ day of _____
2022, in ____________________, Philippines.

_______________
Affiant
Valid ID: ___________
Issued on: _________

SUBSCRIBED and SWORN to before me, this ____ day of May at ____________,
Philippines.

Doc. No. ______; ___________________________

Page No. ______; Notary Public/Province of Leyte
Book No. ______;
Series of ______