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CARPER LAD Form No. 25
(Revised CARP-LAD Form No. 13)

Republic of the Philippines

DEPARTMENT OF AGRARIAN REFORM
Region No._______________
Province of ______________
Municipality of ____________

REQUEST FOR CERTIFICATION OF RETENTION

__________________
Date

The Provincial Agrarian Reform Officer II

_________________________________

Sir/Madam:

May I request for the issuance of a Certification of Retention for my landholding pursuant to Republic Act (R.A.)
No. 6657, as amended by R.A. No. 9700, with a total of ___________ hectares and covered by the following:

TCT/OCT No. : ______________________________

TD No. : ______________________________
Lot No. : ______________________________
Approved Survey No. : ______________________________
Location (Municipality, Barangay) : ______________________________
: ______________________________

I certify under oath my total/aggregate ownership of agricultural land nationwide is ______ has. and I have not
sold or disposed of any agricultural Landholdings after June 15, 1988. This disclosure shall bind me to place under
CARP my excess agricultural lands.

Very truly yours,

___________________________________
(Signature over Printed Name of Landowner)

SUBSCRIBED and SWORN to before me, A Notary Public, this _____ day of
________________________, 20__, at ___________________________________, the above-named landowner
presented to me his/her Identification No. ___________ issued by _______________, valid until
______________, and he/she personally attested to me that the statements contained in herein are all true and
factual.
__________________________________
Notary Public

Doc. No. _____

Page No. _____
Book No. _____
Series of _____

Copy Distribution:
Original - DARPO
Duplicate - Landowner
Triplicate - DARMO