LTC Form No.

Republic of the Philippines )

City/Municipality of ) S.s
Province of Masbate )

APPLICATION FOR ISSUANCE OF LAND TRANSFER CLEARANCE (LTC)

WE, HRS. OF JUANITO BAILON REP. BY THE SPOUSE JEANENA CHING

BAILON and DEOLITA B. DELA CRUZ, both of legal ages, Filipino citizens, married/single
and residents of Poblacion, Cataingan, Masbate, after being sworn in accordance with law,
hereby depose and state that:

1. We are the parties in a ______________________________ involving a parcel of land

covered by TCT/OCT No. P-17285, with Lot Not No.__________, Survey No.
______________, with an area of 2.8344 (hectares), more or less, and located at Gahit,
Cataingan, Masbate or declared under Tax Declaration (TD) No. _____________________;

2. This application for the issuance of Land Transfer Clearance (LTC) is not contrary to law
because both of us are qualified to dispose and acquire described above. In addition, the
said land is neither covered under the agrarian reform program not within the CARPER
LAD balance and that the deed/contract will not violate the retention limit provided
under the law;

3. In support thereto and compliance with DAR A O No. 4 Series of 2021, the mandatory
documents are hereto attached and made integral parts hereof as(please check
appropriate box):

3.1 FOR THE TRASFEROR (All in original copies)

 Official Receipt/Deposit Slip (P2,000) :Annex____

 Electronic Copy of the Title issued within 6 months prior to the :Annex____
date of fling this application for LTC but if copy of the ROD
is lost, a Certification of Lost is issued by the ROD
 Certified True Copy of the Tax Declaration :Annex____
(whether titled or untitled)
 Deed of Conveyance or document to be registered (notarized) :Annex____
 Affidavit of Aggregate Landholding/Retention/ :Annex____
No Pending Case/Non-Tenancy of the transferor and spouse
 Affidavit of Tenancy if tenanted with attached: :Annex____
○ Written Notice to tenant :Annex____
○ Proof of Receipt by tenant :Annex____
 Municipal Assessor’s Certificate of Aggregate Landholding :Annex____
of the transferor and spouse issued within 6 months
prior to the date of fling this application for LTC
 City Assessor’s Certificate of Aggregate Landholding :Annex____
of the transferor and spouse issued within 6 months
prior to the date of fling this application for LTC
 Provincial Assessor’s Certificate of Aggregate Landholding :Annex____
of the transferor and spouse issued within 6 months
prior to the date of fling this application for LTC

3.2 FOR THE TRANSFEREE (All in original copies)

 Affidavit of Aggregate Landholding :Annex____

 Municipal Assessor’s Certificate of Aggregate Landholding :Annex____
of the transferee and spouse issued within 6 months
 LTC Form No.2

prior to the date of fling this application for LTC

 City Assessor’s Certificate of Aggregate Landholding :Annex____
of the transferee and spouse issued within 6 months
prior to the date of fling this application for LTC
 Provincial Assessor’s Certificate of Aggregate Landholding :Annex____
of the transferee and spouse issued within 6 months
prior to the date of fling this application for LTC
 BARC Acknowledgement Receipt :Annex____
 MARPO Certification (LTC Form No. 2) :Annex____

4. Having submitted/attached hereof the mandatory documents as required under DAR

A.O No.4, Series of 2021, I/we hereby file this instant application/request to facilitate the
issuance of the corresponding Certificate on LTC.

IN WITNESS WHEREOF, we have hereunto set our hands this _________ day of
___________________ 20___ at ______________________________________, Philippines.

JEANENA CHING BAILON DEOLITA B. DELA CRUZ

Applicant Applicant
(Transferor/Seller) (Transferee/Buyer)
ID No. _______________________ ID No. _______________________
Date Issued: __________________ Date Issued: __________________

Place Issued: _________________ Place Issued: _________________

Spouse of the Applicant Spouse of the Applicant

(Transferor/Seller) (Transferee/Buyer)
ID No. _______________________ ID No. _______________________
Date Issued: __________________ Date Issued: __________________

Place Issued: _________________ Place Issued: _________________

SUBSCRIBED AND SWORN to before me this _____ day of ______________ 20_____ at

___________________________ affiants upon exhibiting to me their duly issued government IDs
with details stated above.

NOTARY PUBLIC

Doc No. ____;

Book No. ____;
Page No. ____;
Series of 20___.
Copy Distribution:
Original – DARPO/LTC Folder
Duplicate - Applicant
LTC Form No. 1

Republic of the Philippines )

City/Municipality of ) S.s
Province of Masbate )

