AFFIDAVIT

I, _________________________________________________________________________ of legal age single/married, Filipino

Citizen with postal address and residence at _________________________________________ after being sworn to in accordance
with law, hereby depose and state the following:

1. That I am the lawful owner of certain parcel(s) of land located at Barangay _________________________________
Imelda with an area of ____________ square meters/hectares, covered by _______________________________ (Tax
Declaration No./Certification of Land Title/Deed of Sale, etc.);

2. That, the above-mentioned property(ies) is/are the subject of application for Locational Clearance
Certificate of Zoning Compliance for the project _____________________________________
___________________________________________________________; (state project type)

3. That I am giving authority to Mr./Mrs./Ms. _____________________________________________________ to construct

his/her project thereat;

4. That to the best of any knowledge, the above mentioned property/ies is/are situated within alienable
and disposable lands and outside from lands reserved for public domain;

5. That, to the best of my knowledge, the above mentioned property/ies is/are free from any liens or
encumbrances other than _____________________________________________________________;
(indicate/lies/encumbrances, if any)

6. That, I am executing this affidavit to attest in the veracity of the above-stated facts thereby satisfying the
requirements of the municipality of Villanueva / Housing and Regulatory Board (HLURB)relative to the
application for Locational Clearance/Certificate of Zoning Compliance for the project above-mentioned.

Affiant further says nothing.

Done this _____________________________________at Villanueva, Misamis Oriental, Philippines.

________________________________________
Affiant

ACKNOWLEDGEMENT

Republic of the Philippines

(Municipality of Villanueva) S.S.

SUBSCRIBED AND SWORN TO before me this ______day of _____________________, _________, affiant

exhibiting to me his/her Community Tax Certificate No. __________, issued at _________________________________
on ____________________.

________________________
Notary Public