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Republic of the Philippines
DEPARTMENT OF AGRARIAN REFORM
OFFICE OF THE REGIONAL DIRECTOR
Region XIII-Caraga
Ctp Building, Km 4, Libertad, Butuan City
____________________________
Petitioner/s,
-vs- For:
____________________________
Respondent/s
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COMPLAINT/PETITION/PROTEST
I/We, __________________________________ of legal age, Filipino, married/single
(please underline) with permanent address at ______________________________, with
Disclosure Statement under oath and as Represented
by___________________________________ who is our Attorney-in-
Fact, hereto allege that:
1. I am/We are filing this complaint/Petition/Protest against ________________________,
of legal age, Filipino, married/single (please underline) and a permanent residence of
_________________________________________ who is the herein Respondent/s;
2. My complaint against the Respondent involves issue/s on:
Classification and identification of landholdings for coverage under agrarian
reform program;
Initial issuance of CLOA and EP;
Protest or opposition on coverage and/or issuance of EP/CLOA;
Petition for lifting of CARP coverage;
Classification, identification, inclusion, exclusion, qualification or disqualification
of potential/ actual FBs;
Subdivision surveys of land under CARP;
Recall or cancellation of provisional lease rentals, CLTs and CARP Beneficiaries
Certificates (CBCs) in cases outside the purview of PD 816
Issuance, recall or cancellation of EPs/ CLOAs not yet registered with the ROD
Exercise of right of retention by landowner
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Application for exemption from coverage under Section 10 of RA 6657, as
amended
Application for exemption pursuant to DOJ Opinion No. 44 (1990)
Exclusion from CARP coverage of agricultural land used for livestock, swine, and
poultry raising
Cases of exemption/exclusion of fishpond and prawn farm from the coverage of
CARP pursuant to RA 7881
Issuance of Certificates of Exemption for land subject of VOS and CA found
unsuitable for agricultural purposes
Application for conversion of agricultural land to residential, commercial,
industrial or other non-agricultural uses and purposes including protests or
opposition thereto
Determination of the right of ARBs to home lots
Disposition of excess area of the tenant’s/ FB’s landholdings
Increase in area of tillage of tenant/FB
Conflict of claims in landed estates administered by DAR and its predecessors
Case or disputes, arising from the need for continued possession and installation
Of ARBs
Cases or disputes, arising from or regarding the maintenance of possession or
reinstatement of actual tillers not bound by any tenurial relation on landholdings
devoted to agriculture.
In cases with resolutions, orders or decisions which have attained to finality or
have been executed with new controversies arising from change in condition of
the subject landholdings or parties
Such other agrarian cases, disputes, matters or concern referred by the Secretary
to the Regional Director, other DAR officials, or in other cases where the
Secretary assumes jurisdiction.
3. State the material facts here below:
_______________________________________________________________________
_______________________________________________________________________
____________________________________________________________________
___
____________________________________________________________________
___
_______________________________________________________________________
_____________________________________________________________________________
( you may use separate sheets for the additional statement fact to support your complaint/s)
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4. In support of my complaint, I have attached the following documentary evidence/s;
Annexes Name/Title of Documents Purpose of Presentation
(you may use separate sheets, if necessary)
PRAYER
WHEREFORE, premises considered, it is respectfully prayed that:
1. ________________________________________________________;
2. ________________________________________________________;
3. ________________________________________________________;
4. ________________________________________________________;
5. ________________________________________________________;
(you may use separate sheets, if necessary)
MOST RESPECTFULLY SUBMITTED.
Butuan City, Philippines this_____________________.
________________________________________________
Name and Signature of the Complainant/s or Representative
Identification Card No. _____________________________
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DISCLOSURE STATEMENT
I/WE, the undersigned Complainant/Petitioner/Protestant hereby certify under
oath that:
a. Is/are a party –in- interest or property authorized by a party –in- interest;
b. That I/we have not commenced and/or are aware of any action or proceeding
involving the same land, or a portion thereof, or issue in any court, tribunal, or
quasi-judicial agency; and to the best of my/our knowledge, no such action or
proceeding is pending in any court, tribunal or quasi-judicial agency;
c. If there is any action or proceeding which is either pending or may have been
terminated, I/We shall state the status thereof; and
d. If I/We thereafter learn that a similar action or proceeding has been filed or is
pending before any court, tribunal, or quasi-judicial agency, I/We undertakes to
report within five (5) days therefrom to the DAR office where the case for
cancellation is pending.
_________________________________________________
Name and Signature of the Petitioner/s or Representative
Identification: ___________________________________
SUBSCRIBE AND SWORN TO BEFORE ME, this ______day of
________________in _______________________________________________________,
Affiant exhibiting to me their _____________________________ which entries reflected below
his/her name and signature.
Notary Public
COPY FURNISHED TO OPPOSING PARTY ON _______________________
With attached proof of service/receipt by the Opposing party as the case may be
