REPUBLIC OF THE PHILIPPINES

)
) S.S.

AFFIDAVIT OF SELF-ADJUDICATION
I, _________________________, of legal age, Filipino, single/married and a
resident of ________________________________________, after having been
duly sworn in accordance with law, do hereby depose and say:
1. That I am the only daughter of ________________ who died intestate in the
_________________________________________,
on
_________________________ as evidenced by Death Certificate issued by
the Municipality/City of ________________________, Province of
__________________, hereto attached as ANNEX A and made an integral
part of this Affidavit;
2. That the said deceased left deposit in _____________________, in the
amount of P___________________;
3. That the said deceased left no debts;
4. That pursuant to Rule 74, Sec. 1 of the Rules of Court, I hereby adjudicate
unto myself the above described real estate by means of this Affidavit and
hereby files the same with the Register of Deed of ______________ with the
request that the said adjudication be made effective without judicial
proceeding as prescribed by the aforementioned Rules of Court.
IN WITNESS WHEREOF, I have set my hand this _____ day of
____________ at ____________________________________.

Affiant
SUBSCRIBED AND SWORN before me this ____ day of ____________ at
________________________________
affiant
exhibiting
his/her
___________________ as proof of identity.

Doc. No. ________;

Page No. ________;
Book No. ________;
Series of 20___.