Luc 2

LUC FORM NO.
2
SERIES OF 2002
REPUBLIC OF THE PHILIPPINES

MUNICIPALITY OF ______________ ]
PROVINCE OF _________________ ]s.s.
DAR - CALABARZON
AFFIDAVIT OF UNDERTAKING
I, ______________________,
ANJUVEL AÑASCO of legal age, citizen of the
______________________,
PHILIPPINES single or married to ______________________,
RICARDO CONSTANTINO and
with residence address at ________________________having
SAN JOSE, ANTIPOLO CITY, RIZAL been duly sworn in
accordance with law, hereby depose and say that:
1. I am the owner/(authorized representative of the owner[s]) of the

_______________________________________________________
____(number)
1 parcel(s) of land subject of an application for conversion.
2. The land subject of my application for conversion has no vertical nor

horizontal development of any kind that is related to any non-agricultural use.
3. As a sign of good faith, I posted a bond to guarantee the present status of the
land and my/our obligation not to conduct and not to allow any development of
any nature by any person, whether or not acting on my/our behalf, over the
entire property subject of the conversion application, until such time that the
DAR has issued a Conversion Order authorizing development of the project
applied for. The bond I posted is (please write a check mark in the appropriate
*
box) :
[ ] Cash Bond
Amount: ____________________________ Pesos

I hereby state under oath that the above amount is equivalent to two
point five percent (2.5%) of the zonal value of the land applied for
conversion per latest valuation by the Department of Finance.
Official Receipt date: ___________________

Official Receipt number: _________________
Official Receipt issued by:
[ ] DAR Central Office
[ ] DAR Regional Office of __________________
(state region number)
*
Not applicable to application exempt from posting of bond to guarantee against premature conversion
as specified in Sec. 24.5 of DAR AO No. 1, S. 2002.
[ ] Government Service Insurance System (GSIS) Surety Bond, the
original and a clear photocopy of which are attached to this
Affidavit.
Amount: ____________________________ Pesos

I hereby state under oath that the above amount is equivalent to fifteen
percent (15%) of the zonal value of the land applied for conversion per
latest valuation by the Department of Finance.
Surety Bond Date: ________________________

Surety Bond Number: ______________________
4. The total number of farmers, agricultural lessees, share tenants, farmworkers,

actual tillers, occupants, or others directly working on the land is (please write
a check mark in the appropriate box):
[/ ] None
[ ] ________ persons. Their names are (use separate sheet when
necessary):
________________________ _______________________
________________________ _______________________
________________________ _______________________
________________________ _______________________
________________________ _______________________
________________________ _______________________
________________________ _______________________
________________________ _______________________
________________________ _______________________
________________________ _______________________
________________________ _______________________
________________________ _______________________
________________________ _______________________
________________________ _______________________
________________________ _______________________
5. I/we paid (or undertake to pay) disturbance compensation to the following
persons at the following amounts and schedule of payments (use separate
sheet when necessary):
NAME Amount Payment Date

N/A N/A N/A
6. I/we erected _____(number)
1 of billboard(s) and undertake not to remove,
deface, nor destroy said billboard(s), and that I/we shall repair or replace the
same when damaged, until after the approving authority disposes of the
application with finality.
7. I/we have not commenced any action or filed any claim involving the land
subject of my/our application for conversion in any court, tribunal or quasi-
judicial agency. To the best of my/our knowledge, no such other action or
claim is pending therein. I/we have no knowledge of any controversy or
proceeding involving the said parcel of land(s) or the rights of person over its
possession and entitlement to its fruits or rights thereto as beneficiary, the
determination of which is filed before any tribunal, court, the DAR or any other
agency. To my/our own knowledge, no such action or proceeding is pending
in any court, tribunal, or quasi-judicial agency. Should there be any same or
similar action or proceeding involving the property applied for conversion,
which is either pending or may have been terminated, I/we shall report such
fact within five (5) days from knowledge thereof to the approving authority
where my/our aforesaid application has been filed.
8. With this instrument, I/we authorize the DAR to forfeit the bond in paragraph
“3” of this affidavit the moment the DAR finds, upon proper notice, that there is
development within the area, undertaken either before or after the filing of the
present conversion application, that is related to any non-agricultural use
before the issuance of a conversion order.
IN WITNESS WHEREOF, we hereunto affix our signatures on the date and in the
place indicated below.
ANJUVEL S. AÑASCO
____________________________
LANDOWNER/APPLICANT
TIN: _________________
Community Tax Certificate
Number: _________________
Place: _________________
Date: _________________
SUBSCRIBED AND SWORN TO BEFORE ME, this day of

_________________________ in __________________, affiant exhibiting to me
his/her Community Tax Certificate No. issued on ______________________,200___
at _____________________________________________.
Document ____ Notary Public

Page ____ _____________
Book ____ _____________
Series of ____

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LUC FORM NO.

REPUBLIC OF THE PHILIPPINES

1. I am the owner/(authorized representative of the owner[s]) of the

2. The land subject of my application for conversion has no vertical nor

Amount: ____________________________ Pesos

Official Receipt date: ___________________

Amount: ____________________________ Pesos

Surety Bond Date: ________________________

4. The total number of farmers, agricultural lessees, share tenants, farmworkers,

NAME Amount Payment Date

SUBSCRIBED AND SWORN TO BEFORE ME, this day of

Document ____ Notary Public

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