REPUBLIC OF THE PHILIPPINES )

PROVINCE OF PANGASINAN ) S.S

MUN. OF ______________________ )

AFFIDAVIT OF CANCELLATION

That I, _________________________, of legal age, Filipino citizen, and resident of

Brgy. ____________________, __________________________, Pangasinan, after having been
duly sworn to in accordance with law hereby depose and say:

That I am one of the heirs of the late __________________________ who originally in

actual, continuous, open, notorious and exclusive possession and occupation of a parcel of land
identified as Lot ___________________________, situated at Brgy. _____________,
________________________, ______________________, containing an area of
________________________6 square meters;

That said parcel of land is inherited by my late father __________________________

from his father __________________________________;

That lately, I found out that Lot _____________________________, situated at Brgy.

____________________________, ________________________, _____________________
was previously applied for Free Patent Application only by my sister _____________________
under F. P. A. No. _____________________; However, this application did not repined into a
patent;

That I hereby request the authorities concerned particularly the Department of

Environment and Natural Resources to please cause the Cancellation of the Free Patent
Application issued because said parcel of land is not only for my sister ___________________
but it is for all of us the six children of my late father _______________________;

That I have read and fully understood the contents of this Affidavit, that I was not forced,
influenced or intimidated in the execution of this Affidavit but it is my own free act and
voluntary deed and that I hereby affirm to the truth of all the foregoing.

IN WITNESS WHEREOF, I have hereunto set my hand this ________ day of

________________, 2010 at ______________________, _____________________, Philippines.

__________________________________
CTC No. __________________
Issued on __________________
Issued at __________________

SUBSCRIBED AND SWORN to before me this ____________ day of

____________________, 2010 at _______________________, ________________, Philippines.

Doc. No. ________;

Page No. ________;
Book No. ________;
Series of 2010.