APPLICATION FOR ISSUANCE OF LAND TRANSFER CLEARANCE (LTC)

WE, HRS. OF JUANITO BAILON REP. BY THE SPOUSE JEANENA CHING

BAILON and DEOLITA B. DELA CRUZ, both of legal ages, Filipino citizens, married/single
and residents of Poblacion, Cataingan, Masbate, after being sworn in accordance with law,
hereby depose and state that:

1. We are the parties in a ______________________________ involving a parcel of land

covered by TCT/OCT No. P-17287, with Lot Not No.__________, Survey No.
______________, with an area of 1.7069 (hectares), more or less, and located at Gahit,
Cataingan, Masbate or declared under Tax Declaration (TD) No. _____________________;

2. This application for the issuance of Land Transfer Clearance (LTC) is not contrary to law
because both of us are qualified to dispose and acquire described above. In addition, the
said land is neither covered under the agrarian reform program not within the CARPER
LAD balance and that the deed/contract will not violate the retention limit provided
under the law;

3. In support thereto and compliance with DAR A O No. 4 Series of 2021, the mandatory
documents are hereto attached and made integral parts hereof as(please check
appropriate box):

3.1 FOR THE TRASFEROR (All in original copies)

 Official Receipt/Deposit Slip (P2,000) :Annex____

 Electronic Copy of the Title issued within 6 months prior to the :Annex____
date of fling this application for LTC but if copy of the ROD
is lost, a Certification of Lost is issued by the ROD
 Certified True Copy of the Tax Declaration :Annex____
(whether titled or untitled)
 Deed of Conveyance or document to be registered (notarized) :Annex____
 Affidavit of Aggregate Landholding/Retention/ :Annex____
No Pending Case/Non-Tenancy of the transferor and spouse
 Affidavit of Tenancy if tenanted with attached: :Annex____
○ Written Notice to tenant :Annex____
○ Proof of Receipt by tenant :Annex____
 Municipal Assessor’s Certificate of Aggregate Landholding :Annex____
of the transferor and spouse issued within 6 months
prior to the date of fling this application for LTC
 City Assessor’s Certificate of Aggregate Landholding :Annex____
of the transferor and spouse issued within 6 months
prior to the date of fling this application for LTC
 Provincial Assessor’s Certificate of Aggregate Landholding :Annex____
of the transferor and spouse issued within 6 months
prior to the date of fling this application for LTC

3.2 FOR THE TRANSFEREE (All in original copies)

 Affidavit of Aggregate Landholding :Annex____

 Municipal Assessor’s Certificate of Aggregate Landholding :Annex____
of the transferee and spouse issued within 6 months
 LTC Form No.2

prior to the date of fling this application for LTC

 City Assessor’s Certificate of Aggregate Landholding :Annex____
of the transferee and spouse issued within 6 months
prior to the date of fling this application for LTC
 Provincial Assessor’s Certificate of Aggregate Landholding :Annex____
of the transferee and spouse issued within 6 months
prior to the date of fling this application for LTC
 BARC Acknowledgement Receipt :Annex____
 MARPO Certification (LTC Form No. 2) :Annex____

4. Having submitted/attached hereof the mandatory documents as required under DAR

A.O No.4, Series of 2021, I/we hereby file this instant application/request to facilitate
the issuance of the corresponding Certificate on LTC.

IN WITNESS WHEREOF, we have hereunto set our hands this _________ day of
___________________ 20___ at ______________________________________, Philippines.

JEANENA CHING BAILON DEOLITA B. DELA CRUZ

Applicant Applicant
(Transferor/Seller) (Transferee/Buyer)
ID No. _______________________ ID No. _______________________
Date Issued: __________________ Date Issued: __________________

Place Issued: _________________ Place Issued: _________________

Spouse of the Applicant Spouse of the Applicant

(Transferor/Seller) (Transferee/Buyer)
ID No. _______________________ ID No. _______________________
Date Issued: __________________ Date Issued: __________________

Place Issued: _________________ Place Issued: _________________

SUBSCRIBED AND SWORN to before me this _____ day of ______________ 20_____ at

___________________________ affiants upon exhibiting to me their duly issued government IDs
with details stated above.

NOTARY PUBLIC

Doc No. ____;

Book No. ____;
Page No. ____;
Series of 20___.
Copy Distribution:
Original – DARPO/LTC Folder
Duplicate - Applicant

Republic of the Philippines )

City/Municipality of ) S.s
Province of Masbate )

AFFIDAVIT OF THE TRANSFEROR/SELLER

I/WE, HRS. OF JUANITO BAILON REP. BY THE SPOUSE JEANENA CHING
BAILON, of legal age, Filipino citizen, married/single/widow/widower and residents of
Poblacion, Cataingan, Masbate, after being sworn in accordance with law, hereby depose and
state:

