REPUBLIC OF THE PHILIPPINES)

CITY OF ...........................)S.S.

AFFIDAVIT OF SELF- ADJUDICATION

I, (name) , Filipino, of legal age, (single/married), and a resident of

(address) , City, Philippines after having been duly sworn to in accordance with
law, do hereby depose and state, THAT:

1. I am the sole heir of the late (name of decedent) being his/her

only biological son/daughter;

2. The late (name of decedent) passed away on (date of

death) and died without any last will and testament;

3. At the time of death my father/mother had no debts, liabilities or obligations to

any persons, agency or institution;

4. The only property left by my late mother is (name and description of the
property);

5. As sole heir of the herein decedent, I hereby adjudicate the abovementioned

property solely for and in my name as well as any and all liabilities arising from the said
property;

6. I hereby execute this affidavit for the purpose of processing the transfer of the
said property in my name, the settlement of the estate of the late (name of
decedent) , as well as for the release of any other claim or benefit in relation
to his/her death before any government/private office and banking institution and for any
other legal purpose this may best serve.

IN WITNESS WHEREOF, I hereby set my hands this (date) at

Cebu City, Philippines.

(name of affiant)
Affiant

SUBSCRIBED AND SWORN to before me this (date) at City,

Philippines. Affiant exhibited to me his (I.D. and I.D. No.) issued
on _________________ at ______________ as his competent evidence of identity.

(NOTARY PUBLIC)
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