LSA Tenancy Form

The Land Settlement Agency's Tenancy Application Form
Site name *
Name*

First NameMiddle NameLast Name
National Identification Card No.*
Passport No.
Drivers Permit No.
Birth Certificate PIN No.*
Date of Birth*

MonthDayYear
Date
MaleFemale
YesNo
YesNo
Country of Birth*
SingleMarriedDivorcedSeparatedCommon-lawWidowed
Residential Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Occupation*
BIR Number
Primary Contact Number*
Please enter a valid phone number.Format: 000-0000.
Secondary Contact Number
Please enter a valid phone number.Format: 000-0000.
Tertiary Contact Number
Please enter a valid phone number.Format: 000-0000.
Email
example@example.com
Co-Applicant Name(If Applicable)

First NameMiddle NameLast Name
Co-Applicant National Identification Card No.
Co-Applicant Drivers Permit No.
Co-Applicant Passport No.
Co-Applicant Birth Certificate PIN No.
Co-Applicant Date of Birth

MonthDayYear
Date
MaleFemale
YesNo
YesNo
Co-Applicant Country of Birth
Co-Applicant Residential Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Co-Applicant Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Co-Applicant Occupation
Co-Applicant BIR Number
Co-Applicant Primary Contact Number
Please enter a valid phone number.Format: 000-0000.
Co-Applicant Secondary Number
Please enter a valid phone number.Format: 000-0000.
Co-Applicant Tertiary Contact Number
Please enter a valid phone number.Format: 000-0000.
Co-Applicant Email
example@example.com
Section C: Previous Applications
YesNo
Certificate of ComfortVacant Residential Lot ProgrammeLand For The LandlessProbationary Tenancy AgreementHousing and Village Improvement ProgrammeGovernment Aided Self Help Housing ProgrammeHousing Development Corporation House/Land/GrantMinistry of Housing and Urban Development GrantOther
Section D: Ownership of Land
YesNo
If Yes, please provide the registration number of the title document:
Section E: Description of Property and Land
Please state the address of the parcel of State Land you are currently in occupation of:*

Lot/LP No.

Street Address

City
Please State the date you began occupation of the stated parcel:*

MonthDayYear
Date
You MUST upload the following documents (failure to do so will halt the processing of your application): Identification Card (Back and Front) OR Drivers Permit; Birth Certificate; Passport(Optional); Any legally recognized document clearly depicting the Applicant’s name, the address of the parcel of land and a date supporting the Applicant’s occupation before the 14th of June, 2014.(e.g Utility Bills, Bills showing materials purchased for the structure, Statutory Declaration, etc)

Cancelof
Section E: Household Information

Please Specify the number of Occupants per household: (Please include the Applicants' name[s])

Rows	Surname	Firstname	Date of Birth(mm/dd/yy)	Occupation
1
2
2
4
5
6
7
8
9
10

Section F: Declaration & Affirmation
Date

MonthDayYear
Date
I/We First Name* Last Name* and First Name Last Name hereby make an application for a Tenancy Agreement in respect of one dwelling house only upon a lot of State Land situated at Lot#/Lp#* Address Line * City* .
I/We First Name* Last Name* and First Name Last Name certify that the information given in this form is true to the best of my/our knowledge and belief. If there is anything given in the information above which is not true or incorrect, knowingly or unknowingly the the Land Settlement Agency reserves the right to refuse this application.
Applicant's Signature :*
Co-Applicant's Signature :
Should be Empty:

The Land Settlement Agency's Tenancy Application Form

Section C: Previous Applications

Section D: Ownership of Land

Section E: Description of Property and Land

Section E: Household Information

Section F: Declaration & Affirmation