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18-3 Investigation Report on claims for Compensation of Damages
MGB report for investigating on claims for compensation of damages
Your Browser Doesn't Support Canvas. Showing the Text Content of the PDF Instead: MGB Form No. 18-3
Republic of the Philippines
Department of Environment and Natural Resources
MINES AND GEOSCIENCES BUREAU
North Avenue, Diliman, Quezon City
INVESTIGATION REPORT ON CLAIMS
FOR COMPENSATION FOR DAMAGES
Date of Investigation:
I. FINDINGS AND OBSERVATIONS
A.
B.
C.
D.
Name of Claimant:
Capacity:
[ ] Landowner [ ] Landowner-Cultivator [ ] Lessee [ ] Tenant
[ ] Heir/Heiress/Successor-in-Interest
[ ] Administrator
Permanent Address:
Nature of Damage(s) Claimed (Please use another sheet if necessary.)
1.
Damage(s) to lives and personal property(ies)
a.
b.
c.
d.
e.
f.
g.
2.
Location:
Date of occurrence of damage(s):
Date of filing of claim(s):
Particulars (nature/extent and description of lives and personal
property(ies) damaged):
Cause(s)/source(s) of damage(s):
Value of damage(s) as claimed (P):
=
Value of damage(s) as assessed (P):
=
Damage(s) to lands
a.
b.
c.
d.
e.
f.
g.
Location:
Name of landowner:
Applicant for land ownership:
Evidence(s) of land ownership
c.1
Certificate no.:
c.2
Title no.:
c.3
Survey no.:
c.4
Others (please specify):
Land use
[ ] Agricultural [ ] Residential [ ] Commercial/Industrial
[ ] Forestland
[ ] Others, please specify:
Date of occurrence of damage(s):
Date of filing of claim(s):
Damage(s) to lands
g.1.
Particulars (nature and description of land damaged):
g.2
Cause(s)/source(s)/extent of damage(s)
g.2.1 Due to mine waste
i.
Cause(s)/source(s):
ii.
Area damaged (sq m):
MGB Form No. 18-3
iii.
h.
Degree [ ] Light (<= 5 cm)
[ ] Medium (> 5 cm <= 10 cm)
[ ] Heavy (> 10 cm)
iv.
Analysis of samples
Number of samples obtained:
Location of samples:
Result of analysis of samples (elements):
Interpretation of results of analysis of
samples:
v.
Value of damage(s) as claimed (P):
=
vi.
Value of damage(s) as assessed (P):
=
g.2.2 Due to mill tailings
i.
Cause(s)/source(s):
ii.
Area damaged (sq m):
iii.
Degree [ ] Light (<= 5 cm)
[ ] Medium (> 5 cm <= 10 cm)
[ ] Heavy (> 10 cm)
iv.
Analysis of samples
Number of samples obtained:
Location of samples:
Result of analysis of samples (elements):
Interpretation of results of analysis of
samples:
v.
Value of damage(s) as claimed (P):
=
vi.
Value of damage(s) as assessed (P):
=
g.2.3 Others (please specify; use another sheet if
necessary):
i.
Cause(s)/source(s):
ii.
Area damaged (sq m):
iii.
Value of damage(s) as claimed (P):
=
iv.
Value of damage(s) as assessed (P):
=
Damage(s) to improvements
h.1.
Private irrigation facility(ies):
h.1.1. Name of owner/person who introduced the irrigation
facility(ies) damaged:
Capacity: [ ] Landowner
[
]
Landowner-Cultivator
h.2.
[ ] Lessee
[ ] Tenant
[ ] Heir/Heiress/Successor-in-Interest
[ ] Administrator
h.1.2. Evidence(s) of ownership of the irrigation facility(ies)
damaged:
h.1.3. Operating and maintenance costs (P):
=
h.1.4. Particulars (nature/extent and description of the
irrigation facility(ies) damaged):
i.
Nature/extent and description of the irrigation
facility(ies) damaged:
ii.
Date when improvements were introduced:
iii.
Assessed value (P):
=
h.1.5. Cause(s)/source(s) of damage(s):
h.1.6. Value of damage(s) as claimed (P):
=
h.1.7. Value of damage(s) as assessed (P):
=
Other hydraulic facility(ies):
MGB Form No. 18-3
h.2.1. Name of owner/person who introduced the hydraulic
facility(ies) damaged:
Capacity: [ ] Landowner
[
]
Landowner-Cultivator
h.3.
[ ] Lessee
[ ] Tenant
[ ] Heir/Heiress/Successor-in-Interest
[ ] Administrator
h.2.2. Evidence(s) of ownership of the hydraulic
facility(ies) damaged:
h.2.3. Operating and maintenance costs (P):
=
h.2.4. Particulars (nature/extent and description of the
hydraulic facility(ies) damaged):
i.
Nature/extent and description of the hydraulic
facility(ies) damaged:
ii.
Date when improvements were introduced:
iii.
