Republic of the Philippines)

) S.S.

AFFIDAVIT

WE, A and B, both Filipinos, of legal age, and with address at

___________, Quezon City, after having been duly sworn to in accordance with
law hereby depose and say that:

1) We are the only legitimate and surviving heirs of the late _____;

2) C married A on 19 January 1970 in Pateros, Rizal.

Copy of the Marriage Contract of A and C is hereto attached and made an

integral part hereof as Annex “A”.

3) During their marriage, A gave birth to their only child, B on 28 March 1972
in Capitol Medical Center, Quezon City;

Copy of the Certificate of Live Birth of B is hereto attached and made an

integral part hereof as Annex “B”.

4) C, died on 02 October 2012 at Fairview General Hospital;

Copy of the Death Certificate of C is hereto attached and made an integral

part hereof as Annex “C”.

5) C was one of the heirs of the late X and Y.

6) We are executing this affidavit to attest to the truth of the foregoing and for
whatever legal purposes it may serve.

IN WITNESS WHEREOF, We hereby affix our signatures this __th day

of October, 2019 in ______________ City, Philippines.

AFFIANTS

SUBCRIBED AND SWORN TO before me this __th day of October 2019

in _________ City, Philippines, affiant exhibiting to me their competent proof of
identities.

Government Issued ID Date of Validity

=
Doc. No. _____; NOTARY PUBLIC
Page No. _____;
Book No. _____;
Series of 2019.