1. That the total aggregate landholding transferred/sold by me/ me and my spouse to

DEOLITA B. DELA CRUZ involving a parcel of land covered by TCT/OCT No. P-17285,
with Lot Not No.__________, Survey No. ______________, with an area of 2.8344 (hectares),
more or less, and located at Gahit, Cataingan, Masbate or declared under Tax Declaration
(TD) No. _____________________ through a Deed of _____________________ under Doc.
No. 2555, Page No. 92, Book No. 179, Series of 2020, dated on November 16, 2020 of Notary
Public Atty. Ruben A. Songco, does not exceed five (5) hectares and is my retention area or
a portion of my retention area pursuant to Section 6 of RA 6657, as amended.
2. That the said parcel of land has no pending case before any regular court or any other
tribunal and/or has been the subject of a case before the court of
__________________________________ docketed as _________________________________
decided on __________________ and became final on _______________________________;
3. That the said parcel of land is not tenanted, nor is it occupied by any leaseholders, hence,
this instrument is not in violation of RA 6657, as amended; RA 3844, as amended; and other
agrarian laws.
4. That this affidavit is executed in compliance with DAR A. O. 4, Series of 2021.
IN WITNESS WHEREOF, we have hereunto set our hands this _________ day of
___________________ 20___ at ______________________________________, Philippines.

JEANENA CHING BAILON

Affiant Affiant

ID No. _______________________ ID No. _______________________

Date Issued: __________________ Date Issued: __________________

Place Issued: _________________ Place Issued: _________________

SUBSCRIBED AND SWORN to before me this _____ day of ______________ 20_____ at

___________________________ affiants upon exhibiting to me their duly issued government IDs
with details stated above.

NOTARY PUBLIC
Doc No. ____;
Book No. ____;
Page No. ____;
Series of 20___.

Republic of the Philippines )

City/Municipality of ) S.s
Province of Masbate )

AFFIDAVIT OF THE TRANSFEROR/SELLER

I/WE, HRS. OF JUANITO BAILON REP. BY THE SPOUSE JEANENA CHING
BAILON, of legal age, Filipino citizen, married/single/widow/widower and residents of
Poblacion, Cataingan, Masbate, after being sworn in accordance with law, hereby depose and
state:

1. That the total aggregate landholding transferred/sold by me/ me and my spouse to

DEOLITA B. DELA CRUZ involving a parcel of land covered by TCT/OCT No. P-17287,
with Lot Not No.__________, Survey No. ______________, with an area of 1.7069 (hectares),
more or less, and located at Gahit, Cataingan, Masbate or declared under Tax Declaration
(TD) No. _____________________ through a Deed of _____________________ under Doc. No.
2555, Page No. 92, Book No. 179, Series of 2020, dated on November 16, 2020 of Notary
Public Atty. Ruben A. Songco, does not exceed five (5) hectares and is my retention area or
a portion of my retention area pursuant to Section 6 of RA 6657, as amended.
2. That the said parcel of land has no pending case before any regular court or any other
tribunal and/or has been the subject of a case before the court of
__________________________________ docketed as _________________________________
decided on __________________ and became final on _______________________________;
3. That the said parcel of land is not tenanted, nor is it occupied by any leaseholders, hence, this
instrument is not in violation of RA 6657, as amended; RA 3844, as amended; and other
agrarian laws.
4. That this affidavit is executed in compliance with DAR A. O. 4, Series of 2021.

IN WITNESS WHEREOF, we have hereunto set our hands this _________ day of
___________________ 20___ at ______________________________________, Philippines.

JEANENA CHING BAILON

Affiant Affiant

ID No. _______________________ ID No. _______________________

Date Issued: __________________ Date Issued: __________________

Place Issued: _________________ Place Issued: _________________

SUBSCRIBED AND SWORN to before me this _____ day of ______________ 20_____ at

___________________________ affiants upon exhibiting to me their duly issued government IDs
with details stated above.

NOTARY PUBLIC
Doc No. ____;
Book No. ____;
Page No. ____;
Series of 20___.

