TD WM IT M6) CNTN

2,600, OD
fLon M eNLK R. BONPon Ns
MEVN & MW g UAUgad
ChN CF 897, fLS-77
ChANOY AMA

Cho T
 iNIABLE FORM No. 51-C
Revised January, 1992
(ORIGINAL)
Official Receipt
of the
Republic of the Philippines

PAILIPP
NO 1905416 D
Date Roo7
AgencyH R CERRO6boM
Payor
feny_ L. tbes
Nature of Account
Amount
Collection Code
fee m
er

TOTAL

Amountin Words Dye ndhe

rawee Number Date
Cash Bank

Check
Money Order
ReceivedMe amount tedaNIze

AphediosCollecting
7./e ficer
-
NOTE: WrNe the number and date ol this receipt
on
the back of check or money order received.
 Republic of the Philippines
Department of Environment & Natural Resources
COMMUNITY ENVIRONMENT AND NATURAL RESOUHCES OFEICE
REEIAFD
Mobo, Masbate

Note: This application must be submitted in duplicate, otherwise t wil be rëjected

ACRICULTURALFORESHORE RECLAIMEDLAND ORMISCELLANEOUS LEASEAPPLICATION

BUREAU'OF LANDS NO. ktf=_o5A101-13
1 The undersigned hereby makes application under the provisions of Chapter VI
Commonwealth Act 141, as amended, to lease for a period of 2 year
the track of land described as
by fereahore landien_ the follows.A-pertien-£Perestore ta
Beuth byr_Fereshere-lndj on the uded nh
nee77 (Rertion seld-te-Menry-Rey rtones) nt muf Tasty s27,
situaled in thhe barrio of
Calanay ngbry
Philippines, and containing an area of.
kasbate Be
Province of.
hectare areas% centeres, the shape and dimensions of said t e f beien
shape on the back of this application.

2 My name is
1ENRY R-BRIONRS
the place of my birth is.
my age iIS
years
abanatuan Cit am a

citizen of thehilippines- and my post office address is

a SUbd,Dro, Da1i, Antipole_ciam married singale and thea a
Vd is ierie-Anpe rtoues who is a citizen of the.
am employed in the government servip (If a
government employee, he should attach to this application, permission in writing ofthe head of
the Department under which hejis working). I possess funds, personal property as follcws, with
which I expect to put. into beneficial use the land applied for within the period fixed by law

If the applicant is a corporation or association attach a certfied copy of its artictes of

incorporation or co-partnership and evidence of its having been authorized to transact business
in the Philippines.

3. 1 have been examined upon the land applied for and it contains no improvements or
indication of occupation and settlement, except as follows

area
and to the best of my knowlodga and beliof it is neither timber or mineral land contains no guano
or any deposit'of salts or goa

The. following improvements are proposed to be made on the land applied for the same
o be used solely foreacb purposes. (State kind and approximate value of
Resprt
proposes improvements, such as houses, warehouse, factories, wharves, docks, piers. etc. (If
the land will be devoted for agricultural purposes, state the crops to be raised)_
Gettages,atas- ameuntiag-te 0,0000
4. That application is made in good faith for the exclusive benefits ofthe applicant and not either
directly or indirectly, for the benefit of any other person, corporation, assaciation or parthership
and for the actual purpose of using the land for subject specified on this application and for no
other purposes. It will not sell, assign, transfer, subject or in any manner encumber the land or
the right or rights that I may accquire, without the approval of the Secretary of Natural Resources
first had been oblained as provide in Section 40 of Commonwealth Act 141, as amended

5. I agree to defray all the expenses that might be incurred in the suryey of the land applied for
in the advertisement of this application and other legal and necessary expenses and to deposit
on account thereof such amounts ns the Director of LiUNds may iequire and to confprm to
delinitation, classification, survey
of re-suivey of
the lahd applied fQr . D CATRN AEE
6. I am . a member, stockholde. officer.ngpresentative, attorney. agent,
employee. or bondholder of the following corporations, associat or partnership whigh àre
engaged in agrioulture and are holders of agricultural lands in the pines.

w.R.NO/705RLP A
************A* ****
L
 or
7.1understand that this application conveys no right to me to énter úpon, occupy. cultivate,
makes clearing on the land until the same has: Been finallýiáppròvedi iand a lease contract
executed, and that any lease applicant who shall willfully and knowingly submit false.statement
shall be deemed guilty of
or execute false affidavits in conrnection with the foregoing application

perjury and punished by a fine of not more than two thousand pesos and by imprisonment of not
and in addition thereto more than. two thousand. pesos land .by
more than five years.
imprisonment of not more than five years and in addition thereto his applicant
shall be cancelled
shall not be entitld
andall anmount paid on account thereof forfeited.in the goyerhment.andhe
to apply for any public land of the Philippines

(Signalure of Applicant)

AFFIBA VIT
. A

REPUBLIC OF THE PHILIPPINES)

PROWNCF.OF MASBATE S
MUNICity of Masbate

8.1 The person making,: this

Jenry o duly sworn, upon my oath depose and any that Fhave road or have had
riones-
application first being

road to me thoroughly understand the application thatI signed this application and
foregoing
this affidavit in the presence of the officer who, administerd the,oath that each and every
statement and said applicalion istrue and correct. SO HE,P ME GOD.

Applicant

9. BEFORE ME, at the placa aforesaid in the day of etober

personally appeared personally Known to me to
be the same person whose haihe appearslh the foregoing application, and in my presence to
signed the said application and subscribed and sworn to this affidavit.

10 The affiant exhibitud to me his Residence Certificate No.

ssued at-Antiole i sajd
on the
d residence certificate
rasidence day of-SoptenbeVear
which show him at he date of certificate to be,
be.
of age.

TO ALL. OF WHICH I CERTIFY.

Notarial Register No. Page No Book No.

Series No
S0.1

LIAS C. RAMIREZ
LOT ? T? Land manarementa dutinseoath
Oficer auilorizodto acitiniseoath