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City of Tandag…………………………) S.S.



I, ABC, of legal age, Filipino, and a resident of Carrascal, Surigao

del Sur, after having been sworn to in accordance with law, depose and

1. That I am the legal guardian of DEF, incapacitated and daughter of


2. That XYZ died in California, USA, last 2000 and she left a Living
Trust making me as the administrator of all her properties and
guardian of her incapacitated daughter;

3. That during the lifetime of XYZ she owned an agricultural land

covered by OCT No. 123 with an area of 15 hectares;

4. That the said property was administered by her brother 123;

5. That after the death of her brother 123, portion of the land owned
by XYZ, specifically Lot No. 456, Css-13-000095-D containing an
area of Thirty Four Thousand Six Hundred Eight (34,608) Square
Meters situated at Carrascal, Surigao del Sur, was erroneously
titled in the name of MNO, the common law wife of 123;

6. That during the lifetime of XYZ she did not execute any Deed
transferring ownership of a land designated as Lot No. 456, Css-13-

7. That the MNO, is only the trustee of the said property since she
never acquired ownership over that parcel of land;

8. That unless an adverse claim is annotated on the aforedescribed

Katibayan ng Orihinal na Titulo Blg. T-41170, the rightful heir of
XYZ is in danger of being defrauded and deprived of her just and
valid right over the aforedescribed parcel of land and, as such, I am
executing this Affidavit in support of my request for the annotation
of an adverse claim over the parcel of land described herein; and

9. That I may be served with summons and other court process in my

residential address at Carrascal, Surigao del Sur.

IN WITNESS WHEREOF, I have set my hand this _________________,

in Tandag City, Surigao del Sur, Philippines.

ID No. _____________

SUBSCRIBED AND SWORN to before me, this _________________ by

the Affiant whom I have identified through competent evidence of identity
and who exhibited her Government Issued Identification Card (Senior
Citizen ID) as per description appearing below his name.

Doc No.: ________;

Page No.: ________;
Book No.: _______;
Series of 2018.