Republic of the Philippines )

City/Municipality of ) S.s
Province of Masbate )

AFFIDAVIT OF AGGREGATE LANDHOLDING OF THE

TRANSFEREE/BUYER
I/WE, DEOLITA B. DELA CRUZ, of legal age, Filipino citizen,
married/single/widow/widower and resident of Poblacion, Cataingan, Masbate, after being
sworn in accordance with law, hereby depose and state:

1. That the total aggregate landholding owned by me/me and my spouse involving a
parcel of land covered by TCT/OCT No. P-17285, with Lot Not No.__________, Survey
No. ______________, with an area of 2.8344 (hectares), more or less, and located at
Gahit, Cataingan, Masbate or declared under Tax Declaration (TD) No.
_____________________ acquiring from a Deed of Extra Judicial Settlement with
Simultaneous Sale under Doc. No. 2555, Page No. 92, Book No. 179, Series of 2020,
dated on November 16, 2020 of Notary Public Atty. Ruben A. Songco, does not exceed
five (5) hectares and is my retention area or a portion of my retention area pursuant to
Section 6 of RA 6657, as amended.;

2. That this affidavit is executed in compliance with DAR A. O. 4, Series of 2021.

IN WITNESS WHEREOF, we have hereunto set our hands this _________ day of
___________________ 20___ at ______________________________________, Philippines.

DEOLITA B. DELA CRUZ

Affiant Affiant

ID No. _______________________ ID No. _______________________

Date Issued: __________________ Date Issued: __________________

Place Issued: _________________ Place Issued: _________________

SUBSCRIBED AND SWORN to before me this _____ day of ______________ 20_____ at

___________________________ affiants upon exhibiting to me their duly issued government IDs
with details stated above.

NOTARY PUBLIC
Doc No. ____;
Book No. ____;
Page No. ____;
Series of 20___.

Republic of the Philippines )

City/Municipality of ) S.s
Province of Masbate )

AFFIDAVIT OF AGGREGATE LANDHOLDING OF THE

TRANSFEREE/BUYER
I/WE, DEOLITA B. DELA CRUZ, of legal age, Filipino citizen,
married/single/widow/widower and resident of Poblacion, Cataingan, Masbate, after being
sworn in accordance with law, hereby depose and state:

1. That the total aggregate landholding owned by me/me and my spouse involving a
parcel of land covered by TCT/OCT No. P-17287, with Lot Not No.__________, Survey
No. ______________, with an area of 1.7069 (hectares), more or less, and located at
Gahit, Cataingan, Masbate or declared under Tax Declaration (TD) No.
_____________________ acquiring from a Deed of Extra Judicial Settlement with
Simultaneous Sale under Doc. No. 2555, Page No. 92, Book No. 179, Series of 2020,
dated on November 16, 2020 of Notary Public Atty. Ruben A. Songco, does not exceed
five (5) hectares and is my retention area or a portion of my retention area pursuant to
Section 6 of RA 6657, as amended.;

2. That this affidavit is executed in compliance with DAR A. O. 4, Series of 2021.

IN WITNESS WHEREOF, we have hereunto set our hands this _________ day of
___________________ 20___ at ______________________________________, Philippines.

DEOLITA B. DELA CRUZ

Affiant Affiant

ID No. _______________________ ID No. _______________________

Date Issued: __________________ Date Issued: __________________

Place Issued: _________________ Place Issued: _________________

SUBSCRIBED AND SWORN to before me this _____ day of ______________ 20_____ at

___________________________ affiants upon exhibiting to me their duly issued government IDs
with details stated above.

NOTARY PUBLIC
Doc No. ____;
Book No. ____;
Page No. ____;
Series of 20___.

Republic of the Philippines

BARANGAY AGRAGRIAN REFORM COMMITTEE
Municipality of ________________
Barangay of __________________

ACKNOWLEDGEMENT RECEIPT

TO WHOM IT MAY CONCERN:

This is to acknowledge the receipt of the duly notarized Affidavit of the Aggregate
Landholding of the Buyer/Transferee DEOLITA B. DELA CRUZ as required in the application
for DAR Land Transfer Clearance pursuant to DAR A.O. No. 4, Series of 2021 involving the
sale of parcel of agricultural land covered by OCT/TCT No. P-17285, with Tax declaration No.
___________________, Lot No. __________________, containing an area of 2.8344 hectares
located at Gahit, Cataingan, Masbate.

Done this _______ day of ____________________, 20____ at

_____________________, Masbate Philippines.

RANDY DELA CRUZ

BARC Chairman
 Republic of the Philippines
BARANGAY AGRAGRIAN REFORM COMMITTEE
Municipality of ________________
Barangay of __________________

ACKNOWLEDGEMENT RECEIPT

TO WHOM IT MAY CONCERN:

This is to acknowledge the receipt of the duly notarized Affidavit of the Aggregate
Landholding of the Buyer/Transferee DEOLITA B. DELA CRUZ as required in the application
for DAR Land Transfer Clearance pursuant to DAR A.O. No. 4, Series of 2021 involving the
sale of parcel of agricultural land covered by OCT/TCT No. P-17287, with Tax declaration No.
___________________, Lot No. __________________, containing an area of 1.7069 hectares
located at Gahit, Cataingan, Masbate.