Assessed value (P):
=
h.2.5. Cause(s)/source(s) of damage(s):
h.2.6. Value of damage(s) as claimed (P):
=
h.2.7. Value of damage(s) as assessed (P):
=
Others improvements:
h.3.1. Name of owner/person who introduced the
improvements damaged:
Capacity: [ ] Landowner
[
]
Landowner-Cultivator
h.3.2.
h.3.3.
h.3.4.
h.3.5.
h.3.6.
h.3.7.
3.
[ ] Lessee
[ ] Tenant
[ ] Heir/Heiress/Successor-in-Interest
[ ] Administrator
Evidence(s) of ownership of the improvements
damaged:
Operating and maintenance costs (P):
=
Particulars (nature/extent and description of the
improvements damaged):
i.
Nature/extent and description of the
improvements damaged:
ii.
Date when improvements were introduced:
iii.
Assessed value (P):
=
Cause(s)/source(s) of damage(s):
Value of damage(s) as claimed (P):
=
Value of damage(s) as assessed (P):
=
Damage(s) to agricultural crops/forest products
a.
b.
c.
d.
e.
f.
g.
h.
Location:
Date of occurrence of damage(s):
Date of filing of claim(s):
Particulars (nature and description of agricultural crops/forest
products damaged):
Cause/source of damage(s):
Area damaged (sq m):
Extent of damage(s) to crops/products:
[ ] <= 20% damaged
[ ] > 20 to 50% damaged
[ ] > 50% to 80% damaged
[ ] > 80% damaged
Quantity of crops/products damaged as claimed:
MGB Form No. 18-3
i.
j.
k.
Value of damage(s) as claimed (P):
=
Quantity of crops/products damaged as assessed:
Value of damage(s) as assessed (P):
=
Quantity of crop/product harvest:
j.1.
Present:
j.2.
Previous:
j.3.
Loss of production (P):
=
Additional cost of crop/product harvest due to damage(s):
Previous
Estimated
Present
Additional
Estimated
Inputs
Amount Used Cost Amount Used Amount Used
Cost
k.1. Fertilizer
k.2. Pesticides
k.3. Seeds
k.4. Labor
k.5. Others
Total
l.
m.
4.
Damage(s) to marine life/aquatic resources (fish ponds, cages, pens, etc.)
a.
b.
c.
d.
e.
f.
g.
5.
Crops/products originally planted to the area:
Crops/products now planted to the area:
Loss due to change of crop (P):
=
Crop insurance: [ ] Yes [ ] No
If yes,
m.1. Name of crop insurance:
m.2. Address of insurance company:
m.3. Policy contract:
m.4. Amount of crop insurance (P):
=
Location:
Date of occurrence of damage(s):
Date of filing of claim(s):
Particulars (nature and description of marine life/aquatic resources
damaged):
Cause(s)/source(s) of damage(s):
Quantity of marine life/aquatic resources damaged as claimed:
Value of damage(s) as claimed (P):
=
Quantity of marine life/aquatic resources damaged as assessed:
Value of damage(s) as assessed (P):
=
Damage(s) to cultural resources
a.
b.
c.
d.
e.
f.
g.
Location:
Date of occurrence of damage(s):
Date of filing of claim(s):
Particulars (nature and description of cultural resources damaged):
Cause(s)/source(s) of damage(s):
Quantity of cultural resources damaged as claimed:
Value of damage(s) as claimed (P):
=
Quantity of cultural resources damaged as assessed:
Value of damage(s) as assessed (P):
=
MGB Form No. 18-3
6.
Damage(s) to infrastructure
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
m.
7.
Location:
Name of landowner:
Applicant for land ownership:
Evidence(s) of land ownership
c.1
Certificate no.:
c.2
Title no.:
c.3
Survey no.:
c.4
Others (please specify):
Date of occurrence of damage(s):
Date of filing of claim(s):
Description of land:
Name of owner/person who introduced the infrastructure:
Capacity: [ ] Landowner
[ ] Landowner-Cultivator
[ ] Lessee
[ ] Tenant
[ ] Heir/Heiress/Successor-in-Interest
[ ] Administrator
Evidence(s) of ownership of the improvements damaged:
Operating and maintenance costs (P):
=
Particulars (nature/extent and description of the infrastructure
damaged):
j.1.
Nature/extent and description of the infrastructure damaged:
j.2.
Date when improvements were introduced:
j.3.
Assessed value (P):
=
Cause(s)/source(s) of damage(s):
Value of damage(s) as claimed (P):
=
Value of damage(s) as assessed (P):
=
Other damage(s):
a.
b.
c.
d.
e.
f.
g.
Location:
Date of occurrence of damage(s):
Date of filing of claim(s):
Particulars (nature/extent and description of damage):
Cause(s)/source(s) of damage(s):
Value of damage(s) as claimed (P):
=
Value of damage(s) as assessed (P):
=
II. REMARKS AND RECOMMENDATIONS
Certified true and correct:
REGIONAL INVESTIGATION AND ASSESSMENT TEAM
Region No. ___
Leader
MGB Form No. 18-3
Member
Member
Member
Member
Member
Member
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:
