REPUBLIC OF THE PHILIPPINES )

PROVINCE OF CAMARINES NORTE )S.S.

MUNICIPALITY OF LABO )
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AFFIDAVIT OF SELF-ADJUDICATION

I, ______________, of legal age, single, Filipino citizen and with residence and
postal address at _______________________, after having been duly sworn to in
accordance with law, hereby depose and say:

1. That I am the sole heir of the late _______________ being his only biological
son;

2. That the late _________________ died intestate on July 24, 2017 at

__________________________, copy of the Certificate of death is hereto attached
and made an integral part of this Affidavit;

3. That the said deceased left bank deposits at the Philippine National Bank
(PNB), ____________________ under Savings Account Number_________;

4. That at the time of the death of my father, he had no debts, liabilities or

obligations whatsoever to any persons, agency or institutions;

5. That pursuant to Rule 74, Section 1 of the Rules of Court, I hereby

adjudicate unto myself the said bank deposits by means of this Affidavit and hereby
request that the said adjudication be made effective without judicial proceedings as
prescribed by the aforementioned provision of the Rules of Court.

IN WITNESS WHEREOF, I have hereunto set my hand this

____________________________

____________________
Affiant

SUBSCRIBED AND SWORN to before me this 25th day of April 2018 at

___________________________

Doc. No._________;
Page No._________;
Book No._________;
Series of 2 0 1 8 .