Republic of the Philippines

REQUEST: ____________
Department of Environment and Natural Resources
Land Management Bureau No. _________________
Plaza Cervantes, Binondo, Manila
Due Date: ____________
The Director
Land Management Bureau
Plaza Cervantes, Binondo, Manila

Sir:
For whatever Legal purpose it may serve and upon payment of the required fees, may I respectfully request the
following:
[ ] Status [ ] Survey Records
[ ] Public Land [ ] Taguig
[ ] Friar Lands [ ] Others [ ] Plan [ ] T.D [ ] Cadastral Map
GSD Accession No.
Application No. : ________________________________________
Verify/
Name of Applicant : __________________________________________
Lot No. : __________________________________________ Signed by:
Survey No. : __________________________________________ Date Verified:
Location : __________________________________________ Note: Accession nos. do not guarantee
availability of the plan
Certified Photocopy of the following:

Purpose of the request:

Hoping that this request will be acted upon with dispatch

Requesting Party : ___________________________________________________________________

(Pangalan)
Sex : Male Female Age :________________________
(Kasarian) (Edad)
Address : ___________________________________________________________________
(Tirahan)
Identification No.: _________________________________Type/Kind : ________________________
(Pagkakakilanlan) (Uri o Klase)
Date Requested : _________________________________Date Due : _______________________
(Petsa ng Request) (Takdang Panahon)
Log Book Ref. Page No. : ___________________________ Line No. : _______________________

THUMBMARK
Very truly yours,

L R ____________________
(If case party cannot sign/has no Identification) Signature

NOTE: Request not claimed within a period of 30 days shall be subject to the filing of another request.
Strictly no follow-up/transaction ON FRIDAYS.
…………………………………………………………………………………………………………………………………………………………………
CLAIM STUB FORM
[ ] STATUS [ ] PLAN [ ] CAD MAP [ ] T.D
Name: ______________________________________________ Date Due: ______________________________
Lot Location: _________________________________________ Page No. _____________ Line No. __________
Received by: _________________________________________ Date Received: __________________________
NOTE: Accession numbers do not guarantee availability of the plan. CLAIM STUB FORM
REMINDERS: Request not claimed within 30 days shall be subject to the filling of another request. Strictly no follow – up/transaction
On Fridays. Dial 480-00-10 for your Inquiries/Further Information.
ACTION TAKEN:

Use another sheet if necessary

Verified/signed by: Date:

Checked signed by: Date:

Legal Fees:
Official Receipt No. : _________________________
1. Certification Fee P____________________

2. Copy Fee P____________________ Date Issued: _______________________________

TOTAL P____________________
FOR RESTRICTED DOCUMENTS
Pursuant to Section 3.1.4 DENR A.O. No. 97-24 dated July 30, 1997

ATTY. EMELYNE V. TALABIS

Acting Director
MR. NEMESIO R. ANTARAN
OIC, Records and Knowledge Management Division