Republic of the Philippines )

City/Municipality of ) S.S.

AFFIDAVIT OF UNDERTAKING FOR UNTITLED LAND

I, __________________________________________________________, Filipino citizen of legal age,

single/married with residence and postal address at _________________________________________________
after having been duly sworn in accordance with the law hereby depose and say:

That, I am the owner of certain parcel/s of land located at

___________________________________________________________________________ with an area of
________________________________ square meters/hectares, covered by Tax Declaration No./s
_______________________________________ as herewith furnished:

That, the said parcel/s of land was/were acquired through:

___________________________________________________________________________ (state
whether by sale or inheritance, etc.)

That, the said parcel/s of land has/have not yet been issued Certificate of Title/s due to the
following reasons:
___________________________________________________________________________
___________________________________________________________________________
__________________________________________________________________________;

That, the said property/ies is/are alienable and disposable land/s outside land/s reserved
for public domain;

That, the said property/ies is/are free from any lien or encumbrance;

That, the said property/ies which is/are classified as agricultural/ forest land/s is/are not
tenanted, and if tenanted, the name/s of the tenant/s is/are herewith furnished;

That, there are no other claimants to the property/ies as verified from the municipality
where the said property/ies is/are located;

That, I am executing this affidavit to attest to the veracity of the aforementioned facts in connection
with my application for the designation of the property as a TEZ under R.A. 9593

IN WITNESS WHEREOF, I have hereunto affix my hand and signature on this ________ day of
__________________. 20____, in the City/Municipality of _____________________________________.

AFFIANT

NOTARY PUBLIC

Doc. No. _____

Page No. _____
Book No. _____
Series of ______