LUC FORM G

SERIES OF 2002

(To be filled-up by the applicant)

REQUEST TO CONVERT/REFUND CASH BOND

To: ________________________
________________________
________________________

Dear Sir/Madam:

This refers to my application for land use conversion from agricultural to ______________________
use/s of ______________ parcel/s of land with an area of ______________ hectares, located at
Barangay/s __________________, Municipality of _________________, Province of _____________.

With the approval of my application for land use conversion on _______________________ as per
Conversion Order No. _________, Series of __________, may I request that the cash bond paid under
Official Receipt No. ____________ issued by the DAR in the amount of __________________, be:

A. ( ) converted into performance bond

B. ( ) refunded to the undersigned

_______________________________
Applicant

_______________________________
Date