Done this _______ day of ____________________, 20____ at

_____________________, Masbate Philippines.

RANDY DELA CRUZ

BARC Chairman
 SPECIAL POWER OF ATTORNEY

KNOW ALL MEN BY THESE PRESENTS:

That we, the hrs. of JUANITO BAILON, namely, JEANENA CHING BAILON (wife), MA.
BRENDA B. ABO (daughter), MA. BELLA C. BAILON (daughter), MA. BRILLA B. MARISTELA
(daughter) and MA. BRITTA B. REJUSO, all residents of Poblacion, Cataingan, Masbate, to do
hereby NAME, CONSTITUTE AND APPOINT, ROSLIE M. BRIOSO, also of legal age, Filipino, and
with residence at Brgy. Sta. Teresita, Cataingan, Masbate.

To be our true lawful Attorney-in-Fact, for us and in our name, place and stead, to do and
perform the following acts and things, namely:

1. To transact with the buyer of our property regarding the transfer of property in the name of
DEOLITA B. DELA CRUZ and/or secure DAR Clearance for the land, located at Gahit,
Cataingan, Masbate;
2. To represents us before the Office of the Municipal and Provincial assessor, the Register of
Deeds (ROD), Bureau of Internal Revenue (BIR);
3. To receive, signs, execute any and all documents, before the abovementioned offices relating to
the transfer of documents in the name of DEOLITA B. DELA CRUZ;
4. To sign, execute on our behalf, and receive, any and all papers, documents or instruments
necessary to carryout aforementioned purposes;

HEREBY GIVING AND GRANTING unto our said Attorney-in-Fact full power and authority, to
do and perform all and every act requisite or necessary to carry in effect of the foregoing authority as
fully with all intents and purposes as we could lawfully do if personally present, hereby ratifying and
confirming all that our said Attorney-in-Fact shall do or cause to be done by virtue of these presents.

IN WITNESS WHEREOF, we have hereunto affixed our signature this ______ day of
__________________ 20____, at Masbate City, Philippines.

JEANENA CHING BAILON MA. BRENDA B. ABO MA. BELLA C. BAILON

Grantor Grantor Grantor

MA. BRILLA B. MARISTELA MA. BRITTA B. REJUSO

Grantor Grantor

ROSLIE M. BRIOSO
Attorney-in-Fact

SUBSCRIBED AND SWORN TO before me this _______ day of __________________

20____, affiants exhibiting CTC Nos.:

Name CTC Num. Issued On Issued At

 NOTARY PUBLIC
Doc. No. _______
Page No. _______
Book No. _______
Series of ________

SPECIAL POWER OF ATTORNEY

KNOW ALL MEN BY THESE PRESENTS:

That we, the hrs. of ______________________________, namely,

_______________________________________________________, all residents of
__________________________________, to do hereby NAME, CONSTITUTE AND APPOINT,
________________________________, also of legal age, Filipino, and with residence at Brgy.
___________________________________.

To be our true lawful Attorney-in-Fact, for us and in our name, place and stead, to do and
perform the following acts and things, namely:

1. To transact with the buyer of our property regarding the transfer of property in the name of
_________________________________ and/or secure DAR Clearance for the land, located at
_________________________________________;
2. To represents us before the Office of the Municipal and Provincial assessor, the Register of
Deeds (ROD), Bureau of Internal Revenue (BIR);
3. To receive, signs, execute any and all documents, before the abovementioned offices relating to
the transfer of documents in the name of _____________________________________;
4. To sign, execute on our behalf, and receive, any and all papers, documents or instruments
necessary to carryout aforementioned purposes;

HEREBY GIVING AND GRANTING unto our said Attorney-in-Fact full power and authority, to
do and perform all and every act requisite or necessary to carry in effect of the foregoing authority as
fully with all intents and purposes as we could lawfully do if personally present, hereby ratifying and
confirming all that our said Attorney-in-Fact shall do or cause to be done by virtue of these presents.

IN WITNESS WHEREOF, we have hereunto affixed our signature this ______ day of
__________________ 20____, at Masbate City, Philippines.

Grantor Grantor Grantor

Grantor Grantor

Attorney-in-Fact

SUBSCRIBED AND SWORN TO before me this _______ day of __________________

20____, affiants exhibiting CTC Nos.:

Name CTC Num. Issued On Issued At

 NOTARY PUBLIC
Doc. No. _______
Page No. _______
Book No. _______
Series of ________