1. Tanah Kosong a. Tegalan ..................................................... b. Sawah ..................................................... c. Rawa ..................................................... 2. Ada Bangunan a. Permanen ................................................... b. Semi Permanen ........................................ 3. Penguasaan Tanah a. Dikuasai Pemohon .................................. b. Dikuasai Pihak Lain ................................ 4. Pemanfaatan Tanah: