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18-2 Application for Compensation for Damages

MGB application form for damages compensation

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Republic of the Philippines
Department of Environment and Natural Resources
MINES AND GEOSCIENCES BUREAU
North Avenue, Diliman, Quezon City

APPLICATION FOR COMPENSATION FOR DAMAGES
Date of Filing:
Pursuant to the provisions of R.A. 7942 as being implemented by DENR
Administrative Order No. 96-40, Series of 1996, the undersigned hereby applies for
compensation for damage(s) caused by mining operations.
A.
B.
C.
D.

Name of Claimant:
Capacity:
[ ] Landowner [ ] Landowner-Cultivator [ ] Lessee [ ] Tenant
[ ] Heir/Heiress/Successor-in-Interest [ ] Administrator
Permanent Address:
Particulars (Nature/Extent and Description of Damage(s) Claimed) (Please use
another sheet if necessary.)
1.
2.
3.

Location:
Date of occurrence of damage(s):
Nature/extent and description
a.

b.

c.

Damage(s) to lives and personal property(ies)
a.1.
Nature/extent and description of lives and personal
property(ies) damaged):
a.2.
Value of damage(s) (P):
=
Damage(s) to lands
b.1.
Damage(s) to lands
b.1.1. Description of land damaged:
b.1.2. Extent of damage(s)
i.
Area damaged (sq m):
ii.
Value of damage(s) (P):
=
b.2.
Damage(s) to improvements
b.2.1. Irrigation facility(ies)
i.
Nature/extent and description of the irrigation
facility(ies) damaged:
ii.
Value of damage(s) (P):
=
b.2.2. Other hydraulic facility(ies):
i.
Nature/extent and description of the hydraulic
facility(ies) damaged:
ii.
Value of damage(s) (P):
=
b.2.3. Others improvements:
i.
Nature/extent and description of the
improvements damaged:
ii.
Value of damage(s) (P):
=
Damage(s) to agricultural crops/forest products
c.1.
Nature and description of agricultural crops/forest products
damaged:
c.2.
Quantity of crops/products damaged:

MGB Form No. 18-2

d.

e.

f.

g.

4.

c.3.
Value of damage(s) (P):
=
Damage(s) to marine life/aquatic resources
d.1.
Nature and description of marine life/aquatic resources
damaged:
d.2.
Quantity of marine life/aquatic resources damaged:
d.3.
Value of damage(s) (P):
=
Damage(s) to cultural resources
e.1.
Nature and description of cultural resources damaged:
e.2.
Quantity of cultural resources damaged:
e.3.
Value of damage(s) (P):
=
Damage(s) to infrastructure
f.1.
Nature/extent and description of the infrastructure damaged:
f.2.
Value of damage(s) (P):
=
Other damage(s):
g.1.
Nature/extent and description of damage:
g.2.
Value of damage(s) (P):
=

Total value of damage(s) (P):
=

E.

Cause(s)/Source(s) of Damage(s):

F.

Documentary Evidence(s) Attached:
[]
[]
[]
[]
[]

Duly certified proof of ownership of land; e.g., latest tax declaration,
perfected land title, homestead, and free patent
Receipt of expenditures for improvements made in the affected property(ies)
In case of representative, a special power of attorney signed by concerned
parties
Pictures, maps, sketches, if possible
Other evidences, please specify:

I hereby certify that the foregoing information are true to the best of my knowledge.

Signature/Thumbmark of Claimant
Conformed:

Signature/Thumbmark of Landowner
over Printed Name

SUBSCRIBED AND SWORN to before me this
day of
, claimant exhibiting to me his/her Community Tax Certificate No.
, on
, 19 .

NOTARY PUBLIC
Until December 31, 199
PTR No.:

19 at
issued at

MGB Form No. 18-2

Place of Issue:
Date of Issue:
Doc. No.
Page No.
Book No.
Series of 19
 
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